How to go about making the change

Case study part three

Making the plan 01

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Making the plan 02

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One of the key ways that organisations and services can ensure that what they do is relevant and effective, is to make sure that what matters to the individual service user is at the centre of care and support planning. The video clips in this section show two contrasting examples of care and support planning with Ken in the care home. His written plan is also included here. Again subtle differences in the conversation that Ken has with the support worker Jeanette make a difference to how Ken feels about his new life in the care home.

Watch both versions of the scene above and enter your reflections in answer to the three questions that follow below (you'll be able to print your reflections for future reference).

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Question 1 of 3
What did Jeannette do differently in the second version that enabled her to develop Ken’s care and support plan in collaboration with him?

In the second version Jeannette focused on him rather than on what the home offered. She showed an interest in him – “I’d like to focus on you Ken” and made suggestions. She looked for solutions and she did what she had promised at once.

Question 2 of 3
What will need to be in Ken’s plan to support the outcome of him being able to continue walking?

Your answer may have included the following:

  • Clear statement of what matters to Ken
  • Situations/places in which he prefers to walk
  • Support he needs to walk safely – indoors and outdoors
  • Any actions to maintain/increase his mobility
  • Who is responsible for these
  • How Ken will be involved in helping to achieve this outcome
  • Reference to his falls risk assessment
  • How often falls risk assessment to be reviewed
  • Contents of plan communicated to everyone involved

You may like to check out Ken’s personal care plan and review the document Guidance Notes on Care and Support Planning.

Question 3 of 3
Think of a time when a relative or friend of your own needed care. What did (or would have) helped them to feel respected as an individual?

You may have mentioned the importance of being listened to and having your individual preferences respected. In addition acknowledgement of the people who are important to you and the life you have led can make you feel that you are known and respected for who you are. In an outcomes-focused approach time and effort will be spent getting to know the person in order to establish what matters to them.


Key documents

  • Personal plan for Ken

    This plan brings together core information for Ken from a range of sources, identifying links to specialist plans. Despite complexity, the plan paints a picture of Ken as a whole person and clearly sets out his outcomes.

  • Guidance notes on care and support planning

    These notes were written for this resource and sit alongside the support plan for Ken. The notes take into account the complicated specialist and multi-agency processes that sit around care and support planning. The point is to show that core individual outcomes can sit at the centre of all of these processes.

  • Talking Mats help involve people with dementia and their carers in decision-making

    How people with dementia and their family carers can use Talking Mats, a low-tech communication tool, to feel more involved in everyday care decisions

Supporting documents

  • Personal plan for Doris Lomond

    This plan is a real life example which relates to the supporting audio Digital story: Doris Lomond. The plan is based on conversations between Doris Lomond and support staff in the day centre she attends. It sets out the outcomes important to Doris Lomond and to her main carer, her husband.

  • What makes a good life in a care home

    This one page sets out comments from our user and carer group about what they think makes a good care home.

  • Outcomes card game and facilitator notes

    This card exercise has been very popular for staff training sessions. The game is a fun interactive way to illustrate what outcomes are and the facilitator notes explain how they should be used.

  • 12 helpful hints: dementia

    Staff have consistently raised concerns about making sure that people who have communication support needs should be included in identifying their outcomes. A wide range of communication supports are available. This is one simple example.

  • Personal Outcome Statement form

    An example of a blank Personal Outcome Statement form, available here for reference.


Supporting audio