Quality statement 1: Person-centred planning

Quality statement

Older people using home care services have a home care plan that identifies how their personal priorities and outcomes will be met.

Rationale

Discussing individual priorities and needs with older people can help to identify what is important to them, what they feel they can do, what they want to be able to do and what will make them feel safe. It should include identifying priorities arising from physical problems, mental health conditions or sensory loss. Including personal priorities and outcomes in the home care plan will enable home care workers to deliver effective and responsive care including identifying when additional support from another practitioner may be needed. This will help older people to maintain their independence for as long as possible.

Quality measures

Structure

Evidence of local processes to ensure that home care plans for older people identify how their personal priorities and outcomes will be met.

Data source: Local data collection. Person-centred planning is included within the Care Quality Commission's Regulations for service providers and managers.

Process

a) Proportion of older people using home care services whose home care plan includes their personal priorities and outcomes.

Numerator – the number in the denominator whose home care plan includes their personal priorities and outcomes.

Denominator – the number of older people using home care services.

Data source: Local data collection.

b) Proportion of older people using home care services whose home care plan identifies how their personal priorities and outcomes will be met.

Numerator – the number in the denominator whose home care plan identifies how their personal priorities and outcomes will be met.

Denominator – the number of older people using home care services.

Data source: Local data collection.

Outcome

a) Older people's involvement in decision-making.

Data source: Local data collection.

b) Health-related quality of life for older people using home care services.

Data source: Local data collection.

c) Social care-related quality of life for older people using home care services.

Data source: Local data collection. The Health and Social Care Information Centre's Personal social services adult social care survey includes questions on social care-related quality of life.

What the quality statement means for service providers, social care practitioners and commissioners

Service providers (such as independent home care agencies, voluntary sector organisations and local authorities) ensure that older people using home care services have a home care plan that identifies how their personal priorities and outcomes will be met. This should include ensuring that any individual needs arising from physical problems, mental health conditions or sensory loss are identified and responded to in the home care plan.

Social care practitioners (such as home care managers, support workers and social workers) develop a home care plan that identifies how personal priorities and outcomes will be met for older people using home care services. This will include identifying and agreeing how any needs arising from physical problems, mental health conditions or sensory loss will be met.

Commissioners (for example local authorities and clinical commissioning groups) commission services that ensure that older people using home care services have a home care plan that identifies how their personal priorities and outcomes will be met, including any needs arising from physical problems, mental health conditions or sensory loss.

What the quality statement means for people using home care services and carers

Older people using home care services have a care plan that reflects what support they need, what is important to them, what they feel they can do, and what they want to be able to do. It should also take into account their specific health problems or disabilities.

Source guidance

Definitions of terms used in this quality statement

Personal priorities and outcomes

A discussion about personal priorities and outcomes should address the full range of support needed to help the person to live how they choose, including practical support, as well as personal care needs. This could include, for example, support to help a person manage their own financial and personal affairs, do their own shopping and cooking, or socialise. The discussion should include considering any specific needs arising from physical problems, mental health conditions or sensory loss and identify how any needs will be met. The focus should be on empowering the person as much as possible, by recognising what they can and want to do.

[Adapted from Home care: delivering personal care and practical support to older people living in their own homes (NICE guideline NG21), recommendations 1.3.8 and 1.3.13 and expert opinion]

Home care plan

This is a written plan put together after the local authority assessment of overall need. It sets out the home care support that providers and the person have agreed will be put in place. It includes details of both personal care and practical support.

[Home care: delivering personal care and practical support to older people living in their own homes (NICE guideline NG21)]

Equality and diversity considerations

Many older people using home care services may have sensory loss or communication difficulties and it will be important to ensure that information is provided in a format that suits their needs and preferences. In particular, practitioners should identify, record and meet the information and communication needs of people who have hearing loss, sight loss or learning disabilities, as set out in NHS England's Accessible Information Standard.

People with limited independence as a result of a physical disability, mental health problem or cognitive impairment may need additional support, such as an advocate, to identify their personal priorities and outcomes for home care.