This document contains prompts for creating care plans related to communication, continence, daily life/lifestyle, death and dying, emotional support, finance, maintaining a safe environment, medical, medication, mental capacity, mobility, nutrition, personal care, sexuality, and skin integrity. For each topic, it lists relevant assessments and prompts questions about the person's needs, preferences, abilities, diagnoses, and support systems. The goal is to develop individualized care plans based on a holistic understanding of the person's situation.

1. Prompt
notes for
care
planning

2. Communication
Do they communicate
verbally?
Is their eye sigh
satisfactory? Do they
wear glasses? Who is
their chosen opticians?
Is there hearing
satisfactory? Do they
wear aids? Do they need
support in changing
batteries and putting
aids in? Do they often
suffer with blocked ear
and benefit from olive oil
drops?
Body language, What may
they typically display through
there body language when
they are unhappy/happy.
Telephone ? Do they have access
to a telephone within there
bedroom or a mobile. Do they
need a specialist telephone with
large numbers to see ? Do they
need assistance with dialling
numbers.
Are they able to
communicate when they
are in pain? VRS pain score
need to be used or abbey
pain score to be used?
How do they communicate
anxiety/frustration?
Communicating with
others? Do they enjoy
engaging with others?
How are we as a home communicating
events/ activities and news updates?
News boards, activity planners, Home’s
news papers.
Can they use the bell?
How do they summon
assistance?

3. Continence
Linked assessments:
Continence (mandatory)
Eton Constipation (is applicable)

4. Continence
Are they continent? Are
they doubly
incontinent? Personal
care needed.
Do they need continent
aids? Are they being
prescribed and does a
assessment need to be
carried out to have
them prescribed?
Or do they wish to
purchase their own?
What support
level is needed
when using the
toilet?
Link skin
integrity to
the care
plan?
Do they need any aids
when using the toilet?
Toilet raiser? Commode?
Do they suffer with
constipation? What plan is
in place to support this?
Stoma Care. & Catheter
care.
Can the communicate to you if they
need to use the toilet?
Have they made a
preference of female and
male carers?

5. Daily life/ Lifestyle
Linked assessments:
Barthel (mandatory)
Dependency (mandatory)
Please add a Visits Care Plan

6. Daily life/ life
style
Do they have any
specific routines that
they like to follow
during the day and
night?
Have they made any
known wishes regarding
there care? Such as
being disturbed before
8am.
What activities/interests and
hobbies do/did they have?
What do we do to meet
these needs
Dining
preferences.
Life history.
Do they like newspapers,
reading materials or
audios?
Do they prefer to socialise
with others or prefer there
own company?
What do they do in a
normal day?
Do they preferer to spend
more time out in the
gardens or community
than indoors?

7. Death and Dying
Link Assessments:
• Advanced Care Plan

8. Death & Dying.
Do they have a RESPECT
form in place? DNAR.
If they are stable Do
they wish to discuss
their death and dying
wishes? And if so what
are they? Have they
chosen or pre arranged
a funeral director?
If they would like a
particular family
member or friend to be
kept updated with
regards to there health
who would this be?
Have family and
friends made any
wishes in regards
to be informed
whether its day
or night.
Are they on a syringe
driver?
Are they receiving
palliative care and
what is their
prognosis?
Are there any written
statements of wishes made
by the person?

9. Emotional Support
Linked Assessments:
Cornell Depression Scale (if applicable)
Crichton scale (if applicable)
Behaviour Development (if applicable)

10. Emotional
support.
Do they have a cognitive
diagnosis that could
effect their emotional
well being?
Environments? Is there a
preferred environment,
do they find loud
environments
overwhelming?
Who do they seek
emotional support
from? Family, care team
friends?
When might they
need emotional
support?
Do they have any support
from the MHT?
Is there anything
relating to there life
history that can effect
their emotional well-
being?
Do they experience
upset/distressed
behaviour? How can we
support them with this?
Do they know where they
are? Do they accept
being in a care home?

11. Finance.
Does the person have
capacity to make all
decisions relating to
there finances?
Does the person have a
chosen Lasting power of
attorney for financial &
property affairs?
Does the resident keep
their own money on
them or is there money
kept within the safe in
the admin office for use
of small purchase’s?
Care funding. Are they
self funding? Or
receiving financials
support?

12. Maintaining Safe Environment
Linked Assessments:
Falls Risk (mandatory)
PEEP (mandatory)
General risk (if applicable)
Safe smoking (if applicable)
Bed rails (if applicable and unable to consent)
MCA – sensor mat (if unable to consent)
MCA – bed rails (if unable to conset)

13. Maintaining a
safe
environment.
DOLS in place? Refer to
the DOLS if they are
restricted from leaving
the building alone?
PEEP in place and where
this can be located to
use in the event of an
evacuation.
Are they presenting as a
risk of falls?
Are they able to
perceive hazards?
Can they call for help?
Do they need
glasses? Detail
that we need to
prompt people to
wear to aid
eyesight.
Are they mobile?- link to
mobility care plan?
Any known allergies?
Detail the risk of slips trips
and fall removing all
potential hazards from
their environment.
Are they able to
regulate
temperatures ?
Accordingly and
need support?

14. Medical
Add a separate care plan for:
CVA
Parkinson’s
MS
Diabetes
Epilepsy
Wounds
Please add a Covid-19 Care Plan

15. Medical
Do we have a medical
summary and link this to
the care plan.
Do they have a
treatment escalation
plan in place DNAR.?
What is there known
medical diagnosis?
Any known
medical
allergies?
Does the persona have a
chosen lasting power of
attorney for health &
welfare?
Does the person wish
for us to update
family/friends in
regards to any changes
within there medical
health?
Is the person self
medicating or needing
support? Covert
medication?
Registered GP? Are they able
to hold review meetings
with the GP themselves or
would they like support in
arranging this.
Do they need
there blood
sugars, INR,
blood pressures
taken on a
regular basis?

16. Medication
Linked Assessments:
Self Medication (Mandatory)
MCA - Administration of medication (if unable to consent)
MCA – Covert Medication (if applicable)

17. Medication
Are they self
administering their own
medication or need
support? Please
complete a self-med
assessment. Can they
consent to the
administration of meds?
Please state or MCA
Covert medication?
LPA over health &
welfare, inform and
update as the resident
wishes us too.
Do they have any
difficulty with
taking
medication and
do they have a
preferred way in
taking this?
Are they on any time
critical medication, what is
this and reference to the
Emar.
Is there any known
medication allergies?
Reference to the Emar,
FP10 homely remedies and
PRN protocols in place and
where these can be
located.
Is the person
taking any
medication where
they pulse rate will
need to be
measured before
hand? Or there INR
to be tested
rguarly.
Is the person on
any antipsychotic
medication? Due
to be reviewed six
weekly.

18. Mental Capacity
Linked assessments:
Any Mental Capacity Assessment
Please add a DoLS care plan if there is a DoLS application

19. Mental capacity
Have they got capacity?
Has a DOLS been
applied for ? When was
it applied for – link to
DOLS care plan.
Have they got a
appointed person for
Lasting power of
attorney for both
financial affairs and
health and welfare.
Are they able to
contribute in
making decisions
relating to their
care and finical
matters?
Link in any consent forms
that have been signed by
the person or there LPA on
their behalf.
Are they able to be
involved in small decisions

20. Mobility
Linked Assessments:
Falls Risk (mandatory)
Mobility (mandatory)

21. Mobility
Are they mobile or need
assistance with
transferring? What aids
do they need to support
them?
Are they receiving any
support from the Physio
or OT?
Can their motility be
effected if they are
unwell?
Do they have
suitable
footwear?
Do they have bed rails in
place?
Is there any health
issue that will effect
their mobility long
term ?
Are they at risk of falling?
Link in falls assessment
with clear guidance of how
we are supporting this risk
to be reducecd.

22. Nutrition
Linked Assessments:
Nutrition (mandatory)
MUST (mandatory)
Chocking (mandatory)
Fluid Watch (if applicable)

23. Nutrition
Have they got any
dietary likes/dislikes?
Any known food
allergies?
Any dietary
intolerances?
Any specialist
diet? Are they on
a specific food or
fluid texture?
Link in MUST assessment,
are they on weekly or
monthly weights?
Do they have any
adapted cutlery or
crockery? Do they
need support with
eating and drinking?
Are they under weight and
need the support of any
supplements? Or already
under the care of the
detain?
Are they at risk of
dehydration? If so
also create a
general risk
assessment and link
it to this care plan.
Where do they prefer to eat?
Lounge/bedroom

24. Personal Care
Linked assessments:
Barthel (mandatory)
Dependency (mandatory)
Oral Health (mandatory)

25. Personal care
What are the wishes of
the resident? How
would they like to be
supported with personal
care. Bath or Shower?
Foot care, do they need
a chiropodist and who
will this be as well as
frequency of visits.
Does the resident need
support with oral mouth
care?
Nail care, does
the resident need
support with
this? Do they like
to receive a
manicure also?
Does the resident need
support with
shaving/make-up? How do
they prefer to be shaved?
Does the resident visit
the hairdresser and
who is this?
Does the resident need
your help with providing
support in getting
everything ready for them
such as towel toiletries
clothing.
Who purchases
manages toiletries?
Do they use
moisturaisers?
Can they choose clothes?

26. Sexuality
If they are in a
relationship how do we
support there partner to
feel welcomed and have
quality time together
Is there a image that
they are setting out to
achieve daily?
Make up?
Clean shave?
Smart clothing.
What is their sexual
orientation?
What gender do
they identify as?
Are they in a
relationship? Married?
Have they got any active
sexual need? How can we
support them?

27. Skin Integrity
Linked Assessments:
Waterlow (mandatory)
MUST (mandatory)

28. Skin integrity
Any wounds that we are
aware of are to be
recorded in this care
plan as well as in the
wound care plan.
Are wounds managed by
internal nurses or DNs?
Are the district nurse
team involved or is a
referral needed? How
many times are they
visiting? Make reference
to the district nurse
diary.
Do they have or need
any pressure relieving
equipment and what is
this?? Do we check that
those are functioning
correctly daily? MUST
DO actions
Are they under
the care of the
dietitian or need
a referral?
Are the on scheduled turns
to reduce pressure areas?
MUST DO actions
Waterlow assessment
to be updated and
linked to this care plan.
Creams in place that have
been prescribed for their
use? MUST DO actions

29. Sleeping
Have they consented to
acoustic monitoring
record in the care plan
whether they have or
haven’t. Also refer to
hard copy consent
forms.
Do they needs turns in
the night? Air mattress?
What support does the
person need to get
in/out of bed and get
ready for bed.
Are they
continent and do
they continence
checks or help to
use the toilet
during the night?
Are they able to use a call
bell during the night to call
for assistance?
Do they sleep well
during the night? Do
they wake without
stress. Do they require
any medication?
Would they like to be
checked visually during the
night?
What time do they usually go to sleep
and wake up? Do they have any routine?
Do they sleep in pj/underwear/clothes?
Do they want a small light on or do they
prefer to sleep in the dark? Do they
have a drink before sleeping?
Do they have bed
rails? Sensor mat?
Low profiling bed?
Crash mat?

30. Things to Remember
Scanned docs:
Pre-admission assessment
GP summary
Any consent
LPA
Property list
BAME risk assessment
DoLS (if applicable)

31. Things to remember
Planned Care Actions:
Please add a ‘MUST DO’ care action for anything that you state in the
care plan you do regularly
Examples:
Moisturising creams (state in the summary where to apply the cream)
Checking the air mattress (state in the summary the correct settings)
Fluid watch, snacks, weekly weights etc…..

32. Things to remember
Consent:
You need a written consent for the Covid-19 swab and photography. If
the Resident does not have capacity, the LPA for Health and Welfare
can sign the consent. If there is no LPA for Health and Welfare you need
to complete an MCA and BI involving the Resident’s family members in
the decision.
You need a verbal consent documented in the care plan for the
administration of medication, sensor mat and bed rails. If the Resident
does not have capacity, you need to complete an MCA and BI involving
the Resident’s family members in the decision.