Dr. Fionnuala O’Loughlin
Orla O‘Neill
Assistant Inspectors of Mental Health Services
INDIVIDUAL CARE PLANNING
Inspector’s perspective
 Birdseye view of how individual care plans are being
implemented in 63 approved centres nationwide since
2006
 Inspector does not set the standards but has an
independent role to examine against the statutory
requirements
 Aim today is to elucidate the core requirements in
meeting statutory obligations in individual care
planning and to discuss issues identified by clinicians
Definition of an Individual Care Plan as per, Mental Health Act 2001
(Approved Centres) Regulations 2006 (S.I. No. 551 of 2006)
Article 15. Individual Care Plan, states: “The Registered
proprietor shall ensure that each resident has an individual care
plan. “ The Preamble defines this as:“Individual Care Plan” means a documented set of goals developed,
regularly reviewed and updated by the resident’s multi-disciplinary
team, so far as practicable in consultation with each resident. The
individual care plan shall specify the treatment and care required which
shall be in accordance with best practice, shall identify necessary
resources and shall specify appropriate goals for the resident. For a
resident who is a child, his or her individual care plan shall include
education requirements. The individual care plan shall be recorded in
the one composite set of documentation.”
•Documented set of goals
•Regularly reviewed and updated by the resident’s multidisciplinary
team
•In consultation with each resident in so far as is practicable
•Specify treatment and care required in accordance with best practice
•Identify necessary resources
•Specify appropriate goals
•Recorded in one composite set of documentation
•For a resident who is a child include education requirements
Who is responsible for ICP?
 Statutory obligation that each resident must have an individual
care plan (ICP)
 Registered proprietor is charged with the responsibility,
however, all MDT are responsible according to their
professional ethical and legal obligations.
 Doctors are specifically mentioned in the MHA 2001 in the
preamble under “mental health service” which is “under the
clinical direction of a consultant psychiatrist” and under “
“treatment”, in relation to a patient, includes the administration
of physical, psychological and other remedies relating to the care
and rehabilitation of a patient under medical supervision,
intended for the purpose of ameliorating a mental disorder;”
 The patient as expert is responsible
Article 16 on therapeutic services
and programmes is dependent on
Article 15
 Article . Therapeutic Services and Programmes states:
“(1) The registered proprietor shall ensure that each
resident has access to an appropriate range of
therapeutic services and programmes in accordance
with his or her individual care plan.
(2) The registered proprietor shall ensure that
programmes and services provided shall be directed
towards restoring and maintaining optimal levels of
physical and psychological functioning of a resident.”
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Ethical and legal imperative, human rights based
Respect for patient dignity and right to a good life
Good practice, supports clinical reasoning
Better patient communication, co-operation and satisfaction
Good communication with family and helps to involve them in
their relatives care
Communication between multidisciplinary team and different
shifts
Improves measurement of progress towards all goals (outcome
oriented)
Clearer identification and analysis of problems (enables us to do
the right thing in a resource tight environment)
Easier to audit care and treatment provided
A collaborative between the service user and the treating team
It provides a written plan for the service user
Recommended by the MHC, NICE guidelines, Royal College of
Psychiatrists
It provides a multidisciplinary approach
Can save time in the long run
Its the law!
Recent Court Judgments
 Corrigan – v- HSE, 2011: “ The defendant assessed the
plaintiff and drew up a plan for her care. That plan was
reviewed on an ongoing basis by the nursing staff, the
medical staff and the multidisciplinary team”.
 PL and Respondents, 2012: The defendant reported that
:“it is in the applicant’s best interests to remain in the unit
so that the recommended care plan can be followed
through”;
 “what is determining his status is his expressed willingness
to comply with his care plan, which includes being treated
in the high obs area and taking his medication”.
How are we doing?
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A total of 63 approved centres
Full compliance was achieved by 33.3% in 2010
Comparison of 2011 with 2010 compliance with Article 15 (Individual Care Planning)
*Centres not registered in 2010
2010
2010
2011
2011
Compliance
Number
Percentage
Number
Percentage
Fully compliant
21
33.3%
39
61.9%
Substantially compliant
22
34.9%
5
7.9%
Minimal compliance
11
17.5%
2
3.2%
Non compliance
5
7.9%
17
27%
Not Applicable
4*
6.4%
0
0
How are we doing? - Common failings in
Care Plans
 “Not all residents had an individual care plan”
 “No specific goals/ goals not specified
 “No review date/ care plan not reviewed in a timely
way”
 “Vague”
 “Generic”
 “No evidence of input from the resident”
 “Care plan not signed by the resident”
 “No evidence that the resident was given a copy of
their care plan”
Duplication and confusion about ICP where no single integrated case file operates
Confusion between needs and goals
Goals not framed in behavioural terms and therefore interventions and
monitoring are vague
Resources and person responsible for action not identified
Needs which have been identified at the outset are forgotten and disappear from
the agenda
Patient strengths and supports are not included, not Recovery focussed
Family not included (where patient consents)
ICP focus is too narrow, in-patient focussed, symptom relief focussed, not
inclusive of holistic view of patient, does not extend to a community view
Address nursing and medical domains only
One shoe fits all, tokenism, empty paper exercise
Over reliance on standardised assessments
Too many goals listed at one time
ICP process is key
Engagement and shared responsibility
Assessment
Identification of Needs
Identification of goals and prioritisation
Implementation of the ICP
Monitoring
Review
Discharge planning
But where is the evidence to
support ICPs?
 Couldn’t find definitive evidence
 Service user satisfaction higher
 Some evidence that readmission rate reduced
 Outcome feedback in specialist mental health services
associated with symptom reduction
 ICP process is human rights driven and now required
by law and this trumps other considerations
Vignette A
 A 20 year-old single man is referred for emergency
admission by a general practitioner. He is perplexed,
frightened and expresses ideas of persecution, but is
unwilling to be admitted to hospital. He lives in a
student flat but has been threatened with eviction by
his landlord for non-payment of rent. He admits to
dabbling in illicit drugs.
Vignette B
 Mrs. X has been admitted to your unit following an overdose of hypnotic
medication which had been prescribed by her GP. She was found by her sister
who happened to call to the house.
 She is married with two teenage children, a son who “enjoys sports and is a real
extrovert” and a daughter who “is sensitive and has been treated for anorexia “.
Her husband ran a successful business which is now in receivership. Mrs. X is a
homemaker, involved in charities and a member of the local golf club. Mrs. X
described her working class childhood as generally happy, however, her father
drank heavily and to the extent that the family business was bankrupted. He
was violent at times. She left school at 16 years of age and married her
“childhood sweetheart” when she was 20 years old. She described her husband
as her “rock, he always takes care of everything, nothing is a problem”. She
stated that she is worried that they will lose their family home and that her
husband has shut off, will not talk about things. She said she has been worried
for over a year now.
 She considers that her children would be better off without her, that her sister
would be a better mother to them.
Focus our thoughts
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One multidisciplinary team per table and 15 minutes
Choose a vignette
Pick a role
Outline your ICP process
Discuss how you might approach the completion of the ICP for
this patient
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 Nominate a recorder for your group
 Identify and rank factors that help or hinder the ICP process
 10 minutes
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 General discussion - 10 minutes