We recently published a guide to caring for a family member with dementia at home. In this post we’ll explain another aspect of looking after someone with dementia: Writing a dementia care plan. In this article, we look at another important aspect of supporting someone with dementia: creating a Person-Centred Dementia care plan.
We’ll explore who should be involved in writing a dementia care plan, and what you should include in your plan in order to ensure that your loved one gets the specialist support they need.
A good care plan is more than a record of care needs, it captures the person’s life story, preferences, routines, strengths, and what is important to them. In this guide, we’ll explain who should be involved in developing the care plan and the key information it should include to ensure the individual receives compassionate, personalised support that promotes their wellbeing, dignity and independence.
What is a Person-Centred Dementia Care Plan?
A Pearson-Centred Care Plan is a written document that outlines an individual’s care and support needs, while reflecting their personal preferences, wishes, strengths, and goals. It provides guidance on how care should be delivered in a way that promotes the person’s dignity, independence, and wellbeing. A care plan will typically include details about daily routines, personal preferences, medication, communication needs, health conditions, and important contact information.
A Dementia Care Plan follows the same person-centred approach but includes additional information specific to supporting someone living with dementia. Alongside the individual’s care needs, it should capture their life history, familiar routines, likes and dislikes, communication preferences, potential triggers, and activities or approaches that provide comfort and reassurance. It should also identify any adaptations or strategies that help the person remain safe, independent, and engaged in everyday life.
How Often to Review Demential Care Plans
As dementia is a progressive condition, a dementia care plan should be reviewed regularly and updated whenever the person’s needs or circumstances change. As a minimum, it is good practice to review the care plan at least annually, ensuring it continues to reflect the person’s wishes and provides the right level of personalised support.
Who Should Be Involved in Writing a Dementia Care Plan?
A Person-Centred Dementia Care plan is often developed following a Care Needs Assessment carried out by the local authority. If the person has ongoing health needs, the NHS may also create a healthcare plan to support the management of their medical conditions. Family members, carers, and care providers may also develop a more detailed care plan to guide day-to-day care and ensure support is delivered consistently.
The person living with dementia should always be at the centre of the care planning process. Wherever possible, they should be actively involved in developing their care plan so that it reflects their wishes, preferences, values, life experiences, and the outcomes that matter most to them. A truly person-centred care plan focuses on the individual’s strengths and abilities, supporting them to maintain their independence, choice, and dignity for as long as possible.
Family members, friends, and those who know the person well also play an important role. Their knowledge of the person’s life story, routines, interests, communication style, cultural background, and what brings them comfort can help ensure the care plan reflects who the person is and not just the support they need.
An independent advocate may be arranged by the local authority if the person has no family members or friends who can contribute, or if they find it difficult to express their wishes, feelings, or preferences. The advocate’s role is to ensure the person’s voice is heard and that any decisions made are guided by their rights, wishes, and best interests.
What Should a Dementia Care Plan Include?
- Personal Details – List the person’s name, along with their GP, their next of kin, and any existing Power of Attorney arrangements.
- Health Details – If possible, specify the type of dementia they have. Also list any other health conditions they may have, and their current medication.
- Assessed Needs – List all the things the person needs help with. This might include personal care, everyday mobility, health and nutrition, and so on.
- Goals – What does the individual want to get out of their care plan? Beyond just staying safe, do they want to stay at home, or to maintain their social ties?
- Preferences and Routines – How does the person like to be addressed? When do they like to eat, and what type of food do they prefer? What sort of activities do they enjoy? What’s their daily routine like? When do they like to get up, and at what time do they usually go to bed?
- Life History – You can include some details about the person’s background and interests, with some significant life events. This can help carers and other health professionals connect with the person.
- Communication Requirements – List any issues the person might have with talking, or with comprehension. Also list any communication strategies that can help.
- Risks – List any known risks. This could be a risk of falling, or a tendency for the person to wander off. You could also list some known triggers in this section, with some methods for managing or mitigating them.
Further Support For Caring For Someone With Dementia
You’ll find numerous guides on our site to help you care for someone with dementia:
- How much does dementia care cost?
- How to care for family members with dementia at home.
- An introduction to companionship care.
Caring For Dementia Family Members at Home – Help and Support
If you live in Surrey or by its borders, you can get bespoke home help for people with dementia with the Crossroads Direct service.
Whether you need some respite care, some companionship services, or a dedicated home help carer, we’re here to help. Our dedicated team will work closely with you to design a bespoke dementia care plan that meets your specific needs.
Find out more and get in touch for a free care and support consultation today.
