The Fife Dementia Strategy: 2010 – 2020 - The Knowledge Network

4.7.2 Care at home providers regularly review and respond to the
changing needs of service users with dementia, and that this is done
using a multidisciplinary approach with a single, shared care plan.
Dementia is a progressive condition. For many people living with dementia
care at home may be the primary or potentially only support delivered within
the home environment. Care plans are a very important aspect of care at
home services as they guide home care workers, and may also provide vital
information for acute care staff and other health and social care professionals
in an emergency situation. Regular and accurate reviews and updates, and
easy accessibility are necessary to ensure that personalised services are
being provided in an integrated fashion which meets the changing needs of
the individual with dementia. Information must be communicated across
services, and care routines and practices followed as closely as possible –
people must not have multiple care plans with variable information. One care
plan should be utilised and shared across all services the person uses with
channels for sharing changes and updates well established and followed.
Currently for all services provided or commissioned by the Council, formal
care plan reviews are to occur a minimum of every six months, with all
external providers supplying the Council with updates of the review and
notifying the Council to any alterations in the care plan (increased or
decreased need). There are reported issues with the implementation and
monitoring of the current system as changes in need and care plans are not
always communicated to the appropriate bodies. A review is required to
improve understanding of the current issues, and alternate models for
information sharing should be considered to ensure equality in the
assessment of need and allow for better regulation of external providers.
The content of care plans must include relevant information about the person
with dementia, including their personal preferences and needs, and a brief life
history, including their past residences and the contact details of family and
friends. This was identified as being of high importance by the Police and
other services during an emergency situation, especially when a person with
dementia becomes lost or disorientated as they may attempt to return to these
locations. It is also necessary that the care plan is located in an easily
identifiable and accessible location, and that this location is the same for all
individuals receiving support at home.
The single care plan will be used across services in organisations to improve
continuity in care. And, while it is recognised that some information may not
be shared due to data protection, the single care plan will act as the basis for
coordinating care delivery.
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