Assessment, Care Planning and Review
Aim: The care home will understand holistic assessment and its relevance to advance care planning. They will explore systems to discuss, record, review and share assessments appropriately
Objectives:
- Recognise the importance of the assessment, planning and review of holistic care
- Be able to provide individualised Advance Care Planning to support residents wishes
- Understand the implications of the Mental Capacity Act, Best Interest Decision Making and Lasting Power of Attorney
Joint and shared resources
Attendance register
A register that can be used at any events and workshops. Download:
Attendance Register v2
Evaluation form
Provides feedback to the facilitators, which will help continually develop and improve the delivery of the programme. Download:
Evaluation form v2
Six Steps Organisational Programme Resources
PowerPoint presentation
A sample presentation that can be adapted for Step 2 workshop. Download:
Step 2 PowerPoint Presentation v4
Holistic common assessment guide
Guidance to understand a patient’s needs, preferences and priorities for care. Download:
Holistic Common Assessment Guide v2010
Universal Principles for Advance Care Planning (ACP)
This document sets out six high level principles for advance care planning in England. Download:
Universal Principles for Advance Care Planning (ACP) vMarch 2022
Planning for your future care
A simple guide to Advance Care Planning and the different options open to people approaching end of life. Download:
Planning for Your Future Care v2014
Preferred Priorities for Care document
Useful planning guide to help an individual decide their preferences and wishes to plan for the future. Download:
Preferred Priorities for Care Document v2011
Guide to Preferred Priorities for Care
Provides information on how the Preferred Priorities for Care Document can be used. Download:
Guide to Preferred Priorities for Care
Thinking Ahead Looking Ahead ACP Tool
A document to help inform decisions about future care preferences and wishes for people living in care homes (A PACE study document). Download:
Thinking Ahead - Looking Ahead ACP Tool (PACE document)
Mental Capacity Act guide
A guide on the Mental Capacity Act for those working in Heath and Social Care (Office of the Public Guardian). Download:
Mental Capacity Act Guide
Mental Capacity Act guidance
A guide to help health and social care professionals to help people who are are unable to make some decisions for themselves (CQC). Download:
Mental Capacity Act Guidance v2011
Why use the Mental Capacity Act
A guide to help health and social care professionals to consider why they use the MCA (Edge). Download:
Why use the MCA v2021
Capacity care planning
Provides information on capacity and care planning for health and social care professionals (NHS). Download:
Capacity Care Planning v2014
Best Interests at end of life
A guide that provides information on the Mental Capacity Act for those working in Heath and Social Care. Download:
Best Interests at End of Life v2008
The Route to Success in End of Life Care - LGBT
A guide to Achieving Quality for lesbian, gay, bisexual and transgender people on end of life issues. Download:
The Route to Success in End of Life Care - LGBT v2012
Palliative Care and End of Life Care for Black, Asian and Minority Groups
Provides guidance of end of life issues. Download:
Palliative Care and End of Life Care for Black, Asian and Minority Groups v2013
Step 2 to do list
Provides a checklist of actions to be carried out for the next workshop. Download:
Step 2 to do list v2
Six Steps to Learning Resources
Case study
Margaret – A case study around a person who has had a stroke. Download:
Margaret - a case study v4
TO USE WITH – Care plan template to record an individual’s needs. Download:
Care plan for use with Margaret case study v3
Support Sheet - Holistic assessment
Provides information on how holistic assessment should be carried out. Download:
Support Sheet - Holistic Assessment v2
Reflection activity ST2.1
Reflection sheet for a holistic assessment. Download:
Reflection activity ST2.1 v2
Support Sheet - ACP
Provides information on Advance Care Planning. Download:
Support Sheet - Advance Care Planning v2
Support Sheet - ADRT
Provides information on Advance Decisions to Refuse Treatment. Download:
Support Sheet - Advance Decisions to Refuse Treatment v2
Support Sheet - Advance Statements
Provides information on Advance Statements. Download:
Support Sheet - Advance Statements v2
Support Sheet - MCA
Information on the Mental Capacity Act. Download:
Support Sheet - MCA v2
Support Sheet - BID
Information on Best Interest Decision Making. Download:
Support Sheet - Best Interests Decisions v2
Support Sheet - LPA
Information on Lasting Power of Attorney. Download:
Support sheet - Lasting Power of Attorney v1
Doris - Dementia case study
A learning aid providing a case study around a resident with Dementia around Advance Care Planning. Download:
Doris - A case study for a person with dementia v3
Doris - Dementia case study with facilitator notes
Notes for facilitators for the case study around a resident with Dementia and ACP. Download:
Doris - A Dementia Case Study WITH FACILITATOR NOTES v3
Betty - An interactive discussion of future wishes (ACP) (A set of eight videos)
This set of videos provides a learning aid in the form of a case study around Betty, a resident, to discuss her future wishes. This is followed by a discussion with Louise, Betty’s daughter, who has different views to her Mum. There are follow up videos with Betty, Louise and the nurse, Mandy where they reflect on the discussions. Go to the download to find the links to all of the videos and a set of cue notes to use the videos as a teaching aid. Download:
Betty - An interactive discussion of ACP wishes (with 8 videos) v2