Care Planning

• An assessment of your health and social care needs
• You will be offered a written Care Plan detailing the help and support that you will receive
• Regular review meetings to discuss how your care plan is working and agree together changes that may be needed
• A named care co-ordinator who will work specifically with you
• The confidence of knowing who to contact and what to do in times of crisis

Carers will be offered an assessment of their own needs, which should be reviewed every year.

We will meet with you to discuss and assess your health and social care needs and the care and support you need. With your permission, other people who know you well, such as your carer, or close relative, may be asked for their views about your needs. Additionally your GP and other professionals involved in your care will be consulted. We will take account your gender and any issues of culture and ethnicity that are important to you.

With your full involvement we will agree a plan of your care including the support and services that will be provided and what to do and who to contact in times of crisis. You will be given a written copy of your care plan to sign if you are in full agreement. Your carer will be involved in developing this plan if you wish them to be.

You may find it helpful to plan ahead for your care in the event that you are unwell in the future. You can do this through what is called an advance statement in which you can express your wishes about your care. Your care co-ordinator can help you with this.

The care co-ordinator is the professional whose role it is to organise your CPA review meetings, to co-ordinate your care and to ensure that your care and support is provided by those named in your care plan. The care co-ordinator will normally be the central point of contact with services and the person you or your carer generally speaks to. The care co-ordinator may be a nurse, social worker, doctor, psychologist, occupational therapist, or at times and with your agreement, a service in the community that works in cooperation with Surrey and Borders. If issues of gender, culture or ethnicity are important for you, this will be considered, whenever possible, in the allocation of your care co-ordinator.

Your care co-ordinator will arrange with you a date and place for you and everyone involved in your care to attend your CPA review meetings. CPA reviews are a meeting where your care plan is reviewed by discussing what is working well and what may need to be improved or changed. Views can be expressed, problems identified, progress discussed, and medication reviewed and necessary changes to your care plan made. If you find it difficult to express your views in the meetings, you will be encouraged and supported to bring your carer, advocate or a friend to support you.

At the end of the CPA review you will be given a written copy of the revised care plan and asked if it records accurately what was discussed and agreed at the meeting. You will then be given a copy of your care plan to sign.

CPA reviews are on going and a date will be set for your next CPA review at the end of the meeting. You or anyone involved in your care can request a review at any time.

Carers, with the agreement of the person receiving care, can attend and be involved in the CPA review meeting.

You have the right to disagree and are encouraged to discuss the care and support that you are receiving with the staff involved in your care. You should discuss any concerns with your care co-ordinator. If you feel unable to do so, we would encourage you to seek support from someone, eg an advocate who can support or represent your views.

If you are concerned or worried about your CPA review, you can prepare by discussing your concerns with your care co-ordinator or by having an advocate, family member or friend come with you.

Health and Social Services may need to share information about you to make sure you receive the care you need. Your GP will also need to be kept informed about your treatment, progress and care plan. Information will only be passed to other agencies, eg housing or voluntary agencies, with your permission and if they have a direct need to know in order to help you.