Dementia Care Plan – How to Get Dementia Care Planning Right

What is a Dementia Care Plan?

A dementia care plan is written to give caregivers a good understanding of the person who requires care and improve this person’s quality of life. The care plan will include personal and medical information that’s important for caregivers to know and use when working with that person. It should contain information that will help them stay in a good routine and ensure their basic needs are met. It also helps to maintain physical safety, whether they are living as a resident in a group or receiving home care.

Good care planning is vital when it comes to delivering the best care for people living with dementia and providing sufficient support to their families and carers. The Clinical Commissioning Groups Improvement and Assessment Framework (CCG IAF) reiterate the importance of having a high-quality care plan through its inclusion, and they recommend that it be reviewed regularly to meet the needs of the person living with dementia. 

Advance Care Planning Dementia

The Mental Capacity Act allows us to make plans for the future, including notes on how we want to be supported and who can make decisions for us when we lose the capacity to make them ourselves. It’s designed to empower and protect people. During the early stages of dementia, people should receive the support they need to make as many decisions as possible to ensure their future support and care matches their expectations. This is part of ‘advance care planning’ (ACP).

What is Advance Care Planning?

People who are thinking about, discussing and documenting their beliefs, choices and wishes for future care are ‘advance care planning.’ This is important as it helps people make decisions before they no longer can and that’s why it’s crucial for people with dementia. ACP is different to end of life planning, as it creates a record of things you want while you’re still alive.

Most people will require support when creating their advanced care plans. This can be provided by family, friends, care staff and doctors. Discussions surrounding advance care planning will take time and is likely to span over multiple conversations and meetings. Don’t assume that everyone knows about ACP and be prepared for their minds to change during planning.

Advance Care Planning Guidelines

There are some guidelines you need to follow when creating an advanced care plan. People don’t have to do all of the following or they may want to spread it out over time. Here are three things to think about:

• Making statements about future needs and wishes – People can say what they would like to happen if they end up losing the capacity to make decisions for themselves in the future and covers care, support and treatment. Please note that these are not legally binding.
• Making advance decisions to refuse treatment – This includes information on what medication they would not want to receive in the future and have the right to refuse down the line. Advance decisions to refuse treatment have a special status in law.
• Making lasting power of attorney (LPA) – Will consist of property and affairs and health and welfare. This requires the person to write down their preferred LPA, and then sign the form with their attorney in the presence of a witness.

For people in the early stages of dementia, they may or may not have the capacity to complete some parts of their advance care plan. If someone cannot make these decisions, they can’t be completed by others on their behalf.

Care Plan Examples for Dementia

If you are caring for multiple dementia patients, being organised is essential to meeting all of their needs for the day. Having a dementia care plan in place for each individual is the best way to do so. This will help you improve your mindset and feel prepared for the day ahead, so you can care for these people to the best of your ability. Here are examples of what to include in your dementia care plan.

Things to Consider

Before you start your care plan, you need to get to know your dementia patient. This will help you to consider the following before writing up your plan:

• Their likes, dislikes, interests, strengths and abilities
• What a typical day and routine used to look like
• The times of day this person functions at their best
• Ideal times for meals (consider their portion size), bathing and dressing
• Regular times to wake up and go to bed, this is especially important for people who experience sleep problems or sundowning due to their disease

Keeping all of this in mind is key to creating a successful dementia care plan for this person. Make sure you always allow for flexibility within your daily routine to meet their needs and behaviour for that day.

Organising the Day

As the disease progresses, people with dementia will eventually need a caregiver’s assistance to organise their day. Planning structured and pleasurable activities alongside a good routine can reduce agitation and improve their mood. Finding out what works for them works best when you constantly explore and adjust your care plan. Below contains a checklist to consider to help organise the day:

• Typical tasks such as household chores, preparing and eating meals and personal care
• Creative activities e.g. arts, crafts and music
• Intellectual activities e.g. reading and puzzles
• Spontaneous activities e.g. visiting friends, talking to visitors or a shopping trip
• Physical activities e.g. going for a walk and yoga
• Social activities e.g. playing games as a group or socialising over tea or mealtime
• Work-related – this will apply to you as a caregiver and consists of making notes and observations throughout your day

Activity Care Plans for Dementia Residents

You shouldn’t hold back on organising activities for people with dementia. Meaningful activities can give them a sense of purpose and routine. When creating activity care plans for dementia residents, you should acknowledge and use the skills and life experiences of that person. Emotionally nurturing experiences will increase self-esteem and make the person feel valued.

However, don’t feel the need to fill every minute of the day with an activity. People with dementia will need a good balance of activity and rest, plus they may need more frequent breaks and varied tasks compared to people who don’t have dementia. Another few things to consider when writing up an activity care plan are:

• The activities that do and do not work best and why – Keep in mind that the success rate of certain activities may change.
• Times where there is too much or too little going on – Has this person struggled to get through the day or have they been left disappointed and unfulfilled?
• The results of planning spontaneous activities – Does this person enjoy impulsiveness or did it create too much anxiety and confusion?

Please note that the importance of the joy and sense of accomplishment this person gets from participating in an activity far outweighs the type of activity and how well it’s completed. Be prepared to adjust your plan to meet the needs of the person on that day.

Behavioural Care Plan for Dementia

When creating a dementia care plan, you should consider writing notes surrounding behaviours, such as documenting the behaviour, the risks of it and interventions to reduce adverse outcomes. Over time, you will learn how to understand the meaning of these behaviours and will figure out techniques to overcome them. Lastly, it’s vital to record data regarding medication that may improve behaviour.

Don’t forget that no two days are the same for someone who has dementia, so be prepared to adapt your plan and listen to them to ensure your care planning achieves their desired life experience.

Dementia Care Planning Software

Having a good dementia care plan is crucial when it comes to improving care for people with dementia. Advance planning is something you should discuss with all of your service users, to ensure their wishes, beliefs and choices are met when they can no longer make their own decision. Before you get started, you should consider digitising your care service to help produce the best dementia care plans for you.

The Access Group has digitised thousands of care services across the world. With over 30 years of experience, we aim to give you the freedom to do more and have the knowledge to see you through to success. This is why you should consider implementing our integrated care planning software.

By using electronic care planning to create your dementia care plans and conduct assessments, you will be able to deliver efficient, safe and personalised care, as our software allows you to build easy, quick and convenient digital care plans to improve the day-to-day lives of your team and service users. Our system also digitises all of your processes and documents, so your team won’t have to waste their time using and searching through paper-based records, giving them more time to dedicate to care. We also have a convenient mobile app.

Learning everything you can about dementia can help you understand patients and create an effective dementia care plan. We’re here to help. Our A-Z of Care Regulations and Compliance – D is for Dementia allows you to step into their world while containing useful information and resources that can help you improve your quality of care. On our popular Health and Social Care eLearning platform, you can find our dementia awareness training course, which will improve your knowledge and understanding which you can use in your dementia care planning.

If you like the sound of our digital care planning software or you want to give it a try, please contact us to find out more, or complete this form to access a care planning demo. We also have a brochure to download for your perusal.