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Step 2: assessment, care planning and review







Step 2 Workshop

Time: Half day

Aim: The care home representative will understand holistic assessment and its relevance to advance care planning.  They will explore systems to discuss, record, review and share assessments appropriately.

Objectives: By the end of the session the care home representative will be able to:

  • Recognise the importance of holistic care planning
  • Have an awareness of assessing the resident's mental capacity
  • Produce an action plan to implement a system to support advance care planning
  • Develop further the Care Home End of Life Care Policy


Attendance Register - Register

The Route to Success - The programme is based on the Route to Success and guides each workshop.

The Route to Success in End of Life Care - Achieving Quality for lesbian, gay, bisexual and transgender people - provides guidance on end of life issues.

Palliative and End of Life Care for Black, Asian and Minority Groups - provides guidance on end of life issues.

Holistic Common Assessment Guide - provides guidance to understand a patient's needs, preferences and priorities for care.

Support Sheet 16 - provides informaton on how holistic assessment should be carried out.

Case Study - learning aid providing a case study around a patient who has suffered a stroke.

Care Plan - template to be used to record an individual's needs.

Mental Capacity Act Guidance - a guide to help health and social care professionals to help people who are are unable to make some decisions for themselves.

Support Sheet 12 - provides information on the mental capacity act.

Support Sheet 13 - provides information on best interests decision making.

Planning for Your Future - provides a simple explanation of advance care planning and the different options open to people at the end of life.

Capacity Care Planning - provides information on capacity and care planning for health and social care professionals.

Preferred Priorities for Care Document - useful planning guide to help an individual decide their preferences and wishes to plan for the future.

Guide to Preferred Priorities for Care  Document - provides information on how the Preferred Priorities for Care Document can be used.

Support Sheet 3 - provides information on advance care planning.

Support Sheet 4 - provides information on advance decisions to refuse treatment.

Support Sheet 18 - provides information on preferred priorities for care.

Supportive Care Record - template that allows the care home representative to record and monitor individuals at end of life.

To Do List - provides a checklist of actions to be carried out for the next workshop.

Evaluation - provides feedback to facilitators, which will help continually develop and improve the delivery of the programme.