What is included in a care and support plan?

Tip 1: About me 

Reflecting on what matters to the person.

What is an exchange model? 

The exchange model does not dismiss the expertise of the social worker however, it assumes that individuals are experts in themselves (Smale et al., 2000).

An exchange model of communication was used throughout the assessment with P, I acknowledged that P was an expert on her own problems.

My focus was on exchanging information. I assessed P to have capacity around her own care and support.

As a result, I encouraged P to share her views and wishes. In hindsight, I was able to capture what P’s wishes were by engaging in good communication practices such as active listening and paraphrasing.

According to Johnson and Wiggs (2011) effective communication is a vital skill for social workers when engaging with individuals.

For most part of my work with P, I felt that information was exchanged effectively and it could be argued that communication was effective because I had established rapport and listened to P’s views. For instance, I asked P how she would like to be addressed and she preferred me to call her by her first name.

Subsequently, I used her first name throughout the assessment process.

Trevithick (2011) highlights that the ability to listen puts the social worker in connection with the direction of the person’s world and opens the door for involvement.

P was of the view that she wasn’t seeing her children often enough wanted to visit them more frequently.

This was very important to her.

Consequently, I supported her to make travel arrangements in order to see her children every fortnight.

Tip 2: Make it person-centred 

What do I want to change?

A person-centred thinking tool (sorting important to/for) was used to help separate what is important to P from what is important for them and to find a balance between the two (Beresford, 2014).

For instance, P felt that engaging in activities she was able to do in the past such as going to the gym was important to her.

However, she understood she was limited to certain activities at the gym due to her illness and was open to other options.

Through further discussions, P felt that swimming once a week would help provide her with a form of physical activity that she would still enjoy.

This was considered in her care and support plan and time allocated for a carer to take her to the local swimming pool.

P also did not want male carers as she felt uncomfortable around them.

As a result, I highlighted this preference on her care and support plan.

Tip 3: Consider strengths

Assets, relationships and community resources – what do I have?

A coordinated holistic approach involving the Multiple Sclerosis Nurse, Occupational Therapist (OT) and P’s family and carers was employed.

According to Hyer (2014) a meeting of experts is essential in care and support planning in order to bring together people who may have lived experience and those with technical know-how to identify all the concerns, develop solutions and start actions.

Consequently, an OT carried out a home assessment to review the need for possible adaptations in P’s home.

They were able to provide P with a shower chair, walking aids and installation of a stair lift.

The Multiple Sclerosis Specialist Nurse provided information on the impact of MS on an individual and the need for ongoing support.

She also provided information on MS support groups within P’s local area.

It was identified that P can attend the local group meetings independently using her mobility scooter.

My role as a Social Worker meant that I was able to co-ordinate the care and support planning to ensure that it was proportionate to risks identified such as P’s mental health declining.

For instance, sourcing the right care provider to support P.

Based on an understanding of the stress-vulnerability model, I was aware that one way to help reduce the negative effects of stress on vulnerability is through social support which comes from having close and meaningful relationships with other people (Zubin & Spring, 1977).

Mary wanted to have her relationship with her mother repaired.

I encouraged her to be open, discuss and resolve any disagreements they may have.

According to Zubin and Spring (1977) individuals who have good social support are less vulnerable to the effects of stress on their mental disorder.

Therefore, having strong social support enables people with co-occurring disorders to handle stress more effectively.

Conclusion

To summarise, the care and support planning indicated what P wants and hopes to achieve in her day to day living.

It was holistic in nature as it involved family, carers and other professionals.

P had her home adapted to suit her needs, provisions were made for her to attend the local swimming pool once a week, the OT’s were supporting her to relearn basic cooking skills and I supported her to make travel arrangements to visit her children more frequently.

A female only care team was emphasised on the care and support plan.

This preference was also highlighted to the care provider.

Decisions on how P would achieve the outcomes she wants to achieve was recorded on the local authority data base.

A contingency plan was agreed where P’s niece would support when needed.

For instance, if P has a fall, family/carers must contact 111.

A date was agreed for a review of the care package.

How I put together and co-ordinate a care package: final thoughts

When writing a care and support plan, you should always consider the following.

• What’s important to the person
• What the person can do for themselves
• Views of carers, friends, family and other professionals.
• Contingency plan
• Personal budget

3 tips to consider when completing a care and support plan

TIP 1: About me 

Tip 2: Make it person-centred

Tip 3: Consider strengths

JUST FOR YOU:

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