Individual Care Planning
Meeting individual client needs
An individual care plan is the centrepiece of the complex care service. We take the time and the necessary diligence to ensure that the clinical and the personal aspects of our service are documented and agreed in conjunction with the needs of the client. Preparation of the care plan starts with spending time in the home or, where applicable, the hospital.
The care plan takes full account of requirements and clinical risks and is developed in conjunction with the help of the client, family members, existing carers, commissioners and other healthcare professionals that are involved. Once all parties are satisfied, including with respect to funding of the service, we will prepare a client contract to outline roles and responsibilities.
How do we work?
Within a robust care provision framework
Our clients are typically referred to us from an NHS Clinical Commissioning Group (CCG), local authority or from an independent case management company. However, we also work with local authorities and directly with privately funded clients.
When we receive a referral or an enquiry we will make an appointment to meet the client and their family as soon as possible. During this appointment one of our specialist nurses will carry out a detailed risk and needs assessment with respect to the specific care requirements of the client. We use this assessment as a basis for estimating the cost of providing care but, most importantly, as the initial basis for the client’s individual care plan.
At the earliest possible stage, we will introduce our dedicated nurse and operations manager who will lead and oversee the client’s care package and be the primary point of contact for all aspects of our services.
Once we have agreed requirements with the client, their family and the commissioner we begin organising and establishing
the provision of care, including the following:
- Recruitment of care staff that are matched to the specific needs of the client and trained accordingly under the supervision of our clinical specialists;
- Training of a team leader who acts as a key worker within the direct care team;
- Introductions of care staff to the client and family members as appropriate;
- Identification of specialist care needs and matching with the appropriate healthcare professional;
- Establishment of an efficient and consistent rota;
- And access to 24 hour on-call support services is available for clinical or operational matters.