Effective care planning improves residential care by identifying and promoting good practice within your organisation. Individual care plans are developed and updated by the organisation’s Multi-disciplinary Team following initial, and ongoing, resident assessment. Resident / Service User involvement in the development and implementation of the individual care plans should be facilitated and promoted. The individual care plan should cover all aspects of health and personal care and show how the Resident’s / Service User’s individual needs will be met in terms of the care provided to achieve specific outcomes and maximize quality of life. All relevant staff should be appropriately trained to implement individual care plan interventions and support the changing needs of Residents / Service Users through their individual care plans.
VCare Complete is an electronic method of meeting care planning and resident record requirements practically and efficiently. It can assist organisations in reducing the time and physical burden of paper records with an intuitive electronic system.
Care Planning Cycle
VCare Complete can directly assist your organisation through each stage of the care planning cycle.
Stage 1: Assessment
The pre-admission assessment provides a baseline for Residents / Service Users. This assessment ensures the organisation’s suitability to the needs of the prospective Resident / Service User and obtains all necessary information relating to the Resident / Service User’s health, personal and social care needs (HIQA, 2016; S.I. No. 415 of 2013).
At admission, a comprehensive assessment should be completed as soon as practical after admission (HIQA, 2016). The staff involved in the assessment activities should observe residents identifying physical, psychological and emotional state and utilise evidence-based assessment tools and interviews as applicable to the resident to provide valid data.
A general risk assessment should also be completed for allergies and observations, falls and pressure sore formation. The organisation should implement referral arrangements for Residents / Service Users to obtain rehabilitative services from health and social care services as deemed required.
All measurements and assessments can be completed and recorded through use of VCare Complete’s approved assessment tools.
Assessments within VCare Complete
VCare Complete provides a Resident / Service User measuring function that automatically identifies changes in the Resident / Service User’s values and identifies whether they are outside acceptable levels. VCare Complete provides a comprehensive suite of daily living assessments. Automatic recommendations are provided based on outcomes to help identify the necessary care plans. Within VCare Complete there are 26 assessments available to use.
Stage 2: Identification of needs
A Resident / Service User’s needs should be identified by the Multi-disciplinary Team in response to the findings of the assessments completed.
Stage 3: Care Plan Development
The Resident / Service User’s individual care plans shall be developed as soon as practical after their admission, but no later than 48 hours of admission if indicated by the assessment. Care plans should incorporate current clinical guidelines and best practice in the area of focus. The Multi-disciplinary Team should develop a care plan per resident need, specifying the immediate, intermediate and long-term goals in each case and the interventions appropriate for attaining these goals. The Resident / Service User should be consulted with, and participate in, the development of their individual care plans. The Resident / Service User should have access to a copy of their individual care plans in an accessible format.
VCare Complete provides over 30 evidence-based care plans to be customised in line with Resident / Service User’s needs and diagnosis. The Resident / Service User’s assessments and care plan evaluations are scheduled automatically. VCare Complete also provides linked progress notes, event management, incident reporting and appointment scheduling to ensure that the Resident / Service User’s care is continually communicated to required staff.
The care plans should be retained in the resident’s record on VCare Complete.
Stage 4: Care Plan Implementation
Care plans should be communicated and made available to all relevant parties involved with the provision of care to the Resident / Service User. Care plan interventions can be scheduled, managed and tracked by VCare Complete and should be carried out by Nurses, Health Care Assistants, Activities Co-ordinator, and/or Health and Social Care Professionals as appropriate. Completed interventions are automatically recorded within the Residents’ Progress Notes in VCare Complete.
Care should be scheduled and provided with due regard for the Resident / Service User’s needs and preferences and every effort should be made to maintain the Resident / Service User’s daily routine. Implementation of interventions shall be documented within the resident record and a care plan history is recorded in VCare Complete.
Stage 5: Evaluation
The Multi-disciplinary Team should formally review the Resident / Service User’s needs, preferences and care on an ongoing basis at a minimum this shall be every 4 months or more frequently following a change in the Resident / Service User’s needs or circumstances (S.I. No. 415 of 2013; HIQA, 2016).
Staff who are involved in the creation of the care plan should be involved in the evaluation process. The Resident / Service User’s involvement should again be actively facilitated. Any changes should be agreed, documented and communicated. The update can be completed within the VCare Complete system and the updated interventions shall be automatically released to staff via VCare Complete. If there are no changes required, staff should document that the assessment was undertaken, by whom and determine the next review date. This information can be recorded in VCare Complete. If a care plan has ended, this can also be recorded and details retained on VCare Complete. Care plans can be reactivated within the system if necessary.
The process of Care Planning must be audited on a regular basis.
Contact Us If you would like any assistance with care plans contact us on 093 36126 or firstname.lastname@example.org.