A quality framework for care homes for adults and older people
This key question has two quality indicators associated with it.
They are:
5.1. Assessment and personal planning reflects people’s outcomes and wishes
5.2 Carers, friends and family members are encouraged to be involved
Quality indicator 5.1
Assessment and personal planning reflects people’s outcomes and wishes
Key areas include the extent to which:
leaders and staff use personal plans to deliver care and support effectively
personal plans are reviewed and updated regularly, and as people’s outcomes change
people are involved in directing and leading their own care and support.
Very good
People benefit from dynamic, innovative and aspirational care and support planning which consistently informs all aspects of the care and support they experience. People, and where relevant, their families or those important to them, are fully involved in developing their personal plans. Strong leadership, staff competence, meaningful involvement and embedded quality assurance and improvement processes support this happening.
Personal plans reflect people’s rights, choices and wishes. They are person centred and include information on people’s preferences for maintaining contact, the supports needed to achieve this with those important to them, and ways they can remain active and engaged.
Care and support planning maximises people’s capacity and ability to make choices. It reflects a culture of promoting independence, including the potential for people to reduce the support they receive or a change of care setting.
Care and support planning takes account of emergencies or unexpected events and identifies how support will continue to be provided and promote stability in people’s care and support.
Weak
Personal plans are basic or static documents and are not routinely used to inform staff practice and approaches to care and support. They do not accurately reflect the care and support experienced by people who live in the service. People may not know whether they have a personal plan, it may be in a format which is not meaningful to them or kept in an inaccessible place.
The standard of care and support planning is inconsistent and is not supported by strong leadership, staff competence and quality assurance processes.
Personal plans do not include outcomes important to people and focus entirely on people’s needs and tasks to be carried out. There is little recognition of enabling assets-based approaches that nurture personal strengths, social and community networks.
Very good
People benefit from personal plans which are regularly reviewed, evaluated and updated, involving relevant professionals (including independent advocacy, where appropriate) and take account of good practice and their own individual preferences and wishes.
People are helped to live well right to the end of their life by making it clear to others what is important to them and their wishes for the future. This includes receiving care in a place of their choice should they become unwell.
People have an anticipatory care plan (ACP) in place that reflects their wishes and where appropriate, those of their representatives. Staff are familiar with people’s preferences for palliative and end of life care. There is a range of methods used to ensure that people are able to lead and direct the development and review of their personal plans in a meaningful way
Weak
Multi-disciplinary professional involvement in the support planning and review process may be limited. People may not benefit from professional advice because this is not taken account of in the care planning and review process.
Personal plans do not reflect up to date good practice guidance. Care reviews may not be carried out in line with legislation.
Very good
Where people are not able fully to express their wishes and preferences, individuals who are important to them, or have legal authority, are involved in shaping and directing the care and support plans. Advocacy support has been sought where appropriate. Staff understand the planning process and can support people to navigate this, maximising their involvement.
Supporting legal documentation is in place to ensure this is being done in a way which protects and upholds people’s rights.
Risk assessments and safety plans are used to enable people rather than restrict people’s actions or activities. Where restrictions are included as part of an order or court disposal, people understand the impact of this and are supported to comply with relevant conditions.
People are fully involved in decisions about their current and future health support needs. Their plans and wishes for their life in the future are also fully taken account of. Where appropriate, this involves the use of anticipatory (advanced) care plans.
Weak
People may not be involved. or have only limited opportunity for involvement, in their care and support planning and review process and therefore do not consistently experience care and support in line with their wishes and preferences.
Where people are not able fully to express their wishes and preferences, relevant individuals important to them are not involved, or have limited involvement, in the care planning and review process. Supporting legal documentation may not be in place.
The culture within the service can be defined as risk averse, and directly reduces people’s quality of life and experiences as a result of over-protective attitudes and practice. Risk assessments appear punitive or designed to prioritise protecting the organisation rather than promoting risk enablement and ways to keep people safe.
Desired outcomes and aspirations for individuals may be limited by low expectations of people who are involved in assessing and planning their care and support.
Observation of:
experiences of people in the service
staff practices
communication and interactions
Discussions with:
people living in the care home
staff
visitors, such as relatives, friends and carers of people living in the service
visiting professionals
Sampling of:
review minutes and action records
personal plans, including risk assessments
review and action plan minutes.
Consideration of:
how people, and those important to them where appropriate, are supported to be involved in the development and review of their personal plans
whether the personal plan reflects the care and support being provided or required.
Understanding personal outcomes
Talking points – joint improvement team
Outcome-focussed conversations – Joint Improvement Team
HIS guidance on anticipatory care planning
Scottish Independent Advocacy Alliance – companion guidelines
Making it real – how to do personalised care and support
Guide for providers on personal planning
Mental Welfare Commission guidance:
Quality indicator 5.2
Carers, friends and family members are encouraged to be involved
Key areas include the extent to which:
carers, friends and family members are encouraged to be involved and work in partnership with the service
the views of carers and family members are heard and meaningfully considered.
Very good
There is a supportive and inclusive approach to involve all carers and family members in the planning and delivery of care and support if this is important to the person living in the care home.
Where family members have learning or communication difficulties, or where English is their second language, they are appropriately supported to be able to express their views fully. Leaders engage meaningfully with people and, with consent, their families and those important to them. Leaders take a collaborative approach to ensure that they have a thorough understanding of people’s views, wishes and expectations.
The staff understands that the right of family members to be involved in care and decision-making hinges on the consent of the individual, and that the wishes and best interests of the person living in the care home must be taken into account. Where there are disagreements, these are responded to sensitively and a shared way forward is sought.
Where guardianship or power of attorney are in place, staff are clear which legal powers are relevant, and fully involve and consult with the guardian.
Weak
Leaders either seldom engage with the families of people or fail to do so in a meaningful way. There are limited ways for friends or family to be involved and these are often one-way or tokenistic. The views of friends and family are not effectively heard by leaders, resulting in a limited understanding of their views, wishes and expectations. There is little evidence of changes being made to how care and support is provided as a result of this involvement.
Where people are the subject of guardianship or powers of attorney, the care home staff don’t fully recognise or understand what this means, or where decision-making powers lie. Leaders are not clear when someone lacks capacity to consent, or how to proceed if this is the case.
Low expectations or over-protective attitudes from some family members are allowed to define the extent of people’s ambition or desired outcomes.
Very good
The care home is led in a way that is strongly influenced by people who live there, with the opportunity for family members, friends and carers where appropriate, to be involved in a variety of ways. The views, choices and wishes of people who live in the care home, and their family members, inform changes in how care and support is provided, even where that challenges previous approaches.
If the person living in the care home agrees, families, as well as people who live in the service, have the opportunity to be involved in making recruitment decisions in a meaningful way.
The care home staff understand the complexities of family and other close relationships and can provide support to people to try to reconnect with friends or family where these relationships have broken down.
Staff understand the value of positive peer support in providing support and improving outcomes for people.
Weak
Support for those with learning or communication difficulties, or those who have English as a second language, is limited. People, and their families, have no or limited opportunity to be involved in making recruitment decisions, or their wishes carry little weight in decision making.
Information about people living in the care home is shared with their family members, friends or carers without appropriate consent. Leaders lack knowledge about informed consent.
Leaders in the service do not recognise the value of support provided by individuals who are important to the person living in the care home.
Observation of:
experiences of people in the service
staff practices
communication and interactions
Discussions with:
people living in the care home
staff
visitors, such as relatives, friends and carers of people living in the service
visiting professionals
Sampling of:
review minutes and action records
personal plans, including risk assessments
review and action plan minutes
meeting minutes and action plans for people, staff and relatives
systems for acting on feedback, including complaints.
Consideration of:
how people and those important to them (where appropriate) are supported to be involved in their care and support.