Care plans in Northern Ireland

What is a care plan?

The person who carried out the assessment should write a ‘care plan’. This describes which services will be provided. The person with dementia and their carer should be closely involved in the development of the plan. 

The care plan should include: 

• the needs that have been identified 
• the desired outcomes and how they can be met 
• a risk assessment 
• a plan for dealing with emergency changes 
• the result of any financial assessment 
• the support that carers are willing and able to provide 
• the support to be provided to meet the assessed needs
• the date on which the plan will be reviewed.

A carer’s support plan outlines things that are specifically for the carer, for example manual lifting and handling training (which could help you to use a hoist), or having a temporary break from caring. The results of your carer’s assessment may also lead to changes in the care plan of the person you care for. 

Sometimes a carer’s need is best met by giving services to the person they care for. An example is respite care, such as a paid carer coming to spend time with the person, which allows the carer to take a break. Although it is there to help the carer, the actual care is given to the person with dementia as part of their care plan. 

How care and support are arranged 

The main ways that care and support can be arranged are: 

• The HSC trust gives the support directly.
• The HSC trust arranges for a care provider, such as a home care agency, to give the care.
• The HSC trust makes a direct payment to the person to buy their own care and support. 

You may have care and support arranged as a combination of these options. How the care will be arranged is usually discussed in the assessment, and should be in the care plan. 

You can also get information from local care agencies and charities. The Regulation and Quality Improvement Authority (RQIA) lists all registered homecare agencies in each area of the country (see Other resources).

Some services, such as community nursing, are arranged through the GP, either directly or after discussion with social services (adult services).

How long do services take to arrange? 

Once it has been agreed that a person needs services, the HSC trust must make sure these services are provided. In some cases, the HSC trust may provide a service straight away. However, there may sometimes be a wait while they are organised, though this shouldn’t take too long. If there is likely to be a delay, the HSC trust may find another way to meet the person’s needs until the service can be provided. 

Even if an assessment has been agreed to, there may be a wait. If the wait seems unreasonable, you should complain to the HSC trust. 

Direct payments 

If a person’s care is funded by the HSC trust, they may choose to receive this funding in the form of a direct payment. A direct payment is an amount of money that the HSC trust gives to someone to spend on meeting their own eligible care needs. The money can be spent on a wide range of products and services. Direct payments allow people to make their own choices about their care. 

The HSC trust must support people managing a direct payment – this could be through voluntary or charitable services. 

The HSC trust must be satisfied that someone is willing and able to manage a direct payment, either alone or with assistance. If someone has been able to consent to receiving direct payments but is not able to manage them because they lose the capacity to do so, then the trust may continue to make direct payments. This is only if an ‘authorised person’ is prepared to handle them instead. 

The authorised person must be prepared to manage the direct payments and care package on a day-to-day basis on behalf of the person and in their best interests. They must have the correct legal authority from the Office of Care and Protection – for example, the person’s attorney under an Enduring power of attorney.