Person-Centred Care Plans and Pathways
Care plans
The central aim is to enable people to get on with their lives with the right support.
When a person comes to a service there is usually a 12-week assessment period. For most individuals a pre-admission assessment has already been carried out. A key clinician and suitable service will have been identified and an assessment will see us suggest or agree on key objectives with the person, referring or commissioning teams and significant others.
The assessment will inform the development, with the person, of their own Person-Centred Plan. This will take into account all of the elements addressed in the assessment as well as key historical information including family history, background, interests, legal issues including with respect to the Mental Health Act for example, self care and other abilities including cognitive, motor and perceptual, community and domestic skills, communication abilities and social and adaptive skills.
Running through the assessment, is the assessment of risk - as fundamental to developing a positive risk management strategy for the service user.
Person-centred plans help us discover and encourage the individual's wants, wishes, dreams, ambitions and so on and make sure that "clinical" plans don't take up his or her whole time. Person-centred plans address the need for us to listen to people and their expectations and make sure we also monitor their progress in terms of quality of life.
We aim to focus on what progress means for the individual and will produce a plan that states exactly how we will support each person, the standards and outcomes to be achieved and who will deliver each aspect of the plan. This will also identify the resources we need to provide for each person's needs.
The Pathway
A pathway is identified as part of each person's person-centred plan.
Castlebeck usually provides all the support at the acute phase. As people move on, this can be within our services. Our services cover a pathway from acute through rehabilitation services, "step-down" facilities, our Graded Rehabilitation Annexes and our residential homes and further on into community-based services provided by Castlebeck or by other providers perhaps in partnership with Castlebeck, including supported living arrangements.
