Core information standard: CORE INFORMATION STANDARD IMPLEMENTATION GUIDANCE

• It should be possible to restrict access to the care and support plan in most cases based on the individual’s consent preferences. However, a data controller may choose to release all or part of the record for legitimate reasons, for example when a person using services is unable to give consent.
• It should be possible to add attachments or hyperlinks in care and support plans to provide guidance, learning materials, explanatory notes, etc. The date/time of the hyperlink/addition should be included.
• It should be possible to add comments to the plan and to sections in the plan, for example. to identify progress towards a goal (which should have a formal mechanism associated for capturing information). It should also be possible to comment on actions undertaken or suggest changes to actions. Note that adding comments to a plan is not the same as having a dialogue with others involved in the care and support planning process. Separate functionality, e.g. secure messaging would be required for this.

Care and Support Plan > Strengths

• Definition: Any strengths and assets the person has (i.e. things a person is good at or enjoys doing) relating to their goals and hopes about their health and well-being For example, ‘able to participate in leisure activities’ such as a sport in order to improve health and wellbeing by losing weight.

Care and Support Plan > Needs, Concerns or Problems

• Needs are defined as health or care deficits identified by the person with their carer(s) or professionals and are the motivations/indications for healthcare activities. Examples of needs could be (e.g.) ‘to dress myself’; ‘to better understand what my various medications are for’; ‘to reduce pain in my knees’.
• Concerns are gathered information to support continuity of care for a person. Concerns can include biological, psychological or social concerns. They may include things the person or carer is concerned about. For example, a person’s concern may be ‘the quality of social housing’; a professional’s concern could be ‘high blood pressure’
• Problems are defined as: A condition that needs addressing and is important for every professional to know about when seeing a person. Problems may include diagnoses (e.g. COPD; diabetes), symptoms (e.g. joint pain; breathlessness), disabilities (e.g. sensory impairments; amputations), health, social and behavioural issues. Problems recorded here may link to the problem list held in a shared care record or GP system for a person using services.
• Goals and hopes are defined as: The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of importance or priority to the person. For example, ‘weight loss’; smoking cessation’; ‘reducing alcohol intake’; ‘increased sleep’. ‘Goals’ tends to be historically a more medically-used term, whereas ‘hopes’ is used more widely in social care settings.
• It should be possible to include tables (e.g. weekly schedule), diagrams or images (e.g. to illustrate how a person has made progress towards a goal) as well as video and audio clips (i.e. as a communication tool for individuals with complex accessibility requirements).
• It should be possible to prioritise goals, indicating the importance of each goal to the person (e.g. a scale 1 to 10).
• Each action may also have an associated additional indicator showing how confident the person is to carry it out (e.g. a scale from 1 to 10).
• The care and support plan should be structured in a way that supports digital information exchange, with separate sections for strengths, needs and problems which can be linked to specific goals.
• Of particular importance is the link between needs in a care plan and related goals. Each goal must link to specific needs, as well as any actions associated with it. Goals may also have related outcomes.
• The sections associated with goals and actions that are the focus of specific care professionals should be interoperable with the care plan that professional uses for their day to day work.

Updates to the care and support plan section may include:

• Add, edit or archive strengths, needs, concerns or problems. If a strength/need/concern becomes more or less important, then goals may need to be changed, as will associated actions.
• Add, edit or archive goals. When a goal is archived it should be possible to also archive the actions associated with it. If the actions are still valid it should be possible to attach them to another goal.
• Add, edit or archive actions. Once an action has been completed (i.e. status updated to indicate it has been completed), it should be possible to archive it from the care and support plan. It should be removed from the current active view of the plan, but available to view in previous versions of the plan.
• Recording outcomes related to goals. Once a goal has been achieved, it should be possible to archive it from the care and support plan, so that it is removed from the view of the current plan, but available to view in previous versions of the care and support plan.

Care and Support Plan > Agreed with person or legitimate representative

• Agreement of the plan with the person (or representative) should be recorded. If agreement cannot be obtained the reason for this should be documented.
• Where a person has been unable to agree, due to, for example, lacking mental capacity, actions should be undertaken to maximise capacity and the plan should demonstrate how a person’s rights will be promoted. If a person is unable to consent, a mental capacity assessment should be attempted, and if there is no legal representative a best interest decision made.

Care and Support Plan > Care Funding Source

• In health and social care there may be different sources of funding (e.g. personal budget/personal health budgets) to meet the aims and goals of the person. The ‘Care Funding Source’ section should only detail the source of the funding so as to support easy resolution where a question about funding arises. The information should not include the details of the funding, which will be held in separate documents.

Care and Support Plan > Date this plan was last updated

• This information should be automatically retrievable from the system.