Care Plan Guidelines
Guidelines for the collection, creation and maintenance of client Care Plans
Overview
The Care Plan is designed to provide Carers with a comprehensive, easy-to-follow instructions to perform their duties. It should give carers the best understanding of the client’s support needs.
Definitions
Assessment: is the collection of relevant information based on an established criterion relevant to the client’s health care needs.
A carer or support worker is a person who provides personal care assistance, activities of daily living assistance, community access support and/or aspects of health support.
“Carers are not licensed to practice nursing, medicine or any other health occupation requiring a license in New South Wales and are, therefore, not subject to any statutory regulation. Carers are subject to the same civil and criminal law sanctions, accountability for negligence, and competency measures as the sector in which they are employed and their employer. Carers are subject to the vicarious liability of their employer who is required to maintain appropriate Indemnity Insurance.”
Clients: a person or persons receiving services from HWH
Clinical Care Manager (CCM): a person, typically a Registered Nurse, responsible for the case management of HWH clients, including the ongoing assessment and management of their well-being and the required levels of care delivered to HWH Clients.
Care Management System (CMS): The system that HWH utilises to document the Care Plan and record day-to-day Shift/Client Progress Notes from HWH Carers and Care Notes concerning the activities of the evolving care delivery. The CMS is also the repository for all information relevant to providing clients with the care levels required to maximise their well-being at home. As of Jul 2019, HWH utilises BaseCamp as its CMS of choice.
Comprehensive Assessment: This term applies to the collection of the required information and the cooperative health assessment undertaken by the HWH Registered nurse in collaboration with the HWH client and/or the representative and their primary support network – in conjunction with medical and allied health professionals – in preparation, development and implementation of the required Health Care Plans. This structured process provides evidence for delegating health care tasks to Carers for HWH clients.
Care Plan: documents the steps to be undertaken by a Carer to support the client. This Plan usually relates to various aspects of the client’s life domains and activities. This Plan is usually developed...in consultation with the client and their support networks.
Care Plans are developed with medical and allied health professionals for use in various settings.
Supervisor: This term refers to the Carer's line manager.
Responsibilities
The Clinical Care Director is responsible for:
- Ensuring that all employees involved in developing and implementing new or updated Care Plans are appropriately trained and kept up to date with government policies, guidelines, legislation, relevant professional standards and organisational policy and procedural requirements.
- The provision of adequate resources for appropriate staff to enable the timely and comprehensive assessment of the client’s needs
- Upholding and maintaining accountability to funding bodies and individuals for their contractual obligations for a client’s service, as documented in the Care Plan, including facilitation of the appropriate sharing of information
- The development, delivery and review of employee training of the Care Plans.
- Training of all CCMs in the development and review of Care Plans.
- The Care Plan will contain the client-specific information in a language and style appropriate for use by carers, enabling care provision in the nominated environment where assistance is required.
Clients [or their representatives] are responsible for the following:
- The accuracy of the information supplied to HWH CCMs concerning their health and support needs for developing their Care Plan.
- Ensuring that the Care Plan is read, understood and agreed
- Advise changes and/or alterations to their health.
- HWH will ensure that services, as documented in the client-specific Care Plan, are planned and delivered promptly to meet the client’s individual physical, emotional, spiritual and social needs, optimising the client’s independence and participation.
CCMs are responsible for:
- Maintaining a high level of client knowledge to ensure the timely and accurate development and review, in collaboration with clients and other relevant stakeholders, of a Client Support Plan.
- Upon commencement of services, the Care Plan and supporting documents must be completed in Basecamp promptly.
- Providing, as required, Allied Health Professional’s Health Care Plan[s].
- Ensuring documented evidence of communications with the HWH client and/or their representative, HWH staff and the client’s Funding body[s], if any.
- Ensuring the Care Plan from other Agencies can be utilised and implemented within reasonable timeframes and with timely consent by the HWH Clinical Care Manager.
- Determining the appropriateness of Carer knowledge and skills required to meet the HWH client’s support needs per the Care Plan.
- Developing HWH documentation/records for HWH clients when appropriate.
- Acting upon reported changes and/or alterations to the client's health or service, which results in facilitating an immediate or ongoing review [s] of the client’s Care Plan in a practicable, reasonable and timely manner.
- Undertaking a comprehensive assessment of the client’s health care needs before the commencement of service.
- Ensuring the provision of Allied Health Professional’s required Health Care Plan [s] for the client’s Care Plan.
- Assist in determining the Carer competencies required to meet the client's specific health needs per the individualised Care Plan.
- Ensuring Carers have been trained, assessed, and deemed competent to undertake client-specific health care procedures, Following the client’s Care Plan.
- Acting upon reported changes and/or alterations to the client’s health that result in immediate or ongoing review [s] of the client’s Care Plan in a practicable, reasonable and timely manner.
Carers/Support Workers are responsible for:
- Reading and following Care Plan instructions on the CMS.
- Contacting CCMs to report the absence of a client’s Care Plan
- Reporting, verbally and in writing (Basecamp Shift Notes) to the CCM if there are concerns, issues or uncertainties concerning the information and instructions contained within the Care Plan
- Seeking assistance from CCMs if unsure about any duties or tasks they must undertake to meet the client’s support needs as documented in the Care Plan.
- Adhering to all the advice and instructions given by HWH.
Policy
HWH encourages clients to participate and manage their required services to maintain control of all aspects of their life and environment. HWH will manage this support to enable clients to maintain their self-determination, dignity, individuality and lifestyle choices. Care Plans will reflect these choices where reasonably practicably.
The Care Plan is designed to provide Carers with a comprehensive, easy-to-follow set of instructions to perform their duties. It should give Carer’s the best understanding of the client’s individual support needs.
HWH will respect the Client’s right to privacy and confidentiality and their right to direct their own life.