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What goes into a live-in care support plan?

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We can provide care in your home anywhere in England & Wales

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What is a support plan?

A support plan is a detailed document that contains everything about the customer that a live-in carer needs to know when they are providing care. It includes details of their next of kin, medication, health condition(s), hobbies and interests, meal preparation and personal care, as well as information on their property and general likes and dislikes.

Every customer has a support plan that is created during the initial live-in care assessment by the local Live-in Care Manager and the customer before care begins. Some customers choose to have family members or care professionals – such as occupational therapists or social workers – present during the assessment, which can often help with providing all of the information the Live-in Care Manager will need.

A copy of the support plan is kept in the customer’s property so that the customer or carer can access it at any time.

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What information is included in a support plan?

The information within a support plan is very detailed to ensure that all aspects of care are carried out in a safe and effective manner and to your wishes. It follows the Activities of Daily Living nursing-based model, which identifies key factors that aid independent living for the individual receiving care, such as maintaining a safe environment, communication, mobilising and sleeping.

Support plans are written in first person so that they are from the customer’s point of view, giving the document a more personal touch and ownership for you.

The following information is included in a Helping Hands live-in care support plan:

Live-in care and carerPersonal details – name, address, next of kin contact details, GP and other health professionals, Power of Attorney (if in place), Do Not Resuscitate document (if in place), other people living in the property.

All about me – life history, interests and hobbies, end of life wishes, what you want to achieve from care, medical and health conditions.

Weekly timetable – a detailed account of what, how and when you would like support throughout each day. This is split into waking, morning, lunch, afternoon, dinner, evening, going to bed and nights. For example: ‘I would like to be woken up every morning at 8am by my carer gently knocking on the door, coming in, opening the curtains and putting a cup of tea on my bedside table. After 10 minutes, I’d like them to return and help me to sit up in bed so I can drink my tea.’

Personal care – what you need support with and how, and what you would like to do yourself. For example, you may have a bed bath every morning but prefer to wash your face yourself with a damp flannel.

Mobility requirements – mobility aids, moving and handling requirements and risks, equipment available, details on how to transfer you to your bed, toilet, chair etc.

Medication – what type of medication is required, how it is administered, who administers it, allergies, pharmacy details (more information in Medical Administration Record [MAR] chart)

Making a drinkNutrition and hydration needs – preparing meals, dietary requirements, allergies, administering food i.e. PEG feeding or if you need your food cutting up by your carer.

Finances – whether the customer, carer or family member handles money and the Power of Attorney for property and financial affairs.

Environmental needs – fire evacuation procedure, ease of access in and around home, location of gas and electric meters etc.

Live-in carer requirements – where they sleep, food arrangements, break arrangements, other carers involved i.e. visiting carer for moving and handling procedures.

Consent – signed consent to care and for service agreement.


Meet Clinical Nurse Lead, Natasha Johnson

Natasha has recently joined Helping Hands and has brought with her a wealth of clinical experience spanning over 10 years. She has worked in both the public and private sector, spending the first part of her nursing career on specialist wards and intensive care, specialising in invasive and non-invasive respiratory care and spinal injuries, as well as stoma and catheter management.

Her role at Helping Hands is to work with a team of registered nurses, expertly trained carers and personal assistants across the country to deliver person-centred care to individuals with complex care needs, enabling them to be able to live within their own home.

Find out more about Natasha here.


How often are support plans reviewed?

Support plans are reviewed every 6 months (every 3 months in Wales), regardless of whether there are significant changes of circumstances or not. There may be reasons to update your support plan sooner, for example if your health condition changes or elements of your property change. This can be initiated either by your live-in carer or yourself.

The process of this review mimics the initial assessment that took place before care started; the local Live-in Care Manager will visit you in your home and go through all aspects of your care requirements, often with a family member or care professional present too.

Any changes to your health, medication, preferences, carer or property will be recorded, and an updated support plan will be created. Whether you have a new carer or an existing carer that has been with you for some time, your carer will be fully briefed with your updated support plan and any significant changes made.


What input do I have to my support plan?

Creating a support plan with a customer is very much a collaborative process; the support plan should be tailored around you and your specific needs and requirements, whilst giving as much information as possible for your carer to provide the very best care for you.

To ensure that the customer’s best interests come first, we always uphold the Mental Capacity Act and ensure that we create a support plan that adheres to the wishes of the customer. If a customer has a Power of Attorney and is unable to make decisions about their care, we will ensure that their nominated individual(s) is fully involved in the support plan process.

The Live-in Care Manager will work very closely with you when creating the support plan, ensuring that both your practical and emotional wellbeing are catered for. It’s important that you raise any concerns in order to reach an agreement to the care being provided and the outcomes you want to achieve.

Feeding the ducksIf required, the Regional Clinical Nurse Lead will also be involved in creating your support plan if there are any clinical elements to your care, such as stomas, PEG feeding or tracheostomies. They will be involved with any reviews that take place too.

So, if you love going to your local park to feed the ducks once a week but need specific support with your mobility in order to get there safely, those exact preferences and instructions will be noted and actioned in your support plan so that you can live the life you want to lead, just with a little support along the way.


Page reviewed by Natasha Johnson, Clinical Nurse Lead on November 14, 2019

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