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CARE PLAN FOLDER CONTENT
Every care plan folder should include an Index - clearly indicating what is in the care plan,
this allows others to easily navigate their way to particular areas of the care plan. Ideally the
care plan folder should have dividers that match referencing.
As we all know there is no one way of setting up a care plan folder, this is guidance based
on good practice and can be used by you if you feel this is appropriate for you, your staff
and the people you support.
Good practice guidance suggests that a care plan folder should have 6 sections:
1. Initial Assessment
2. Person Centred Profile
3. Support and Risk Management Plans
4. Daily care notes and other professional notes
5. Risk Assessment Charts as required
6. Reviews
Each section will be described separately.
The fundamental principle to remember is that this care plan is for the
individual, it enables the individual to confirm and agree how they wish to
supported by staff - it is not a tool or a folder simply for staff - it belongs to the
individual.
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CARE PLANNING INDEX
Section 1
Initial assessment
■ How I communicate
■ My care and wellbeing
■ What is working/not working for me
■ Initial Assessment
Guidance notes for Section 1
● How I communicate (example)
● My care and wellbeing (example)
● What is working/not working for me (example)
● Initial Assessment (example)
Section 2
Person Centred Profile – This is about me
■ One page profile
■ All about me and my life
■ My circle of support
■ People I like to stay in contact with
■ What is important to me
■ To support me you need to know me
■ End of life support
■ Good/bad days
■ How I make decisions
■ Likes/dislikes
■ Service users signature
Guidance notes for section 2
● Person centred profile guidance
● All about me and my life (example)
● My circle of support (example)
● People I like to stay in contact with (example)
● What is important to me (example)
● To support me you need to know me (example)
● End of life support (example)
● Good/bad days (example)
● How I make decisions (example)
● Likes/dislikes (example)
● Service users signature (example)
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Section 3
Support Plans and Risk Management Plans
■ Care plan at a glance
■ My Daily Routine
■ Care Support Plan (generic)
■ Communication
■ Medication and pain management
■ Personal Care and Dressing
■ Risk Assessment
■ Risk Management Plan
Guidance notes for section 2
Examples for Older persons and Physical disability
● Communication
● Medication and pain management
● Personal Care and Dressing
Examples for Learning disabilities
● Communication
● Medication and pain management
● Personal Care and Dressing
Section 4
Daily Care Notes and other professional notes
● Daily Care Notes
● Residents daily log report
● Monday
● Tuesday
● Wednesday
● Thursday
● Friday
● Saturday
● Sunday
Section 5
Risk Assessment Charts Guidance
Section 6
Reviews record
Guidance on reviews
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How I communicate verbally
Gestures I may use and what this may mean
Body Language and what this may mean – how I may sit, stand, facial expressions etc.
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HOW I COMMUNICATE WITH OTHERS
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(CONTINUED)
Behaviour and what this may mean – how will you know I am happy, how will you know I am sad, what do I
say when I am angry
Other ways I may communicate – example other communication support I may use
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HOW I COMMUNICATE WITH OTHERS
My medical well being
I have the following medical diagnosis:
What do I not want to happen:
My social well being
How you can support my social well being
What do I not want to happen
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MY CARE AND MY WELL BEING
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(CONTINUED)
My emotional well being
How you can support my emotional well being
What do I not want to happen:
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MY CARE AND MY WELL BEING
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INITIAL ASSESSMENT
What’s working for me right now?
What is not working for me right now?
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Personal Information for
My Full Name
My First Name
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Other names I have
My Surname
I like to be called
Previous Address
Current Address
My Date of Birth
My Nationality
My relationship status
My religious beliefs
My Maiden Name
My previous occupation
Details of my immediate next of Kin
Contact for person holding Lasting Power of Attorney if applicable
Reason that I have been referred for care and support
Date of referral
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Eye Colour
Height
Hair Colour
Weight
Build
My sensory needs
Any known allergies I have
Any special needs / comments I have
Any concerns I have regarding pressure sores or skin concerns
Emergency Contact Details
Emergency Contact should I need someone to represent my best interest for care and
support
Other Family Contact details I want you to know
Any Other contact details for me
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Health Service contact details
My GP Contact Details
My Hospital Contact Details
My Physiotherapist Contact Details
My speech and language therapist Details
My Occupational Therapist Contact Details
My Consultant Contact Details
Any Community Team Details
My Care Manager Details
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Other contact details I need you to know
My Medical History
My nutritional needs and any existing dietary requirements
Please tell us if you are self
medicating
Medication / Dosage
Instructions
Start Dates
Notes
Further Information
Medication / Dosage
Instructions
Start Dates
Further Information
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Yes / No
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Signed by Service User…………………………………………….Date
The following people have supported me in this initial assessment
Signed by relevant staff member................................................ Date
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ONE PAGE PROFILE
How best to support me when I need
help
Things that are important to me
Insert photo here
PaCT Care Plan template Text_revise
............................................. ........................................
12/3/12
09:35
Page 1
What those who know me
say they like and admire
about me?
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ALL ABOUT ME AND MY LIFE
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MY CIRCLE OF SUPPORT
WHO IS IN MY LIFE
This could be health
professionals, day centre
staff
This could be other
family, friends,
neighbours
People Closest to me.
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PEOPLE I LIKE TO STAY IN CONTACT WITH
Name:
Address:
Birthdays:
Name:
Address:
Birthdays:
Name:
Address:
Birthdays:
Name:
Address:
Birthdays:
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WHAT IS IMPORTANT TO ME?
What Is Important
to Me?
Support I Need To Make This Happen
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How to support me in maintaining my relationships and friendships
This is why I need support
This is what I can do for myself
This is what I need you to help me
with
This is what I can do for myself
This is what I need you to help me
with
Fitness and Mobility Support
This is why I need support
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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS
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(CONTINUED)
My personal care support
This is why I need support
This is what I can do for myself
This is what I need you to help
me with
This is what I can do for myself
This is what I need you to help
me with
My medication support
This is why I need support
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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS
(CONTINUED)
Getting up and going to bed
This is why I need support
This is what I can do for myself
This is what I need you to help
me with
This is what I can do for myself
This is what I need you to help
me with
My eating and drinking support
This is why I need support
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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS
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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS
(CONTINUED)
Staff support
How would you like staff to
approach you and treat you?
What are you concerns about coming here and how staff will support
you?
Other areas of support as required
This is why I need support
This is what I can do for myself
This is what I need you to help
me with
(CONTINUED)
Looking after my environment
This is why I need support
This is what I can do for myself
This is what I need you to help
me with
This is what I can do for myself
This is what I need you to help
me with
Activities I like and hobbies
This is why I need support
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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS
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(CONTINUED)
My sexuality
This is why I need support
This is what I can do for myself
This is what I need you to help
me with
This is what I can do for myself
This is what I need you to help
me with
Looking after my finances
This is why I need support
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TO SUPPORT ME IN MY LIFE YOU NEED TO KNOW THIS
Please tell us about any arrangements you currently
have in place, including whether you have a Will.
If you do not have anything in place how would you
like us to support you with any arrangements?
Do you have any specific spiritual beliefs that you
would like support with?
Who would you like with you?
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MY END OF LIFE PLAN
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(CONTINUED)
Should this situation arise who else would you like us
to contact to let them know?
If you do not have anyone who can support you would
you like us to support you with an advocate or
befriending service to offer support?
Would you like any special arrangements in your room?
Would you like any other special arrangements?
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MY END OF LIFE PLAN
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PERSON CENTRED PROFILE
The Following are examples of what a good day is for me – please
help me to have good days
The Following are examples of what a bad day is for me – please
help me NOT to have a bad day
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HOW I MAKE MY DECISIONS
Please work from the basis that I want to be involved in all of my decisions
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MY LIKES & DISLIKES
Activities/Leisure
I Like
I Dislike
Food/Drink
I Like
I Dislike
Anything Else
I Like
I Dislike
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Signed by Service User ........................................................ Date
The following people have supported me in this assessment and it forms part of
my agreed care plan
Signed by relevant staff member ........................................................ Date
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12/3/12
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My Support plan in brief
My health
and well
being
My
Communication
My mobility
and safety
My physical health
is good
I have no known
allergies
Page 9
Highlight all appropriate boxes
I have several
I have diabetes
conditions that cause
me difficulties
I am allergic to :I self medicate
I am happy to take
my medication
I need you to
observe me for
signs of pain
I am able to
verbalise all my
wishes
I do not like to take I suffer with pain
my medication
I have a dementia
I have good
understanding of
what is said to me
I can become
confused and
muddled / anxious
at times
I have limited
understanding of
what is said to me
I can become
confused and cross
at times
I need assistance
with my
medications
I am able to tell you
about my pain
I have limited ability I use sign / gestures I am not able to
to make wishes
/ body language to communicate my
known
communicate my
wishes
wishes
I have a good
memory
I have a poor
memory
I can be verbally
aggressive at times
I can be physically
aggressive at times
I have good eye
I have poor eyesight I wear glasses all
sight
the time
I have good hearing I have poor hearing I wear hearing aid
in left ear
I can use the nurse I am unable to use
call system
the nurse call system
I am fully mobile
I have good balance I have poor balance
I have restricted
mobility
I need assistance of
1 person walk /
transfer
I am cared for in
bed
I am at risk of falls
I have epilepsy
I use a walking stick I use a walking
frame
I need assistance of I use the hoist to
2 people to transfer transfer
I have bed rails when
in bed
I would find stairs
dangerous
I eat a soft diet
I am able to move
myself in bed
I am at risk of
leaving the building
I eat a puree diet
I would like my
food cut up
I eat a diabetic diet I need a fortified diet I have food
restrictions
I have thickened
I have a good
I have a small
fluids
appetite
appetite
I have a PEG/ PEJ
I am unable to take I need assistance
feed
diet or fluids
with eating and
drinking
I wear glasses for
reading
I wear hearing aid
in Right ear
I can transfer
independently
I use a wheelchair
I forget that I need
help
I need assistance to
move in bed
I smoke
I am at risk of
choking
I drink normal fluids
I have adapted
cutlery
I need assistance
with mouth care
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My personal
care
12/3/12
I am fully
independent
I prefer to bath
I need assistance
with oral hygiene
My
continence
My Skin
Care
At night
EOL wishes
09:35
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I need a little
assistance from 1
person with some
aspects of personal
care
I prefer to shower
I wear dentures
I am able to use the I need assistance to
toilet independently reach the toilet
I am doubly
incontinent
My skin is healthy
I am at risk of skin
breakdown
I wear continence
aids
My skin is dry /
fragile
I need assistance to
reposition to
prevent skin
breakdown
I am independent
My night time needs
and abilities are the
same as in the day
I am continent
I get up during the
during the night
night to use the
toilet
I am incontinent at I use continence aids
night
I sleep poorly
I take medication to
help me sleep
I wish staff to
I do not wish staff to
attempt
attempt resuscitation
resuscitation
I need full
assistance of 1
person with most
aspects of personal
care
I prefer female care
staff
I need assistance
with shaving
I am unable to
participate and
need full help of 2
people
I prefer male care
staff
I like to wear
jewellery and/ or
make up
I am sometimes
I am sometimes
incontinent of urine incontinent of
faeces
I have a catheter
I have a stoma
My skin is
I like / need to have
oedematous
cream applied
I use pressure
I have a wound/s
relieving equipment
I need more
assistance at night
when I am tired
I like to use a
commode at night
I like to choose
when I go to bed
and get up
I use a bottle
I can use the nurse I sleep well at night
call system
I like the bed rails
up
DNACPR is in
place
Other comments / things I would like you to know
My preferred daily routine
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Staff Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . .
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MY DAILY ROUTINE
If I have one I would like to complete this
Time
Routine
Support I may need to do this
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Name of individual
Place of residence
Date of birth
Support plan completed by
Date of completion
Scheduled next review
What are my Abilities, What can I do?
What are the Outcomes I wish to
achieve?
What do I need support with?
How can my needs be met by the care staff
The following people have supported me in this assessment
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Signed by Service User ........................................ Date
Signed by relevant staff member ........................................ Date
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SUPPORT PLAN
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Name of individual
Place of residence
Date of birth
Support plan completed by
Date of completion
Scheduled next review
What are the Outcomes I wish to
achieve?
What do I need support with?
How can my needs be met by the care staff
Communication
What are my Abilities, What can I do?
The following people have supported me in this assessment
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Signed by Service User ........................................ Date
Signed by relevant staff member ........................................ Date
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SUPPORT PLAN
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Name of individual
Place of residence
Date of birth
Care plan completed by
Date of completion
Scheduled next review
What are the Outcomes I wish to
achieve?
What do I need support with?
How can my needs be met by the care staff
Medication Support and pain relief
What are my Abilities, What can I do?
The following people have supported me in this assessment
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Signed by Service User ........................................ Date
Signed by relevant staff member ........................................ Date
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SUPPORT PLAN
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Name of individual
Place of residence
Date of birth
Care plan completed by
Date of completion
Scheduled next review
What are the Outcomes I wish to
achieve?
What do I need support with?
How can my needs be met by the care staff
Mobility
What are my Abilities, What can I do?
The following people have supported me in this assessment
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Signed by Service User ........................................ Date
Signed by relevant staff member ........................................ Date
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SUPPORT PLAN
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Name of individual
Place of residence
Date of birth
Care plan completed by
Date of completion
Scheduled next review
What are the Outcomes I wish to
achieve?
What do I need support with?
How can my needs be met by the care staff
Personal care and dressing needs
What are my Abilities, What can I do?
Personal care
Hair washing
Denture / teeth care
Makeup and creams
Dressing
The following people have supported me in this assessment
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Signed by Service User ........................................ Date
Signed by relevant staff member ........................................ Date
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SUPPORT PLAN
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Risk Assessment Details
1. What is the
decision or
choice to be
made?
2. What are the
potential
benefits?
3. How likely are
these to be
achieved?
4. What could go
wrong? Is there a
possibility that
anyone may be
harmed?
Please complete additional sheet for any other choices/decisions to be considered
5. a) How likely
is this to occur?
b) If something
went wrong,
what would the
severity of the
outcome be?
6. What are the
existing factors
which promote
benefit and
reduce the
chances of
anything going
wrong?
7. What
additional actions
would promote
benefit and
reduce the
chances of
something going
wrong?
8. What risks will
remain after
action plan is in
place?
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RISK ASSESSMENT
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Risk Assessment Details
1. What is the
decision or
choice to be
made?
2. What are the
potential
benefits?
3. How likely are
these to be
achieved?
4. What could go
wrong? Is there a
possibility that
anyone may be
harmed?
Please complete additional sheet for any other choices/decisions to be considered
5. a) How likely
is this to occur?
b) If something
went wrong,
what would the
severity of the
outcome be?
6. What are the
existing factors
which promote
benefit and
reduce the
chances of
anything going
wrong?
7. What
additional actions
would promote
benefit and
reduce the
chances of
something going
wrong?
8. What risks will
remain after
action plan is in
place?
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RISK ASSESSMENT
Risk Management Plan: Please give details of actions agreed which will promote benefits and reduce the chances of something
going wrong, and specifically how risks remaining identified (column 8) could be managed and who will be responsible for these.
Risk Management Plan - Action agreed
Who will be responsible
When will this be reviewed
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RISK MANAGEMENT PLAN
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(CONTINUED)
Please complete additional sheet for any other actions agreed
Back up Plan - What could go wrong?
Action agreed
Who will be responsible
The following people have supported me in this assessment
Signed by Service User ........................................ Date
Signed by relevant staff member ........................................ Date
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RISK MANAGEMENT PLAN
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I (complete name:)
. …………………………………………………………………………………..
confirm that I have contributed and consent to the content of each of the following plans:
(Complete plan titles)
1.
2.
3.
4.
5.
6.
Signed:
Dated:
================================================================
I ……………………………………………………………………………………….
Representative of service named:
…………………………………………………………………………………………
having carried out an assessment** recorded it and my rationale, can confirm that the
following plans were unable to be consented to by:
…………………………………………………………………………………………..
and that they have therefore been developed and will be followed with the person’s best
interest in mind at all times.
(Complete plan titles)
1.
2.
3.
4.
5.
6.
Signed:
Dated:
**consider using the Hampshire County Council Mental Capacity Toolkit
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DAILY CARE NOTES
Name of service user: ..................................................
Date
Report
Signature
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SUPPORT PLAN REVIEW RECORD
Service Users name:
Date
Comments
D.O.B
Signatures:
Service User
Relative
Care Manager
Key Worker
Other People present
and involved
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SUPPORT PLAN REVIEW RECORD
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(CONTINUED)
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INITIAL ASSESSMENT
What’s working for me right now?
What is not working for me right now?
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