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

4.10.4 Care plans are developed in partnership with the person with
dementia, their carers and family and are individualised to each resident
in order to provide the right care to meet their needs.
As highlighted by the recent report Remember, I’m Still Me 62 and in Sections
4.7.2 and 4.9.2 it is important to know about how a person lived before they
developed dementia. Care plans for people living in long term care are vital to
the care they receive as they highlight the needs and preferences of the
individual. Recording personal information and a life history will help care
workers to individualise the care of the person with dementia and support
them to maintain their identity. Information about the individual, their needs
and preferences should be added to care plans whenever it comes to light,
not only during periods of formal review. All staff should have access to and
regularly review the knowledge and information stored in a care plan which
will allow them to provide appropriate individualised care.
In line with the National Care Standards for Care Homes, all care homes will
work with people with dementia to develop comprehensive care plans which
include life histories and a personal plan which details the needs and
preferences of the person with dementia and sets out how they will be met. It
is recommended that these principles are extended across all long term care
facilities in Fife including care homes and long term care wards.
In order to achieve this Fife Council Residential Care Services will work in
partnership with NHS Fife staff and independent providers to redesign the
current care plan template, ensuring there is adequate space and direction to
include personal and individual details. These will be based on similar care
plans which have been successfully used in learning disability and children’s
and family services. The universality of care plans used in Fife will be
welcomed by emergency services and carers alike as it may improve ease in
access and understanding. All care workers in long term facilities will receive
training on developing care plans including the addition of information
collected during both informal and formal reviews.
My husband has been here (in care) for some years. He came here
initially for day care, regularly, and then he came into respite to give me a
break. And then, eventually, I was getting as old as he was and so he
came here. I cannot remember how long he has been…but he came here
so regularly, it was like his second home. He called it his condo. (Carer)
4.10.5 Ensure all long term care facilities have regular involvement of
trained activities coordinator who works with the care staff to provide
meaningful activities to residents on a regular and ongoing basis.
As highlighted in Section 4.9.1 activities and programmes must be available
which are suited to the individual and based on an understanding of what
gives their life meaning. Activities for people in long term care must be a
62 Care Commision & Mental Welfare Commission for Scotland (2009).
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