Care Planning, Review, Culturally Appropriate and Person Centred Care

Person and relationship centred care, moves away from professionals deciding what is best for an individual, and places the individual at the centre as an expert of their own experience.

At Derbyshire house, the individual and their family/advocates, where appropriate, will become an equal partner, not only in the planning of their care and support, but also in the design and delivery of the service, ensuring we meet the needs, goals and outcomes, with the emphasis on doing with rather than doing to.

The application and initial needs assessment on line forms will start this process wherever possible and should be completed prior to the pre-admission assessment, which is used to start the processes of information gathering. On admission and during the 12-week probationary period further information is gathered through discussions, activity and observation from staff at all levels in order to help create a holistic individual plan of care.

The care plan will be used as a tool to collect personal choices and preferences. As well as any culturally appropriate care, it will concentrate also on emotional, social, religious, health and nutritional needs and support. It will include preferences with regard to privacy and social media content. Mental capacity will be considered for each section and not assumed and consent to care recorded. Where choices or consent to care is compromised, a referral to DoLS will be made.

Culturally appropriate care

Culturally appropriate care is emphasised throughout the care plan and individual life history, which pays attention to the finer details and allows us to be alert and responsive to individual beliefs or conventions that might be determined by cultural heritage/identity.
Cultural heritage/identity varies, and are not just based on religion or ethnicity. They include region where a person is from or grew up or lived, family background, working life, life history and experiences and family values.
We will ask questions as to the way individuals identify with their culture and consider that these can change through time.
We will not make assumptions about a person needs based on generalisation about any cultures. We will communicate with individuals and where appropriate, their families/advocates, which we consider vital to meeting cultural needs. If there is conflicting views, the individuals own wishes will be put first.

We will strive to:

  • Ensure that the information gathering process is sensitive and adheres to legislation, guidance and recommendation set out in the homes GDPR (Data Protection) and privacy policy statements.
  • Is collected at times that suit the individual and/or their advocates in a sensitive manner.
  • Only shared with those who have a need/right to access or have been given consent by the individual
  • Ensure that it is used for the purpose of enhancing wellbeing and social connections and for all reasons which directly benefit the individual.
  • Ensure people have access to information and advice if they need to make an informed decision.
  • Be fully engaged with the process of change
    Demonstrate a culture that actively promotes personalised services with maximum choice, preferences and control for people living in or using our services.
  • Ensure staff have the necessary learning and development opportunities to support the principles of putting people first.
  • Fully involve people, and where required, their families/advocates, in the design and delivery of services to ensure needs outlined can be met.
  • Work collaboratively with health and social care authorities and any other identified professional involved in meeting the individual needs.
  • Uphold the privacy, dignity and respect of people whilst allowing engagement for which they long.

Derbyshire house intends to support good practice in care planning through a summary of good standards, guidance and recommendations which:

  • Meets professional, local and national standards.
  • Outlines our aims to deliver person centred care that is delivered by culturally competent staff, the actions we will take to achieve this and our responsibilities to the individuals and their family/ advocates.
  • Supports care planning under systems such as Dementia Care Matters, Gold Standards Framework, Culturally Appropriate Care and GDPR regulations.
  • Interacts effectively with everyone involved.
  • Is accessible to people who play a fundamental part in the care and wellbeing of the individual.

Reviewing and monitoring

As health needs change, preferences and choices may also change and goals to be achieved and outcomes expected may need to be reviewed. Reviews are an important part of the care planning process as it allows care plans to be as up to date as practicably possible and needs to be met accordingly.

Our aim is to carry out mini care plan reviews monthly with the individual and/or their advocates. Every 6 months or on condition change a full review is carried out which goes through every section of the care plan and is thoroughly updated and reviewed. Mini reviews are an opportunity to keep in touch and talk through any concerns or goals that you may have and work towards achieving them and discuss any aspect of care or emotional needs. All reviews identify if there is a need for any further intervention from outside professional or referrals that may need to be made including those that need to be made to DoLS. All of this is recorded and any goals or outcomes recorded.

Senior care staff carry out reviews and start by making appointments with the relevant family member, advocate or individual. These can be short or lengthy but both are important and it is recommended that appointments are kept to ensure that concerns are discussed. Should appointments need to be changed or cancelled we ask that you let the senior staff member know as soon as practicably possible ideally at least 72 hours before the date and time of the appointment. Senior staff will, wherever practicably possible, allow 72 hours for changes of appointment where a work need arises.