As dementia progresses, the things someone needs help with can change. A routine that worked well six months ago may no longer feel right, or a family member who was managing most of the care may start to need more support themselves.
A personalised dementia care plan gives everyone involved a clearer picture of what the person needs, what matters to them and how their care should be provided. It can help them live well in the home they love, with support that respects their choices, routines and independence.
A good care plan should reflect the person behind the diagnosis, including their preferences, interests, relationships and the way they like to live. It should also be updated as their needs and preferences change.
In this guide, we’ll look at what a dementia care plan is, what it should include, who helps develop it and how care planning can work at home.
What is a dementia care plan?
A care plan is a written record of the care and support someone needs. It’s used across health and social care and can cover everything from personal care and medication to daily routines, communication and personal preferences.
A dementia care plan is tailored to the individual. It should bring together their care needs, wishes and preferences and explain how those needs will be met.
A care needs assessment is usually an important part of this process. At Trinity Homecare, our assessment looks at more than the practical tasks someone needs help with. We also take time to understand their routines, preferences and what matters to them day to day. This information helps shape the care plan and the careful matching of a carer.
A dementia care plan may outline:
- The person’s care needs, wishes and preferences
- The support they need and when they need it
- Their usual routines and interests
- Who will provide the care
- How the care should be provided
- Any risks or concerns that need to be considered
- Important information about their health, medication and wider support
The terms “care plan” and “support plan” are sometimes used interchangeably. A support plan may focus more on practical, day-to-day help, while a care plan may take a broader view of someone’s health, preferences and care arrangements.
What is the purpose of a dementia care plan?
A dementia care plan helps everyone involved understand what good care looks like for that particular person.
Dementia affects people in different ways, so there isn’t a standard routine that works for everyone. Someone may feel more comfortable getting up early, while another person may prefer a slower start to the day. One person may find music reassuring, while another may become unsettled by too much noise.
Recording these details gives carers a better understanding of the person they’re supporting.
A dementia care plan can also:
- Keep care person-centred: It records the person’s preferences, likes, dislikes, personality, history and routines alongside their practical care needs.
- Identify potential risks: It can highlight things carers and family members need to be aware of, such as mobility difficulties, medication requirements or situations that may cause distress.
- Help everyone work consistently: When more than one person is involved in care, a clear plan helps everyone understand the agreed approach.
- Prepare for changing needs: As dementia progresses, the type or level of support someone needs can change. The care plan provides a starting point for reviewing what’s working and what needs to change.
A dementia care plan should be a living document
A care plan should develop with the person, rather than remain fixed when care begins.
As someone’s dementia and wider circumstances change, their care plan should be reviewed and updated. Changes in mobility, sleep, appetite, medication, communication or personal care needs may all be reasons to look at the plan again.
Regular reviews also give the person, their family and care team an opportunity to talk about what’s going well and whether anything needs to be done differently.
At Trinity Homecare, care plans are reviewed as part of ongoing care so they can continue to reflect the person’s needs and circumstances.
What’s included in a dementia care plan?
What goes into a care plan will depend on the person’s health, abilities, routines, preferences and support needs.
It may include information about:
- Likes, dislikes and interests: Favourite activities, music, television programmes, hobbies, foods and other things the person enjoys.
- Personality and communication: How they prefer to communicate and what helps them feel comfortable.
- Daily routines: When they usually wake up, eat, rest, go to bed and take part in activities.
- Life history: Important memories, relationships, work, family, interests and experiences that may help carers get to know the person.
- Beliefs and values: Cultural, religious or personal preferences that should be respected as part of their care.
- Personal care: The level of help needed with washing, dressing, toileting and other everyday activities.
- Meals and nutrition: Food preferences, mealtime routines and any difficulties with eating or drinking.
- Medication: Current medication and the type of support needed to take it safely.
- Mobility: Any difficulties moving around, equipment used and support needed to move safely.
- Sleep: Usual sleeping patterns and any difficulties that affect the person’s nights.
- Communication and behaviour: Things that may cause distress, as well as approaches that help the person feel calm and reassured.
- Safety: Any risks in the home or situations where additional support or supervision may be needed.
- Healthcare: Relevant medical history and details of healthcare professionals involved in the person’s care.
The plan should give carers enough information to provide consistent support while helping the person continue to make choices about their everyday life.
Who’s involved in developing a dementia care plan?
A good dementia care plan is developed with the person, not simply written for them. The person living with dementia should be supported to take part as much as possible, with their views, preferences and choices at the centre of the discussion.
Family members can provide valuable information about the person’s routines, personality, history and what they’ve noticed at home. Depending on the person’s circumstances, their GP and other healthcare professionals may contribute information about their health or treatment.
The care team brings these different perspectives together with an assessment of the support needed at home. This helps everyone understand what has been agreed and how care should fit into the person’s everyday life.
At Trinity Homecare, a member of our care team carries out the care needs assessment, taking time to understand the person’s needs, routines and preferences. The assessment helps shape their personalised care plan and the careful matching of a carer to their care needs, personality and lifestyle.
Dementia care plans for home care
Dementia care at home can look very different from one person to another. Some people may need a few visits each week, while others may eventually need several visits a day or live-in care.
The care plan helps determine what level of support is appropriate and gives the care team a clear understanding of how that support should work.
Early-stage dementia care
In the early stages of dementia, someone may continue to manage many parts of their everyday life independently. They may simply need a little more help with things such as remembering appointments, preparing meals, managing medication or keeping to a routine.
At this point, care may be about providing support without taking over.
Visiting care can be arranged around the person’s existing routine. This might mean help with meals, household tasks, shopping or appointments, as well as companionship and encouragement to continue with activities they enjoy.
Trinity’s visiting care can range from occasional visits to several visits throughout the day, depending on what the person needs.
Putting a care plan in place early can also make it easier to spot changes over time and adjust the support when necessary.
Middle-stage dementia care
As dementia progresses, everyday tasks can become more difficult. Someone may need more help with washing, dressing, eating, using the toilet or getting around safely.
They may also experience changes in their sleep, become more confused about their surroundings or need greater reassurance at certain times of day.
A care plan can help carers understand what usually works well for the person and how to respond when they become unsettled or confused.
For some families, this is also when visiting care may need to increase or transition to live-in care. A live-in carer can provide one-to-one support in the person’s own home while helping them maintain familiar routines and activities.
The level of care should be based on the person’s needs rather than simply the stage of dementia. Trinity’s dementia care service can range from visiting care to full-time live-in care.
Late-stage dementia care
In the later stages of dementia, someone is likely to need considerably more help with everyday activities. This may include eating and drinking, personal care, continence, mobility and communication.
The care plan may become more detailed as the person’s needs increase. It can set out how personal care should be provided, what helps them feel comfortable, how meals and drinks should be prepared and any support they need when moving around the home.
Some people may need care throughout the day and night. Where this is the case, the care arrangement needs to be planned around the level of support required, including appropriate overnight care.
A person’s healthcare needs should also be considered alongside their home care. GPs, nurses, therapists and other healthcare professionals may remain involved depending on the individual’s circumstances.
The benefits of dementia home care
A dementia care plan can support someone wherever their care is provided, but for many families, staying at home is an important part of the plan.
Home care can offer several benefits.
Personalised one-to-one care
At home, care can be built around the individual’s routines, preferences and choices.
A carer can get to know how someone likes to start their morning, which meals they enjoy, what they like to talk about and what helps them feel at ease.
That familiarity can be particularly helpful when dementia makes new situations or changes to routine more difficult.
Care can also be adjusted to encourage independence. Rather than automatically doing something for the person, a carer can give them the time and support they need to take part themselves.
Staying in familiar surroundings
Home is full of familiar things: photographs, furniture, favourite possessions, neighbours, pets and memories.
For someone with dementia, being able to remain in familiar surroundings can be an important part of feeling comfortable and secure.
Home care also means family and friends can continue visiting as part of the person’s normal routine.
Flexible support
Not everyone needs the same amount of care. Someone in the earlier stages of dementia may only need a few visits a week, while another person may need several visits a day or live-in care.
Home care can be adjusted as circumstances change. If someone needs more help following an illness, a change in mobility or progression of dementia, their care plan can be reviewed and the support adapted.
Support for the whole family
Dementia can affect the whole family, particularly when relatives are providing much of the care themselves.
Having professional support in place can take some of the pressure off family members. A carer can help with personal care, meals, household tasks, appointments, medication prompts and companionship, giving relatives more time to spend with their loved one as family.
Knowing that agreed support is in place can give family members greater peace of mind. Trinity Connect also helps keep loved ones informed with updates about their care, offering reassurance when they cannot be there themselves.
Trained and experienced carers
Dementia care requires patience, understanding and an approach that respects the individual.
Trinity carers receive specialist training and are carefully matched according to the person’s needs, personality and lifestyle. The aim is to build a comfortable relationship while making sure the carer has the experience needed to provide the agreed support.
Our dedicated care management team oversees the care provided, with regular reviews to help keep the personalised plan aligned with the person’s needs. Families also have a team to turn to with questions or concerns.
Frequently asked questions
Who writes a dementia care plan?
A dementia care plan is developed with the person living with dementia, their family and the care team. Their GP or other healthcare professionals may also contribute relevant information. At Trinity Homecare, the care needs assessment helps bring this information together.
What’s the difference between a care plan and a support plan?
The terms are sometimes used interchangeably. A support plan may focus on practical, day-to-day help, while a care plan may cover health, personal care, preferences and wider support. The terminology can vary, so ask the provider what their plan includes.
How often should a dementia care plan be reviewed?
A dementia care plan should be reviewed regularly and whenever care needs or circumstances change. Changes in mobility, medication, sleep or communication may prompt a review. Ask your care team when the next review is planned and how to raise concerns.
Can a dementia care plan change as someone’s needs increase?
Yes. A dementia care plan should be updated as the person’s needs change. This may mean adjusting daily routines, increasing visits or arranging a different level of support. Changes should reflect the person’s current needs and preferences, rather than their diagnosis alone.
Does every Trinity Homecare client receiving dementia care have a personalised care plan?
Yes. Every client receiving dementia care from Trinity Homecare has a personalised care plan based on their individual needs, preferences and routines. The plan is reviewed as those needs change, so the support continues to reflect what matters to the person.
Talk to us about dementia care at home
Putting a dementia care plan in place doesn’t mean you have to predict exactly what will happen in the future.
It’s about understanding what matters to the person now, making sure their care reflects those needs and having a plan that can change as their circumstances do.
At Trinity Homecare, we’ll start with a conversation about your needs or those of your loved one and arrange a free care needs assessment. From there, our care team can develop a personalised care plan and carefully match a carer to the person’s needs, personality and lifestyle.
To speak to a care expert about dementia care at home, call 0207 183 4884 in confidence or complete our online enquiry form.
