Intent of this requirement
A care and services plan is expected to be documented and reflect the outcomes of assessment and planning for each consumer. Accurate and up-to-date care and services plans are important for delivering safe and effective care and services, as well as positive outcomes for consumers.
A care and services plan, which includes a person’s needs, goals and preferences, should be available to the consumer in a way they can understand. This may involve support to have information in an accessible language and format, or to help consumers understand the content. It may include involving consumers in discussions, inviting them to meet and encouraging them to ask questions about their care and services plan. This will help consumers understand and have ownership of the care and services plan as they are entitled to have.
The care and services plan can take different forms. It can be a single document or several documents that show an overview of the care and services to be delivered. It should be available to those providing care and services to the consumer. This doesn’t mean the care and services plan needs to be available at all times and to all members of the workforce, but the relevant information must be available when and where it is needed to support safe and effective care and services.
Relevant risks to a consumer’s safety, health and well-being need to be documented in the care and services plan to make sure their safety isn’t compromised. This includes things such as allergies and other risks relating to the consumer’s needs.
When two or more organisations, individuals or service providers share a consumer’s care and services, or where there are integrated services, the care and services plan and outcomes from assessment and planning need to be shared. Information sharing needs to happen promptly and comply with obligations relating to privacy of information.
- How does the organisation communicate assessment and planning information in a way the consumer understands?
- When a consumer asks for a copy of their care and services plan, how promptly does the organisation provide it? Is it in a format they understand?
- When a consumer has trouble understanding outcomes of assessment and planning, how does the organisation support the consumer? Are interpreters available when explaining the plan? How are the consumer’s representatives involved?
- How does the organisation document care and services plans? Are they in plain English?
- What systems are in place to make sure relevant information for delivering a consumer’s care and services is available where the care or service is actually delivered?
- What processes are there to communicate critical information in a care and services plan to the workforce, including information alerts and risks?
- Is the level of detail in the care and services plans enough to enable the appropriate and correct delivery of care and services to the consumer to optimise consumer health and well-being? For example, the consumer’s preferences for personal hygiene, oral health care, taking medication, how to check a hearing device is working properly and where glasses are kept.
Examples of actions and evidence
- Consumers say they know how to get a copy of their care and services plan if they want it. They say it will be in a format they can understand and they will get it in a timely manner.
- Consumers say they have been supported to understand their care and services plan and can describe how it meets their needs, goals and preferences.
- Consumers can describe the details of their care and services plan and who will provide the care and services.
- Consumers confirm they are involved if changes are made to their care and services plan, and they understand the changes.
Workforce and others
- The workforce can describe processes for documenting the outcomes of assessment and planning in a care and services plan.
- The workforce can describe how they access the care and services plan and how they use the information in it that is relevant to their role to deliver safe and effective care and services.
- The workforce can describe how changes to the care and services plan are communicated and say they receive updated information promptly.
- The workforce say care and services plans are current and contain enough detail to deliver appropriate and correct care and services for the consumer.
- Workforce orientation, training or other records that show how the organisation supports the workforce to document and communicate the results of assessment and planning and meet this requirement.
- Policies and procedures explain the organisation’s systems, so that outcomes of assessment and planning are fully documented and are available where care and services are delivered.
- Evidence that care and services plans are accurate and reflect the outcomes of the most up-to-date assessments and reviews of consumer needs, goals or preferences.
- Evidence the consumer or their representative is involved in developing and reviewing the care and services plan.
- Evidence of how the organisation monitors the effectiveness of the care and services plan and documents assessment and planning process to improve outcomes for consumers.