A care plan is the single most important document relating to someone’s care and wellbeing. It’s the cornerstone of the service you’re providing to your service users and the key to delivering person-centred, individualised care.
During a mock CQC inspection, we’ll take a look at your care plans to make sure you’ve included everything your team needs to give Outstanding care as well as everything your inspector will be looking for.
1. Make sure your care plan is in line with your policies
If you want to demonstrate that you’ve put a lot of thought and consideration into your policies, they should be created from scratch, in-house, and comply with CQC regulations, fundamental principles of care and frameworks that are designed to lead to real outcomes.
Some care providers use online tools to generate care plans but don’t understand them well enough to implement them properly. Your inspector will be able to pick up on this and they won’t be impressed; especially if management has changed and bad habits have been passed on during handover.
2. Include the right information
Care plans need to contain a lot of different types of information. All relevant stakeholders involved in a person’s care must be listed, including contact details for social workers and next of kin.
Next you need to cover the healthcare basics of your service user: any conditions they have that are being treated or that are known about and not currently being treated, what medication they are taking, in what dosage, how often and when they’re due a medication review.
Then get into what the service user’s assessed care needs are, including any specialist equipment or adaptations to their homes, whether they have a personal alarm, their scheduled visits or social calendar, and of course, the type of care they receive.
Finally, the admin side of things. Include relevant risk assessments that you’ve carried out, outcomes they wish to achieve as well as a breakdown of which stakeholders are responsible for which activities, their budget and whether there are any direct payments coming from the council.
3. Involve your service user
Your service user should be heavily involved in their own care plan, or, if they’re deemed incapable of participating, then their legal representative should be involved. Documents need to comply with Accessible Information Standards for people with sensory loss, disability or mental impairment.
4. Review and audit your care plans
Care plans should be reviewed at least once a year, or more often if the person’s care needs are changing rapidly. You should be able to demonstrate that service users, their family and/or their legal representative feel confident enough to approach you with any concerns they have about their care plan. Additionally, your staff should be able to proactively flag anything in the care plan that they think needs updating.
It’s also crucial to audit your own care plans and demonstrate that you do this regularly. A lot of companies forget to include care plans when they’re auditing documents, but if there are significant process changes that need to be made regarding care plans you need to be able to demonstrate how you identified them, implemented the changes and reviewed them to make sure your care plans are up to scratch.
If you want more advice on how to create an Outstanding care plan or any other aspect of your CQC inspection, get in touch with the team on 0333 444 5344 or email email@example.com or arrange a mock CQC inspection today.