The Home Spirit Environment Person Centred Planning Tool

How this tool should be used

This tool should be used to consider the whole life of a person living with dementia.

The aim of this tool is to balance what is important for the person with what is important to the person. It is essential to ensure that what is important to the person remains at the centre of any support or care intervention. It is necessary for a person with capacity to give consent to their care and support

There are a number of domains. It is not necessary to complete all the domains but ones that are relevant to the person with dementia. Each area may need to be updated as there are changes in the person. The domain asks what is important for the person. For example, it may be important for a person with diabetes to have a low-sugar, healthy diet. But it may be important to them to eat sweet food.

Each domain encourages the ‘how’ to support the person. This should include a balance of what is important for and to. For example, the person with diabetes may want to eat sweet foods daily, and this may be achieved by making or purchasing low-sugar desserts for the person to each most days with, perhaps, a once a week option of a sugary dessert. This, of course, would increase risk and should be noted in the column where notes are taken about what the person is good at. Placing an ‘R’ in this box would highlight the need to a complete a risk assessment.

The family are likely to complete very simple oral risk assessments, whereas, a home care agency is expected to complete full risk assessments in line with CQC regulation. At the foot of the domains list is an area where the person with dementia or others can make note of their fears and concerns, using the ‘R’ from the right hand column. This will ensure that each risk is assessed and managed.

So, the person with diabetes may continue to eat sugary foods one day a week and this may need to be reflected in an appointment with their GP to adjust their medication, or for person, family or staff to be aware that close monitoring of the blood sugars is necessary to adjust insulin. In this way, what is important to the person remains at the centre of any intervention, without ignoring what is important for them.

This tool can be completed over a period of time and is likely to change as the person changes. This, in turn, will affect the ‘how’ and the risk assessment. A dynamic tool that ensures the person is supported in a way that they want keeps them at the centre of their decision making process, understands their best interests and works with them on ‘how’ to provide such support.

For people with dementia who do not have capacity to make many of the decisions within each domain, it is essential they are as involved as they can be in creating the support plan. For the person unable to give consent to professional care and support, a best interests meeting would be necessary to ensure that the consent can be obtained.

The domains to consider are:

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