Creating a care plan

Basic Care Plan Framework

1. Personal Information

  • Patient’s full name, DOB, NHS number

  • Next of kin / main contact

  • GP details

  • Social worker / care coordinator

  • Care agency contact (if applicable)

2. Daily Living Needs

  • Food & nutrition: type of meals (home-cooked by carer, ready-made, delivered meals on wheels)

  • Shopping: who does it, how often, delivery vs. in-person

  • Hydration: monitoring fluid intake if needed

3. Mobility & Equipment

  • Mobility aids: walking frame, wheelchair, sticks

  • Furniture/equipment: correct type of bed, mattress (pressure care), supportive chair, rails, grab bars

  • Physiotherapy / exercise: sessions arranged, home-based exercises

4. Medication Management

  • Who administers medication (carer, district nurse, patient themselves)

  • How medication is organised (dosette box, blister packs, pharmacy delivery)

  • Monitoring side effects / missed doses

5. Environment & Safety

  • Risk assessment:

    • Layout of accommodation (stairs, bathroom access, hazards)

    • Fire safety / fall prevention

  • Sanitation / cleaning:

    • Who cleans, how often

    • Laundry, hygiene support

6. Health & Nursing Care

  • District nurse visits: frequency and purpose (dressings, injections, monitoring)

  • GP involvement: medication reviews, health checks

  • Specialist input: physiotherapy, occupational therapy

7. Type of Care Arrangement

  • Care at home:

    • Agency carers (hours per day/week)

    • Family carers (what tasks, what times)

    • Voluntary/community support (befriending, transport, meals)

  • Extra care housing or care home if needs exceed safe support at home

8. Financial Assessment & Costs

  • Local authority financial assessment (means-tested) for care costs

  • NHS-funded options (e.g., Continuing Healthcare if complex medical needs)

  • Identify gaps where family is paying out of pocket (private carers, equipment, transport)

  • Explore savings:

    • Equipment loaned via NHS/OT rather than purchased

    • Voluntary sector support (day centres, transport, respite care)

    • Attendance Allowance / Carer’s Allowance eligibility

9. Roles & Responsibilities

  • Patient: what they can do independently

  • Family carer / next of kin: what you cover (meals, shopping, appointments)

  • Care agency: personal care, medication prompts

  • Social worker: care package reviews, financial assessment

  • GP & nurses: medical oversight

10. Reviews & Updates

  • Care plan should be reviewed regularly — every 6–12 months, or sooner if needs change

  • All updates shared with: GP, care agency, social worker, next of kin