Care Plans

Individual Personalised Care Plans

When a resident joins us at Orchard House, a tailored and individual care plan is created by the nursing team in consultation with the resident and where appropriate, their relatives.

 

The Care Plan is created to provide a programme of the best possible care for the individual and reflects the needs and choices of the resident. Care Plans are reviewed every four weeks and updated to reflect any changing needs and ensure that the objectives for health, personal and social care are appropriate. Each plan is developed with the involvement of the resident.

Families and relatives are encouraged to participate in the residents daily routine as far as is practicable, and are invited to formal reviews. Residents and their relatives are always welcome to discuss their progress, level of support and the care being provided.

Care Plan Review

All residents’ files, assessments, care plans, risk assessments and nutritional needs are personalized and are formulated to recognize the needs of the individual, whether related to culture, dignity, equality, diversity, their preferences, right to privacy or independence. Residents who have the capacity are encouraged to enter into an agreement by signing their care plan, which reflects their aims and aspirations whilst in our care. Residents have a note made within their care plan, which individually identifies if they can or cannot consent to treatment.  The care plan clearly states when a best interest decision is being made. Staff deliver the care to the care plans that have been discussed and entered into with the resident or the family/advocate, in the event of poor capacity. In turn relatives/advocates/staff can identify quickly when care is not to the agreed targets.

 

All residents will be offered an advanced care plan to reflect their wishes in their end of life or given the option to opt out if they do not want to participate.

 

When a service user /family have chosen to make end of life choices in their care an advanced care plan is formulated with the resident/family and professionals involved.  This in turn is communicated to the GP and out of hour’s link to promote the choices and rights of the individual.

 

Residents and their relatives are always welcome to speak with a member of care staff if they have any concerns.

 

The Care Plan is reviewed at the following levels:

 

• Daily on a shift-to-shift basis – Care Plan can be updated by the Nurse-in-Charge or senior carer.
• At the end of the four week settling-in period
• Thereafter a formal care plan review on a monthly – 3 monthly basis. Families are not necessarily invited unless large changes need discussing or the family request a meeting.

 

Any amendments and changes are agreed between the Home and the resident at the review or earlier if necessary. All care plans; reviews, risk assessments and professional visits are monitored to ensure all receive the same standard of service.

 

All amendments to the care plan will require the authorisation of the Manager; certain amendments may require the authorisation of the resident’s GP or Social Worker.