Page 1 of 23 aspecmaps.free.fr/NVQ3/HSC3020.pdf …aspecmaps.free.fr/NVQ3/HSC3020.pdf · 1.3 Describe ways the assessment and planning process or documentation can be adapted to maximise

Page 1 of 23 aspecmaps.free.fr/NVQ3/HSC3020.pdf

Facilitate person centred assessment, planning, implementation and review by Gaël Romanet.



HSC 3020 - Facilitate

person centred

assessment, planning,

implementation and review

Unit purpose and aim

This unit is about knowledge and skills required to facilitate person centred assessment, planning, implementation and review.



Task 1 - Understand the principles of person centred assessment and care planning

1.1 Explain the importance of a holistic approach to assessment and planning of care or support (See page 8 to

10)

1.2 Describe ways of supporting the individual to lead the assessment and planning process (See page 11 to 12)

1.3 Describe ways the assessment and planning process or documentation can be adapted to maximise an

individual’s ownership and control of it (See page 13 to 18)

Task 2 - Be able to facilitate person centred assessment

2.1 Establish with the individual a partnership approach to the assessment process (See report by NVQ3 trainer)

2.2 Establish with the individual how the process should be carried out and who else should be involved in the

process (See report by NVQ3 trainer)

2.3 Agree with the individual and others the intended outcomes of the assessment process and care plan (See

report by NVQ3 trainer)

2.4 Ensure that assessment takes account of the individual’s strengths and aspirations as well as needs (See


2.5 Work with the individual and others to identify support requirements and preferences (See report by NVQ3

trainer)



Task 3 - Be able to contribute to the planning of care or support

3.1 Take account of factors that may influence the type and level of care or support to be provided (See report by

NVQ3 trainer)

3.2 Work with the individual and others to explore options and resources for delivery of the plan (See report by

NVQ3 trainer)

3.3 Contribute to agreement on how component parts of a plan will be delivered and by whom (See report by

NVQ3 trainer)

3.4 Record the plan in a suitable format (See report by NVQ3 trainer)

Task 4 - Be able to support the implementation of care plans

4.1 Carry out assigned aspects of a care plan (See report by NVQ3 trainer)

4.2 Support others to carry out aspects of a care plan for which they are responsible (See report by NVQ3 trainer)

4.3 Adjust the plan in response to changing needs or circumstances (See report by NVQ3 trainer)



Task 5 - Be able to monitor a care plan

5.1 Agree methods for monitoring the way a care plan is delivered (See report by NVQ3 trainer)

5.2 Collate monitoring information from agreed sources (See report by NVQ3 trainer)

5.3 Record changes that affect the delivery of the care plan (See report by NVQ3 trainer)

Task 6 - Be able to facilitate a review of care plans and their implementation

6.1 Seek agreement with the individual and others about; who should be involved in the review process; criteria to

judge effectiveness of the care plan (See report by NVQ3 trainer)

6.2 Seek feedback from the individual and others about how the plan is working (See report by NVQ3 trainer)

6.3 Use feedback and monitoring/other information to evaluate whether the plan has achieved its objectives (See


6.4 Work with the individual and others to agree any revisions to the plan (See report by NVQ3 trainer)

6.5 Document the review process and revisions as required (See report by NVQ3 trainer)

Task 7 – Be able to carry out an assessment process regarding the review and update of care plan within care setting

7.1 Write reflection related to the assessment process regarding the review and update of care plan within care

setting (See page 19 to 23)



Exemplification – HSC 3020

The individual is the person requiring care or support. An advocate may act on behalf of an individual

Others may include; Carers; Friends and relatives; Professionals; Others who are important to the individual’s wellbeing

A care plan may also be known by other names, such as a support plan, individual plan or care delivery plan, my day my life

care plan. It is the document where day to day requirements and preferences for care and support are detailed

Factors may include; Feasibility of aspirations; Beliefs, values and preferences of the individual; Risks associated with

achieving outcomes; Availability of services and other support options

Options and resources should consider; Informal support; Formal support; Care or support services; Community facilities;

Financial resources; Individual’s personal networks

Revisions may include; Closing the plan if all objectives have been met, reducing the level of support to reflect increased

independence, increasing the level of support to address unmet needs, changing the type of support, changing the method of

delivering support



Assignment task – HSC3020 Answers

Task 1 - Understand the principles of person centred assessment and care planning

What is the person centred approach?

The person centred approach is a way of working developed from the work of the psychologist Dr Carl Rogers

(1902 – 1987). In health and social care settings, the person centred approach is a way of working that put the individual at the

heart of the care planning process. This will provide a framework for the individual to plan and set a direction of their care

planning process according to the individual's physical and psychological needs, spiritual beliefs, culture, likes and dislikes,

family and friends. The person centred approach method is linked with the active participation method, which is a way of

working that recognises an individual’s right to participate in the activities and relationships of everyday life as independently as

possible; the individual is regarded as an active partner in their own care or support, rather than a passive recipient.



1.1 Explain the importance of a holistic approach to assessment and planning of care or support (3 pages to

answer the question – Page 8 to 10)

What is a holistic approach?

A holistic approach is a term referring to a healthcare philosophy in which the entire individual is evaluated and

treated. It means taking into consideration all the aspects of the human being, regarding wellbeing e.g. the physical, the

emotional, the mental, the spiritual, and the social needs. It’s the concept that the human being is multi-dimensional. We have

conscious and unconscious aspects, rational and irrational aspects. We are a body mind. Not just intellect, but emotion,

instinct, intuition, as well. To resume, a holistic approach regarding assessment and planning of care or support means

showing interest regarding to engage and to develop the whole wellbeing of the individual that include the physical, the

emotional, the mental, the spiritual and the social needs.



I am working as a senior care assistant. Within the health and social care work setting, the importance of a holistic

approach to assessment and planning of care or support means staff to ensure an effective holistic approach to assessment

and planning of care or support through identifying individuals' concerns and needs that will lead; to a whole picture regarding

the individuals’ wellbeing through needs and supports e.g. referrals for an individual with eating disorders or loss of weight and

lack of nutrition associated with a chronic illness; to better diagnosis of consequences of care provided; to improved

communication and better equity of care.

The holistic approach to assessment and planning of care or support ensure that the whole individuals’ wellbeing regarding the

physical, the emotional, the mental, the spiritual and the social needs are met in a timely and appropriate way, and that

resources are targeted to those who need them most. The information gathered from a holistic approach to assessment and

planning of care or support can also be shared with others (Carers; Friends and relatives; Professionals; Others who are

important to the individual’s wellbeing) to improve an individual’s management and care, and the data collected can influence

commissioning of future services.

Duty of staff to promote a holistic approach to assessment and planning of care or support; will ensure a centred person

approach that will put the individual at the heart of the care planning process - centred person approach mean the way staff

approach and support individuals and families and each other as workers, the aim is to ensure that in all of staff approaches

staff work hard to demonstrate person centred values and offer assistance in a way that enhances equal citizenship for the

individuals; will help staff to encourage the individual when providing active participation - active participation is a way of

working that recognises an individual’s right to participate in the activities and relationships of everyday life as independently as

possible, the individual is regarded as an active partner in their own care or support, rather than a passive recipient; will ensure

an active participation regarding the holistic needs of an individual e.g. the physical, the emotional, the mental, the spiritual and

the social needs; will help staff regarding theories of motivation and changing behaviour; will help staff regarding using

incentives through highlighting advantages and benefits of active participation by recording the outcome into the individual's

care plan; will help staff to work within the person centred values (individuality, rights, choice, privacy, independence, dignity,

respect, partnership) - person centred values is a set of values that are firmly based in citizenship and inclusion, advocating

that everyone has the right to exercise choice and control in directing their lives and support, this includes designing good

support that will assist individual to do this in a way that makes sense for the individual; will help staff to provide useful

information and choice e.g. asking to the individual to read the menu and to make choice regarding foods and fluids; will help

staff to set meeting involving staff and the individual, carers, friends and relatives, professionals, others who are important to

the individual e.g. N.O.K, social worker, advocates, GP - regarding to maintain the mobility, wellbeing, independence, and self-

esteem of the individual; will help staff to ensure effective communication according to the individual preferred method of

communication; will help staff to write individual's care plan through centred person approach that includes the individual in the

centre of the care planning process - this will promote active participation by enhancing the individual's wellbeing by feeling

valued as part of the care team.



What are the factors that contribute to the wellbeing of

an individual?

Factors that contribute to the wellbeing of an individual are the following; emotional; relational; physical; financial;

intellectual; environmental; vocational; career; spiritual.

Other factors that contribute to the wellbeing of an individual living within a health and social care sector may include aspects

that are; cultural e.g. staff to respect and to promote the individual's likes and dislikes, choices and preferences; religious e.g.

individuals going to the Church, means relationships with other individuals sharing the same religion, belief, faith; social e.g.

staff to promote inclusion through group activities with other individuals; political e.g. individuals voting for elections; emotional

e.g. individuals having close bonds with own family and friends, sharing good memories, looking at photos. Others values that

underpin within my work setting and contribute to the wellbeing of individuals through the rights; to be treated as an individual;

to be treated equally and not be discriminated against; to be respected; to have privacy; to be treated in a dignified way; to be

protected from danger and harm; to be supported and cared for in a way that meets their needs, takes account of their choices

and also protects them; to communicate using their preferred methods of communication and language; to access information

about themselves.



1.2 Describe ways of supporting the individual to lead the assessment and planning process (2 pages to answer

the question – Page 11 to 12)

What is an assessment?

An assessment is a plan of care that identifies the specific needs of an individual requiring care or support and how

those needs will be addressed by the health and social care work setting. An assessment is the evaluation of the health status

through questions asked to the individual that take into account; the individual' health history, wishes and preferences regarding

care needs; take into account others who are important to the individual’s plan of care e.g. carers, friends and relatives,

professionals, N.O.K, social worker, advocates, GP - regarding to maintain the mobility, wellbeing, independence, and self-

esteem of the individual. An advocate may act on behalf of an individual if the individual lack cognitive impairment e.g. living

with Alzheimer dementia. A care plan may also be known by other names, such as a support plan, individual plan or care

delivery plan, my day my life care plan. It is the document where day to day requirements and preferences for care and support

are detailed. Wellbeing include aspects that are; emotional; relational; physical; financial; intellectual; environmental; vocational;

career; spiritual; cultural; religious; social; political; to be treated as an individual; to be treated equally and not be discriminated

against; to be respected; to have privacy; to be treated in a dignified way; to be protected from danger and harm; to be

supported and cared for in a way that meets their needs, takes account of their choices and also protects them; to

communicate using their preferred methods of communication and language; to access information about themselves.

What is a planning process?

Within the health and social care work setting, a planning process means how the care needs will be provided

according to the individual's plan of care assessment. A planning process ensure the good delivery of the care needs according

to the individual' health history, wishes and preferences regarding care needs as documented in the individual's plan of care

assessment. A planning process sets how the care needs will be provided day to day.



Ways of supporting the individual to lead the assessment and planning process; mean staff promoting Active

Participation - A way of working that recognises an individual’s right to participate in the activities and relationships of everyday

life as independently as possible, the individual is regarded as an active partner in their own care or support, rather than a

passive recipient; mean staff promoting Person Centred Values - A set of values (individuality; rights; choice; privacy;

independence; dignity; respect; partnership) that are firmly based in citizenship and inclusion, advocating that everyone has the

right to exercise choice and control in directing their lives and support. This includes designing good support that will assist

individual to do this in a way that makes sense for the individual; mean staff promoting Person Centred Approaches - The way

we approach and support individuals and families and each other as workers. The aim is to ensure that in all of our approaches

we work hard to demonstrate person centred values and offer assistance in a way that enhances equal citizenship for

individuals; mean staff promoting Person Centred Thinking - A range of useful questions or tools that form the basis of Person

Centred Planning. They help to focus on the individuals, their gifts and skills, what is important to them and what makes good

support for them; mean staff promoting Person Centred Planning - A continual process of listening to what is important to the

individual now and in the future with the support of family and friends and creating action or changes based upon this; mean

staff promoting Person Centred Reviews - A process that can be used as a statutory review which looks at the individual’s life

and supports, what is working and not working and what needs to change now and in the future to create outcomes that are

right for the individual; ; mean staff promoting Family Centred Care - An approach to the planning, delivery, and evaluation of

care needs that is based on a strong, effective, and respectful partnership between the family and the health and social care

work setting. Family Centred Care for children with special care needs is associated with improved health and wellbeing,

improved satisfaction, greater efficiency, improved access, better communication, better transition services, and positive

outcomes.



1.3 Describe ways the assessment and planning process or documentation can be adapted to maximise an

individual’s ownership and control of it (6 pages to answer the question – Page 13 to 18)

Within the health and social care work setting, ways the assessment and planning process or documentation can be

adapted to maximise an individual’s ownership and control of it mean staff to work in a centred person approach and active

participation way. By promoting a person centred approaches that include the individual requiring care or support at the heart of

the care planning process will also promote active participation by enhancing the individual's wellbeing by feeling valued as part

of the care team. To maximise an individual’s ownership and control of the assessment and planning process or

documentation; mean the assessment and planning process or documentation are adapted to the individual's preferred method

of communication and preferred language; mean staff ensure Person Centred Values; mean staff working in a way that

promote person centred care through Person Centred Thinking, Person Centred Planning, Person Centred Reviews, Family

Centred Care; means staff to provide care needs that are respectful and responsive to an individual's preferences, needs, and

values, and ensure that the individual values guide all care need decisions according to the individual's cognitive impairments;

mean staff doing everything that is possibly possible to ensure the individual understands the assessment and planning

process or documentation, this will ensure custom care needs, for example, the assessment and planning process or

documentation can be adapted to maximise an individual’s ownership and control of it e.g. staff using communication album

such as books with large pictures (aid memoir personal communication, aid memoir medical communication, aid memoir daily

life communication, aid memoir food communication) that describe the questions or choices to enable the individuals that lack

mental capacity (individuals living with Alzheimer dementia) to understand the assessment and planning process or

documentation.



What is a shared decision making?

Below is an example of model that shows how the influences, expertise and roles of staff and individuals should

inform shared decision making.

Individual’s influences Staff’s influences

Own desires, ambitions, and priorities Care guidelines and policies

Commitments in life Workplace procedures

Friends and family opinions Availability of local services

Personal past experiences Medical expertise and evidence

Self-knowledge of treatment Allocated budget

Own research, including on Internet Workplace targets

Individual’s expertise Staff’s expertise

Set out impact of condition regarding: Set out treatment and opinions, such:

Own desires, ambitions and priorities Likely outcomes

Set out combined impact regarding: Individual role in treatment

Physical and mental health conditions Exchange Value of treatment

Understand impact from friends and family Information Recommends preferred treatment

Is aware of treatment

Individual input: Staff input:

Decision Shared Decision

Decision



What is Person Centred Planning?

Within the health and social care work setting, a person centred planning is a set of approaches designed to assist

an individual to plan their life and supports. It is used most often as a life planning model to enable individuals with disabilities

or otherwise requiring support to increase their personal self-determination and improve their own independence. (Page 16

Template of Person Centred Planning). Person centred planning is a process of constant review, learning and listening. Person

centred planning focuses on the immediate and the future, taking into account the needs, thoughts, concerns and opinions of

the individual, and consulting others that include carers, friends and relatives, professionals, and others who are important to

the individual’s wellbeing.

Person Centred Planning is an approach to organising assistance to individuals with intellectual disabilities. Developed over

nearly thirty years in the United States of America, it has recently assumed particular importance in England because it forms a

central component of the 2001 White Paper Valuing people. John O'Brien is a leading thinker who has written widely in the field

of disability. He is a pioneer and lifelong advocate of Person Centred Planning. His values based approach emphasises

learning with each individuals about the direction their lives could take, challenging and overcoming practices, structures and

values that lead to segregation and underestimation rather than inclusion, and an approach to change in individual's lives

based on the idea of "imagining better". His thinking is based on Social Role Valorisation (See page 17) and the Social Model

of Disability (See page 18).

Person Centred Planning takes into account the eight person centred values, also called the 8 Core Care Values, which are an

agreed set of principles that are believed to be the foundation of all good care practice and provide care workers with an agreed

set of principles and standards by which care workers benchmark their practice which ensures they conduct themselves in a

way that embraces these principles. The 8 Core Care Values are the following: individuality; rights; choice; privacy;

independence; dignity; respect; partnership.





What is Social Role Valorisation?

Within the health and social care work setting, Social Role Valorisation is the name given to an analysis of human

relationships and human services, formulated in 1983 by Wolf Wolfensberger, as the successor to his earlier formulation of the

principle of Normalization - Normalization refers to social processes through which ideas and actions come to be seen as

normal and become taken-for-granted or natural in everyday life.

Social Role Valorisation is theory based on the idea that society tends to identify groups of individuals (Individuals with learning

disability, children in care, the elderly, physically disabled, psychiatric patients, and ethnic minorities) fundamentally different

and of less value than everyone else. It catalogues the methods of this devaluation and analyses its effects. The emphasis of

Social Role Valorisation is to prevent individuals with learning disability being cast in damaging social roles and to establish

them in positive or culturally valued social roles in all areas of life by making available to individuals with learning disability

patterns and conditions of everyday life which are as close as possible to the norms and patterns of mainstream society. The

principles of Social Role Valorisation require service providers to ensure that disadvantaged individuals have opportunities to

enjoy the positive life experiences which other individuals in the society in which they live, also enjoy. Social Role Valorisation

is a powerful set of ideas useful in addressing the marginalization of individuals in society by supporting them to have access to

the same good things in life enjoyed by typical individuals.

Below is a caricature of Stephen William Hawking, an English theoretical physicist, cosmologist, author and Director of

Research at the Centre for Theoretical Cosmology within the University of Cambridge. Stephen William Hawking suffers from a

rare early-onset, slow-progressing form of Amyotrophic Lateral Sclerosis (ALS), commonly known as motor neurone disease in

the UK, that has gradually paralysed him over the decades. He now communicates using a single cheek muscle attached to a

speech-generating device. Hawking married twice and has three children.



What is the Social Model of Disability?

The social model of disability says that disability is caused and made worse by societies’ attitudes and how it is

organised, rather than by a person’s own impairment or difference. It looks at ways of removing barriers that restrict life choices

for disabled individuals. When barriers are removed, disabled individuals can become more independent and equal in society,

with real choices and control over their own lives.

Disabled individuals themselves developed the social model of disability because the traditional model did not explain their

personal experience of disability or help to develop more inclusive ways of living.

Traditional model of disability shows problems born of assumptions, stereotypes and labels e.g. special schools, charity,

sympathy, special transports, doctors, medical treatment, educational psychologists, social workers, rehabilitation centres,

occupational therapists, speech therapists, physiotherapists, sheltered workshops.

The social model of disability shows barriers born of ignorance, fear, stigma, lack of education and knowledge, inflexible

employment, underestimated/devalued, inaccessible information, inaccessible transport, inaccessible facilities, lack of

employment, inflexible employment, sheltered workshops, segregated services, medicalised, overprotected/hidden in homes by

families, lack of social network.



Task 7 – Be able to carry out an assessment process regarding the review and update of care plan within care setting

7.1 Write reflection related to the assessment process regarding the review and update of care plan within care

setting (5 pages to answer the question – Page 19 to 23)

The following is a reflection related to the assessment process that I carried out on Sunday 17th April 2016 regarding the

review and update of care plan for one of my resident within my care setting - which includes the beginning, the middle, and the

end of the assessment process.

Assessment process regarding the review and update of

care plan for Mr F D – Medical history

I am working as a senior care assistant. Within my health and social care setting for individuals living with Dementia,

Mr F D is an individual; living with early Alzheimer Dementia that affects his cognitive impairments; living with a history of a

minor stroke that affects the right side of his body, and speech impairments. Despite his medical history, Mr F D is well aware of

the daily routine within my care setting, and he is able to express verbally in English in a formal and informal manner his wishes

and preferences regarding his daily needs, choices and decisions over care. Mr F D is mobilising; for long distance using his

personal wheelchair; using his personal Zimmer frame for transfer from the bed/chair to wheelchair assisted by two members of

staff that ensure his safety. Mr F D is note safe to self-medicate – he needs to be assisted by senior care staff regarding

administration of his medications as prescribed on his M.A.R sheet by the GP. Mr F D is; double continent; eating and drinking

independently; free of problems regarding breathing and circulation. Mr F D was on Sunday 17th April 2016 the resident of the

day – which means, duty of staff to review and update his care plan, which allows; the staff to know how he is feeling within my

care setting regarding daily routine; updates regarding his person centred care planning; improvement and other referral if

needed, with his consent.




care plan for Mr F D – The beginning of the assessment

process

Within my health and social care setting for individuals living with Dementia - the beginning of the assessment

process regarding the review and update of care plan for Mr F D includes; ways to establish with Mr F D a partnership

approach to the assessment process; mean staff to ensure an active listening approach with Mr F D that improves mutual

understanding during the assessment process e.g. listening to what is important for Mr F D regarding his preferences, hopes

and concerns, and his own ideas for what might work; mean staff to promote effective communication with Mr F D that

encourages reflection, shared decision making, open questions and sometimes negotiation; mean staff to ensure shared

decision making through the assessment process to understand what is important for Mr F D e.g. night staff to ensure his

SUDOCREM is applied on his right ankle before to go to bed and after personal cares on the morning; mean staff to take into

account consideration of the anxieties that Mr F D can have regarding the assessment process e.g. due of his cognitive

impairments, Mr F D lacks confidence/has lower levels of health literacy and activation so he needs more encouragement and

support to participate in the assessment process; mean staff to take into consideration the importance of helping Mr F D to

understand how the assessment process is structured e.g. staff need to consider how they might tailor their approach to suit

the different levels of knowledge, skills and confidence that Mr F D has; mean staff to carried out the assessment process in a

centred person approach that puts Mr F D at the heart of the assessment process e.g. staff to promote a holistic approach to

the assessment process to ensure the whole Mr F D’ wellbeing regarding the physical, the emotional, the mental, the spiritual

and the social needs are meet; mean staff to take into consideration of factors that contribute to the wellbeing of Mr F D e.g.

emotional, relational, physical, financial, intellectual, environmental, vocational, career, and spiritual; mean staff to carried out

the assessment process if possible with others such are friends and relatives, professionals, others who are important to Mr F

D, N.O.K (his wife), social worker, advocates, GP – on Sunday 17th April 2016, despite Mr F D’ wife being informed about the

assessment process three weeks before, his wife couldn’t attends the assessment process as she was in Gabon for personal

reasons; mean staff to promote choice regarding ways to establish with Mr F D where the assessment process should be

carried out - Mr F D chooses the location of the assessment process on the morning of Sunday 17th April 2016. Mr F D told

staff the assessment process will takes place in his room where he feels at home.




care plan for Mr F D – The middle of the assessment

process

Within my health and social care setting for individuals living with Dementia - the middle of the assessment process

regarding the review and update of care plan for Mr F D means staff to; understand Mr F D’ medical history better by feeling

more confident regarding Mr F D’ health and care; to take an equal role with Mr F D in a shared decision making (See page

14); to understand the options available according to Mr F D’ medical history; to build on Mr F D’ strengths by making him

supported in doing and achieving what matters most for him by maintaining social connections e.g. to attend his day centre 5

days per weeks; to take into account Mr F D’ personal budget to help meet own needs e.g. buying newspapers and playing

bingo outside his day centre; to listen to what is important to Mr F D now and in the future by using a person centred planning

that will helps to describe the balance between what is important to Mr F D regarding his strengths, aspirations and the

supports that he requires as well as his needs; to recognising Mr F D’s capabilities and personal qualities through ways that

encourage and support Mr F D to makes the maximum use of his personal strengths and aspirations as well as needs by

working in a way that build on what Mr F D already has, to think about how he can achieve what he wants, and to overcome

problems and difficulties he experiences by providing the right support and the right encouragement; to do a Strengths

Assessment - A Strengths Assessment helps to build a unique and full picture of an individual by identifying what the individual

has achieved and enjoyed previously, what qualities and resources the individual has in place, and what the individual's

priorities are. To agree with Mr F D the intended outcomes of the assessment process and care plan mean staff to focus the

discussion on what is being aimed for, from Mr F D’s perspective, and in specific terms what can be done better e.g. staff

referred him to the physiotherapist as his mobility is getting much better. The intended outcomes of the assessment process

and care plan will usually fall under one of the following; change in health and wellbeing, including emotional, relational,

physical, financial, intellectual, environmental, vocational, career, and spiritual; change in capabilities for managing condition;

change in health related behaviours; change in use of health services; referral of health services.

Intended outcomes

Mr F D Staff

Assessment process Care plan




care plan for Mr F D – The end of the assessment

process

Within my health and social care setting for individuals living with Dementia - the end of the assessment process

regarding the review and update of care plan for Mr F D means staff to; work with Mr F D and others professionals e.g. District

Nurse (regarding the administration of his insulin injection twice a day), Physiotherapist (regarding his referral as his mobility is

much better compared to the admission day), Dementia Care Team (regarding assessment if changes of his cognitive

impairments), GP (regarding the review of his medications as he keeps refusing one medication that is too big for him to

sallow); Others who are important to Mr F D’ wellbeing e.g. his N.O.K (his wife – he wants his wife to visit him as soon as she

will be back from Gabon) to identify support requirements and preferences; means staff to work using a centred person

approach care plan e.g. Mr F D’ My Day My Life care plan, that place Mr F D at the heart of the care planning process; means

staff to review through monthly update Mr F D’ My Day My Life centred person approach care plan according to any future

changes of Mr F D’ support requirements and preferences; means staff to promote active participation by enhancing Mr F D's

wellbeing by feeling valued as part of the care team; means staff to work as a team with Mr F D and others to identify any

changes regarding support requirements and preferences.

Mr F D’ My Day My Life centred person approach care plan gives up to date and relevant information regarding; Mr F D' senses

and communication; choices and decisions over care; lifestyle; what make Mr F D a healthier and happier life; to ensure Mr F D'

safety is meet when moving around using his personal wheelchair/personal Zimmer frame; Mr F D’ skin care by ensuring the

night staff as well as the day staff is applying his E45 and SUDOCREM creams as required; Mr F D' washing and dressing

preferences; personal hygiene; eating and drinking preferences; any breathing and circulation problems; Mr F D’ mental health

and wellbeing; and future decisions. All those information are about two main questions. What can Mr F D do for himself? What

support does Mr F D need from staff? My Day My Life care plan folder is person centred approach.

Some of my other residents are on D.O.L.S. That mean their live under Deprivation of Liberty Safeguards because they are no

longer able to make decisions regarding their care planning process due of living with advanced dementia. D.O.L.S act in their

best interests – which is not the case of Mr F D. In this situation, I refer to the pre-admission notes that were with the resident

when being assessed. The pre-admission notes is a summary of information about the resident's next of kin; medical history;

expectations; date of birth; NHS number; current GP; first language; previous occupation; current medicines; relative

expectations; relationships and community involvement; cultural, spiritual and religious practices; promoting a healthy lifestyle;

wellbeing and social activities; senses and communication; safety; eating and drinking preferences; personal hygiene;

elimination; skin integrity; mobility; sleep and rest; breathing and circulation; temperature control and pain; future decisions;

mental health and dementia care; mental capacity and deprivation of liberty.




care plan for Mr F D – The outcomes of the assessment

process

Within my health and social care setting for individuals living with Dementia - the outcomes of the assessment

process regarding the review and update of care plan for Mr F D are the following; Mr F D has been referred to the

physiotherapist (regarding improving his mobility - he is living with a stroke that affect his right side of the body); Mr F D’

concern regarding night staff carer that didn't applied his SUDOCREM on his right ankle (saying to Mr F D that is a nurse job) -

this concern has been spoken with the night staff carer by person in charge on the following day. I feel I could have approached

Mr F D’ assessment process in a more efficient way as I was expecting Mr F D's wife to be part of the review process (to found

out more information) but for personal reason his wife couldn't attend the review process on Sunday 17th April 2016, as she

was in Gabon for personal reasons.

Before the assessment process regarding the review and update of care plan for Mr F D, I gave him a bath and a shave, with

his consent, for him to relax as I know he was stressed about his assessment process. I also put a small table and three chairs

in his room with his consent, and I wanted him to feel at home like he said.

At the beginning of the assessment process regarding the review and update of care plan for Mr F D, I focused on the positive

parts of his days within my care setting by saying verbally to him that his mobility is much better and I would like him to be

referred to the Physiotherapist, with his consent, as I believe he can be able to mobilise independently using his personal

Zimmer frame for short distances – which means being more independent regarding mobility.

At the middle of the assessment process regarding the review and update of care plan for Mr F D, I asked him after consent

gain, to answer to 15 questions regarding geriatric depression scale to found out what is impacting his wellbeing within my care

setting. I also promoted choices regarding his fluid intake as Mr F D wants to drink only water – which he said verbally that his

GP told him to drink only water.

At the end of the assessment process regarding the review and update of care plan for Mr F D, I verbally said to him that I will

personality speak with the night care staff that refused to apply his SUDOCREM on his right ankle as this is very important for

him, regarding his skin integrity. After the assessment process regarding the review and update of care plan for Mr F D, I

promised him that after updating his care plan, we would play some dominos that he learns in his day centre. Mr F D is my

friend as all the other residents I care for, and I will miss him when he will be discharged in a few months.

Documents

Page 1 of 23 aspecmaps.free.fr/NVQ3/HSC3020.pdf …aspecmaps.free.fr/NVQ3/HSC3020.pdf · 1.3 Describe ways the assessment and planning process or documentation can be adapted to maximise