Do you worry when visiting your loved one at the care home whether your views, as attorney on the dementia care plans is good enough?

I can see you nodding your head.

You are not alone.

Every attorney has doubts about his or her supervision of their loved one in a care home. The person with dementia no longer has capacity to make most of those care related decisions.  The carers often do not recognise that the attorney has a legal and moral duty to act in the person’s best interests.

The good thing is that supervision of the many dementia care plans of your loved one leads to becoming an expert by experience. Every view you input as attorney in all of the decisions made by the care home and clinicians is a step along the road and makes you a more skilled attorney. The benefits are timely comfort and dignity for the person and appreciation by the family of the consequent risks of harm if any of the care plans are not followed.

Whilst travelling along this road, you can either travel the long road – or use shortcuts.

Using shortcuts means learning to spot and fix mistakes in order to make the dementia care plans better.

Following on since Part 1 of this Blog, Reeta Ram, Family Representative describes in this Part,  steps 4 to 9 of secrets to getting a successful care plan.

In Part 1, Reeta describes many care plans in each area of need.  There are care plans on behavioural problems, personal care charts, cognitive needs, emotional and psychological, communication, mobility, nutrition, skin, continence, medication, risks and interrelated needs.

Blog Part 1 has already covered the first 3 fixes:

1: The art of being most familiar with needs and wishes with an example of a conversation between an agency nurse and the wife/attorney.

2: Supervise agreed action points with follow up, if not, you may need to persuade the care home to complete the agreed action.

3. Get the care home used to your supervision role from the outset by reading the care home plans once a month in your own time and then injecting your views as and when required.

Reeta’s Blog part 2, covers the remaining 6 fixes.   


4. Is it care plan obvious?


When you start commenting on the records, check there are planned solutions to needs and risks.

Look at the following care plan on communication needs:

Unable to communicate well.

Does the nurse know the dementia plan on communication needs?

The fix

Grab the problem and ask the nurse to include all the solutions. Some care interventions do work well and some work a bit, after all many different staff will read the care plan to familiarise themselves with the person’s needs

Is the solution “the person has to have most of their needs anticipated because of inability to communicate?”


5. Unpack sentences


A simple guide to better care planning is to focus on one risk of harm at a time. Unclear and inconsistent sentences make reading a drag. Here is an example:

He does present with some challenging behaviour during personal care and staff are able to manage his needs by doubling up and two staff attending to him during personal care, his moods respond to prompts and reassurance varies on a day to day basis. Although he is fully dependant on carers, staff are usually able to manage his behaviour with planned intervention and alternative plans in place.

There are so many ideas in this sentence that it’s difficult to follow.

The fix

What personal care are they referring to? washing, oral care, foot care, shaving, haircuts etc

Why are two staff needed and what do they do e.g. one to encourage and reassure with the other on nailcare?

What are alternative plans in place? Do the alternative plans work better and should be reviewed?

What happens when “staff cannot manage behaviour” and what are the risks of not managing those risks?

Is there any safe restraint by the two carers which should be authorised by the clinical team, potentially known as a deprivation of liberty?


6. Tight is Good


Some advocates of the Mental Capacity Act 2005 say if there is no person centered care there is a risk of potential discrimination that everyone with dementia is described as having one set of needs with no respect for a person’s wishes and preferences.

Take a look at this excerpt from Jim’s care record. It is so generic is a problem for many people with severe dementia. “Unclear in speech”.

Is the nurse skilled enough to identify care needs are in fact “there is unreliable communication verbally and non verbally. Cannot reliably indicate site of pain”. The wife attorney can helpful provide examples. There was a chest infection when Jim couldn’t report pain, when there was an altercation and a bruised hand, no pain was reported by Jim or indicated through non verbal gestures. When the painful area is pressed, Jim may jump but this is NOT communication it is a reaction to pain probably which must be anticipated by the specialist GP or Nurse.

The fix

Tight is good on detail in the care plan. It must be relevant and proportionate to create the most helpful care plan. This will be one way to maximise comfort and dignity.


7. Observe what is working


At times, there are too many areas in the care plan to comment on.

Walking problems, likely to fall

Problems eating meals and weight loss

Skin care needed and special mattresses

Complex care with being bedbound etc

Problems are interrelated in different areas of need. Tackle each area in small doses. If one plan doesn’t work, perhaps this will lead to another plan. Do not hesitate to ask for a short period of 24 hour monitoring, say 5 days to find out what is working well or for hints. If one carer makes the plan work but the majority of carers report it doesn’t work, ask the Carer to share the secret of her success with the others.

The fix

Look at whether the description does match your loved on in their care plans. If they are not person centered they are likely to describe any person with symptoms of dementia. Use additional examples to drip feed the essential background information.


8. Make comfort and dignity count


Any carer should be able to pick up a care plan designed to maximize comfort and dignity through the fluctuations and progression of dementia. We all appreciate the care staff do their best to juggle all of their responsibilities to all residents. There is a reason the attorney’s view is valuable to the care plan. It is simple. The attorney is only focusing on one care plan and has most knowledge of the wishes of the person with dementia before they lost capacity to reliably express their wishes. The attorney can focus on what the person with dementia would have wanted in their care plans.


9. Warning: in all of this lies a danger


If you are only given an overview of the dementia care plan in a short meeting instead of reading it, you may not spot much needed changes. You have a right as attorney to read the records in your own time. This may take a few hours depending on how complex the problems are and how familiar you are with medical jargon. Apply the fixes in a meeting with the nurse only after you’ve carefully read the care plan and reflected on suggested changes.

Let your views on trying to improve care plans be transparent, ask to work together to be open to further review of the agreed care plan if they do not work.

Put your suggested fixes and views aside, wait for at least one day. Then apply the nine instant fixes above – and transform your views into a thing of great assistance to the dementia care plan belonging to your loved one.

If you are wondering how to inject your views in the care plans – follow these tips and you will be amazed how your input improves the quality of care received.

If you experience great resistance from a nursing home to even listen to or consider your views in care planning, consider engaging an advocate who will help you with the process of pushing for the rights of the person with dementia to be respected and actioned.


Thoughts? Examples? Please share in the comments

About the author: 

Reeta Ram is Family Representative and Director of Dementia Partners. Alzheimer’s Society warns us that one person every 3 minutes will develop dementia this year with funding lagging. Is it time for attorneys to closely supervise dementia care plans? Reeta helps attorneys inject their views in the dementia care plan in any setting. The attorney has a legal duty under the Mental Capacity Act 2005 and a moral obligation to inject views in the best interest decision making for the person with dementia. This is where the person no longer has capacity to make those care related decisions.