Quality statement 4: Assessment and personalised care plan

Quality statement

People with dementia have an assessment and an ongoing personalised care plan, agreed across health and social care, that identifies a named care coordinator and addresses their individual needs.

Quality measure

Structure: Evidence of local arrangements to ensure services are tailored to an individual's needs.

Process:

a) Proportion of people with dementia whose individual needs are assessed and whose care plan states how those needs will be addressed.

Numerator – the number of people with an assessment of individual needs and a care plan addressing identified needs.

Denominator – the number of people with dementia

b) Proportion of people with a named health or social care coordinator.

Numerator – the number of people with a named health or social care coordinator.

Denominator – the number of people with dementia.

What the quality statement means for each audience

Service providers ensure that protocols are in place to ensure that personalised care plans identify named care coordinator and address the individual needs of people with dementia.

Health and social care professionals ensure that personalised care plans identify a named care coordinator and address the individual needs of the person with dementia.

Commissionersensure that services are commissioned that tailor interventions to the individual needs of a person with dementia.

People with dementia can expect to receive a care plan that identifies a named care coordinator and addresses their individual needs.

Definitions

'Individual needs' arise from:

  • Diversity, including gender, ethnicity, age (younger or older), religion and personal care.

  • Ill health, physical disability, sensory impairment, communication difficulties, problems with nutrition, poor oral health and learning disabilities.

  • The life story and preferences of people with dementia and their carer/s (where possible) including diet, sexuality and religion.

  • Maintaining independence.

  • Information needs.

'Care coordinator/health and social care coordinator': These terms refer to a professional who has lead responsibility for a person's treatment and care. It is not suggested that all people with dementia will supported by a CPA care coordinator.

Data source

Structure: Local data collection.

Process:

a) Local data collection. Acute Trusts can collect data on the content of assessments using the National Audit of Dementia case note audit, section 2.

b) Local data collection. Contained within NICE CG42 audit support, criterion 6.