AG1 Develop, implement and review care plans for individuals

Overview

For this standard you will be expected, with the support of other staff, to develop, implement and review care plans. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. codes of practice and conduct, and standards and guidance relevant to your setting and own and the roles, responsibilities, accountability and duties of others when developing, implementing and reviewing care plans
2. current local, national and European legislation and organisational requirements, procedures and practices for:
1. data protection
2. health and safety
3. risk assessment and management
4. employment practices
5. protecting individuals from danger, harm and abuse
6. your responsibility for keeping yourself, individuals and others safe
7. making and dealing with complaints and whistle blowing
8. multi-disciplinary and multi-agency working
9. working in integrated ways to promote the individual’s well-being
10. the planning and provision of services
11. developing, implementing and reviewing care plans
3. key government initiatives which affect the development and review of care plans to meet individual needs, preferences and circumstances
4. how to access, evaluate and influence organisational and workplace policies, procedures and systems for developing, implementing and reviewing care plans
5. how to access and record information, decisions and judgements for care plans
6. how different philosophies, principles, priorities and codes of practice can affect inter-agency and partnership working when developing, implementing and reviewing care plans
7. how and where to access literature, information and support to inform your practice when developing, implementing and reviewing care plans
8. the following:
1. literature related to best practice in the development, implementation and review of care plans
2. government reports, inquiries and research relevant to the development, implementation and review of care plans
3. government reports, inquiries and research into serious failures to protect individuals, families, carers and other key people
9. theories of:
1. facilitating empowerment and participation of individuals and key people in the development, implementation and review of care plans
2. the role of family and social support networks in meeting individuals’ needs
3. how social and economic circumstances may impact on the individuals’ social care, well-being and life chances
4. human resource management in relation to the development, implementation and review of care plans
5. human growth and development
6. managing loss and change
7. how stress can affect behaviour
8. how power and influence can be used and abused when developing, implementing and reviewing care plans
9. multi-disciplinary and multi-organisational working
10. knowledge of the physical, emotional and health conditions of the individuals for whom you are developing, implementing and reviewing care plans and how to use this information to make informed decisions for the content of the care plans
11. the factors to take account of when evaluating whether your organisation has the resources (human, physical and financial) to provide the services and facilities
12. how to analyse, interpret and balance:
1. individual needs and preferences
2. views of key people
3. evidence, knowledge and practice based information
4. knowledge of individuals’ conditions
5. resources and capacity within your organisation (to enable you to assess individuals’ needs and preferences, fairly and ethically)
13. methods of supporting individuals and key people to:
1. express their wishes, needs and preferences about the delivery of services and facilities
2. understand and take responsibility for promoting their own health and well-being
3. identify how their care needs should be met
4. assess and manage risks to their health and well-being
14. methods of supporting staff to work with individuals, key people and others to deliver, implement and evaluate care plans
15. the stages, procedures, paperwork and people involved in developing, implementing and reviewing care plans
16. the use of evidence, fact and knowledge based opinions in records and reports and why it is important to differentiate between these and make clear the source of evidence
17. what is meant by needs-led and service-led planning and their relevance for reviewing care plans
18. reasons for changing resources and care plans and how to deal with the affect this may have on individuals
19. why and how the review and revision of care plans may have implications for individuals, key people and the existing provision
20. legal and organisational requirements on equality, diversity, discrimination, rights, confidentiality and sharing of information when developing, implementing and reviewing care plans
21. knowledge and practice that underpin the holistic person-centred approach which enable you to work in ways that:
1. place the individuals’ preferences and best interests at the centre of everything you do
2. provide active support for the individuals
3. recognise the uniqueness of individuals and their circumstances
4. empower individuals to take responsibility (as far as they are able and within any restrictions placed upon them), and make and communicate their own decisions about their lives, actions and risks (when developing, implementing and reviewing care plans)
22. how to manage ethical dilemmas and conflicts for individuals, those who use services and staff/colleagues when developing, implementing and reviewing care plans
23. how to challenge, and to support individuals, key people and others to challenge information, documents, systems, structures, procedures and practices that are discriminatory
24. the ways that health and social care values may differ from those of the individuals and key people you are working with
25. how to form relationships that promote the individuals’ rights, choices and well-being

Performance Criteria

You must be able to do the following:

1. identify and agree the roles and responsibilities of all concerned with the development of care plans
2. access and review:
1. information about individuals’ needs and preferences and any specific requirements they may have
2. literature and knowledge based research relevant to individuals’ needs and preferences
3. work with people within and outside your organisation to ensure the development of the best possible care plans for individuals
4. involve and support individuals and key people to contribute at every point in the development of the care plans
5. identify and agree the content of care plans, ensuring that:
1. individual needs and preferences are placed at the centre of care plan activities
2. the plans provide active support for individuals
3. individuals and key people are protected from danger, harm and abuse
4. risks are managed
6. develop care plans:
1. according to legal and organisational requirements
2. in a format and language that is understandable and useable by all who need and are required to access and use them
7. check the details and make sure that individuals and key people understand the contents of the plan
8. provide evidenced based records and reports, that detail:
1. actions and decisions about the content of the plan
2. aspects of the plan where there was any disagreement and how this was resolved
9. complete, and support individuals to complete, any necessary paperwork when the final plan has been agreed
10. ensure that the plan is stored and able to be accessed within confidentiality agreements and according to legal, organisational and any service requirements
11. support individuals and key people to understand:
1. the arrangements for the implementation of their care plan
2. their roles and responsibilities in implementing the care plan
3. any areas where their preferences have not been able to be met and why
4. how any emerging problems and crises will be addressed
5. how they can compliment, challenge and complain about the care plan and its implementation
12. identify and agree the roles and responsibilities of all concerned with the implementation of care plans for individuals
13. carry out your own role and responsibilities in implementing care plans, in ways that illustrate best practice to all with whom you work
14. support staff involved in the implementation of care plans to:
1. work effectively, holistically, inclusively and provide active support for individuals and key people when implementing care plans activities
2. understand their role and responsibilities in carrying out specific activities
3. understand and use the best methods to implement the care plan activities to meet individual needs and preferences
4. record and report any discomfort and change in individuals when working with individuals and implementing care plan activities
15. support individuals and key people to identify their views and preferences and provide feedback on the implementation of the care plan
16. work with all involved to identify and report any changes arising from the impact of the care plan on the health and social well-being of the individual
17. address any difficulties arising from changes in resources and to the needs, circumstances and preferences of individuals
18. identify and agree the roles, responsibilities and criteria for judging the quality and effectiveness of care plans with all involved
19. work with individuals, key people and others within and outside your organisation to:
1. review all aspects of the care plan
2. agree changes to the care plan
3. identify resources necessary to implement any changes
20. contribute to, participate in and run meetings and discussions to agree revisions to care plans, taking account of any benefits and risks
21. ensure that review meetings are arranged and run in ways which promote the full participation of individuals and key people
22. collate review information and revise care plans within agreed timescales
23. ensure that individuals and key people understand the revisions that have been made to the care plans and the implications of these for the health and care services that individuals receive
24. provide evidenced based records and reports, that detail:
1. actions and decisions about the revisions to the plan
2. aspects of the plan where there was any disagreement and how this was resolved
25. complete, and support individuals to complete, any necessary paperwork when the revised plan has been agreed
26. ensure that the revised plan is stored and able to be accessed within confidentiality agreements and according to legal, organisational and any service requirements

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB2 Assessment and care planning to meet health and wellbeing needs This standard has replaced HSC416.