A live-in care support plan is a written record of how you like to live and the help you need to do it. It can cover personal care, medicines, meals, mobility, safety around the home and the practicalities of having a carer living with you.
It’s also something your carer will use every day, so the detail matters. It might include what time you usually get up, how you take your tea, which things you want to keep doing yourself and where you’d like a hand.
If you’re helping a relative or friend arrange care, their wishes and preferences should be at the heart of the plan.
When is a live-in care support plan written?
At Trinity Homecare, your free care needs assessment is used to create your support plan, which may also be called a care plan or personal support plan. It’s developed with you and agreed before care begins.
The assessment usually takes place in your own home. It looks at how you live, what matters to you and where you need help, rather than simply making a list of care tasks.
Our care team can talk you and those close to you through the planning process while keeping your wishes at the centre. You can have a relative, friend or advocate with you, and with your agreement, professionals who know you, such as an occupational therapist or social worker, can also contribute.
What does a support plan include?
Your support plan gives your carer a clear picture of your needs, preferences and daily routine. Depending on your circumstances, it may cover:
- About you: Your background, relationships, interests, beliefs, daily routine, house rules, communication preferences and what you want from your care. You can also record wishes for the future, including end-of-life care.
- Your details and key contacts: Your GP and other professionals involved in your care, emergency contacts and anyone who holds a registered lasting power of attorney.
- Personal care: What you can do for yourself, where you’d like help and how you prefer that help to be given.
- Mobility and equipment: How you get around, any equipment or mobility aids you use and how your carer should support you safely.
- Medication and health: Your health conditions and medicines, whether you manage these yourself or need agreed support, plus any clinical tasks and who is responsible for them.
- Food and drink: Your dietary needs, likes and dislikes, mealtimes and any professional advice around eating or drinking.
- Living with your carer: Their bedroom, meals, working hours and breaks, including who provides support during breaks if you need someone with you. Overnight arrangements should make a clear distinction between occasional help and regular night-time support, which may need additional care.
- Your home: Access arrangements, pets, appliances, where to turn off the water, gas and electricity, and what to do in a fire or other emergency.
- Risks and how they’re managed: Things such as falls, poor nutrition or skin damage, along with practical ways to reduce those risks while respecting your choices.
Important care decisions and documents
Your plan should record any advance decision to refuse treatment or do not attempt cardiopulmonary resuscitation (DNACPR) form, including where the document is kept.
An advance decision to refuse treatment is made by you while you have capacity. A DNACPR decision relates to cardiopulmonary resuscitation (CPR) only. It may reflect your wishes or a doctor’s clinical judgement and doesn’t mean other appropriate care or treatment should stop.
A plan that starts with what you want
Our case study of a safe return home shows how someone’s own wishes can shape their care.
A man returning home after almost five weeks in hospital wanted to continue managing his own medication. Rather than taking this responsibility away from him, his care team supported his choice with appropriate oversight and regular reviews involving his family and healthcare professionals.
As his strength returned, his plan was reviewed and his live-in care was replaced with three care visits a day.
Every situation is different, but that’s what a support plan is there for: to help someone live the way they want to, with the right support around them.
Who does what once the plan is in place?
At Trinity Homecare, your support plan is part of a fully managed care service. There’s a team behind your live-in carer, so you’re not left to manage everything yourself.
- Your live-in carer is carefully matched to your care needs, interests and personality. They follow the agreed plan and record the care they provide.
- Your care manager coordinates your care, keeps the plan up to date as your needs and preferences change and is there to help if something isn’t working.
- Clinical support is available when your needs are more complex. Your plan explains who provides clinical input and when your carer should seek advice. If a nurse or another regulated healthcare professional delegates a healthcare task, your carer must have the appropriate training, be assessed as competent and receive suitable support and supervision.
Keeping you and your family informed
Your support plan and daily care notes are stored digitally in TrinityConnect. You can access your records, and family members can be given access at your request and with your consent.
One relative using TrinityConnect to follow their mother’s care says access to the notes “has helped me to feel so much more connected.”
How are consent and decision-making supported?
Your consent to care
Your consent is needed before care is provided. Agreeing your support plan doesn’t mean you lose the right to change your mind or refuse a particular type of support.
The Care Quality Commission (CQC), England’s care regulator, treats consent as an ongoing process. If you have capacity to make a particular decision, your choice to refuse that support must be respected.
Support to make your own decisions
Under the Mental Capacity Act, which applies in England and Wales, you’re assumed to have capacity to make your own decisions unless it’s established otherwise.
You should be given help to make a decision wherever possible. Making a choice that someone else considers unwise doesn’t, on its own, mean that you lack capacity.
Capacity is assessed in relation to a particular decision at the time it needs to be made, and it can change over time. Needing help with one decision doesn’t mean you lose your say in other areas of your life.
When someone needs to decide on your behalf
If you lack capacity to make a particular care decision, that decision must be made in line with the Mental Capacity Act and in your best interests. The person making the decision must also consider whether your needs could be met in a way that places fewer restrictions on your rights and freedom.
A registered health and welfare lasting power of attorney allows your chosen attorney to make decisions within the authority you’ve given them, but only when you lack capacity for the decision concerned.
People close to you should be consulted about your wishes where appropriate. Being consulted, however, isn’t the same as having the legal authority to make the decision.
How often is a support plan reviewed?
At Trinity Homecare, support plans are reviewed regularly to make sure they continue to reflect your needs and provide the right standard of care. We’ll confirm the review arrangements with you before care starts.
Your care plan is there to change when your circumstances change. You can contact your care manager if something has changed rather than waiting for your next scheduled review.
As general guidance for older people receiving home care, NICE’s quality standard recommends a review within six weeks of the service starting and at least once a year afterwards. A review may also be needed sooner if circumstances change, such as after a hospital stay.
Frequently asked questions
Is a support plan the same as a council care and support plan?
No. A provider’s support plan explains how that provider will care for you.
In England, council care and support planning starts with a local authority needs assessment. The assessment is free and anyone can ask for one.
You can arrange care privately without a council assessment. If you want to seek support from the council, you’ll normally need an assessment. Help with care costs also depends on eligibility and a financial assessment.
Can I see my plan and ask for changes?
Yes. You can read your plan, ask questions about anything in it and speak to your care manager about making changes.
Your plan should continue to reflect your needs and preferences as they change rather than treating the original arrangement as permanent.
What should I have ready for the assessment?
It can help to have a list of your medicines, contact details for your GP and other professionals involved in your care, and any registered lasting power of attorney or advance decision you have.
You might also make a note of your usual routine, the things you want to keep doing yourself and any questions you’d like to ask.
How to arrange live-in care with Trinity
Arranging live-in care with Trinity involves five simple steps:
- Speak to our care team about your needs.
- Have a free, no-obligation consultation and arrange a care assessment.
- We create your support plan after the assessment and agree it with you.
- We carefully match you with a live-in carer based on your care needs, personality and preferences.
- Care begins, with ongoing management and reviews as your needs and preferences change.
Speak to a care expert about your support plan
Our care team can talk you through the assessment process and what your support plan might cover, with no obligation to go ahead.
Get in touch with Trinity Homecare to discuss care for yourself or someone close to you, or to arrange a free assessment.
