Purpose:

The purpose of this part of SRI 2 is to help practitioners reflect on ten current care plans, through a structured process facilitated by the coordinator. This opportunity for reflective practice generates discussion and scores and that are fed into the SRI 2 website by the coordinator and used later in the creation of the action plan.

Care plans are one of the three sources of documentary data, the other two being assessments and service information.

The care plan data collection sheets are printed from the SRI 2 website and used to record practitioner’s ratings and comments. You should print one care plan data collection sheet for each care plan being reviewed. For example, if you plan to review ten care plans then you should print ten data collection sheets.

The first page of these data collection sheets contains the following guidance.

SRI 2 Data Collection Sheet - Care Plans

About this data collection sheet

This sheet forms part of the SRI 2 data collection process. Completing this sheet will help your service reflect on whether the care plans you have selected for review are recovery focused.

Complete one data collection sheet per care plan. Completing ten care plan data collection sheets should take no more than two hours.

In gathering information we recommend:

  • You review ten current or recent care plans.
  • As many of the team as possible are involved in reviewing care plans.
  • You protect confidentiality by ensuring information recorded is anonymous.
  • You only use written evidence from the care plan. Staff interpretation and opinion should not be counted as evidence.

Gathering information

Once you have reviewed a care plan:

  • In the space provided write examples of how the care plan matches the opening statement, e.g. Basic needs are routinely addressed.
  • Based on the extent to which you think the care plan matches the statement make a judgement on a scale of 1 to 5, where 1 is strongly disagree and 5 is strongly agree. If the indicator is not applicable or relevant to your service circle NA.
  • The person co-ordinating should retain all completed sheets for later use. They will enter the scaled responses into the SRI 2 website. Supporting evidence and examples recorded on this sheet will be discussed during the action planning stage.

Recovery Indicators and associated statements

There are ten recovery indicators, eight of which are considered in relation to care plans. Each of these has an associated statement that recovery focused services aspire to, for example, the first recovery indicator is Basic needs are identified and addressed, and the associated statement is Basic needs are routinely addressed. The recovery indicators and associated statements are shown below.

Recovery IndicatorAssociated statement to rate between 1 and 5
Basic needs are identified and addressed. Basic needs are routinely addressed.
Goals are identified and addressed. Personalised self-set goals are routinely addressed.
Personalised services are provided. Considerable variation between care plans.
Service is strengths based. Strengths are routinely integrated.
Service promotes social inclusion. Mainstream services and community integration are routinely addressed.
Service promotes and acts on service user involvement. NO DATA REQUIRED.
Informal carers are involved. Informal carers are routinely involved.
Service encourages advance planning and self management. Advance plans and self management plans are routinely integrated.
Staff are supported and valued. NO DATA REQUIRED.
Practice is recovery focused. Responsibilities are routinely shared.

Guidance for Rating

This section of the guidance will help the team rate their care plans against the associated statements, and offer suggestions as to what kind of factors influence the rating.

The degree to which practitioners feel their ten care plans achieve the aspirations of the eight statements will be derived from hard evidence recorded in the care plans, as opposed to being guided by a general feeling or subjective opinion.

High scoring recovery focused care plans include evidence of such things as actions, goals, and agreed outcomes that have been collaboratively produced to address the issues identified through ongoing assessment. Such care plans develop and evolve, and the priorities change with the person’s circumstances and wishes.

Care plans achieving a high rating would show evidence of continuous monitoring and appraisal of progress in collaboration with the person themselves along with carers, advocates and other relevant partners. High scoring care plans make it clear who is responsible for what and by when.

As well as planning for risks and problems, highly rated care plans evidence the following:

  • Ensuring all partners are working to the same clear outcomes goals and timescales.
  • Monitoring of milestones and progress.
  • Utilisation of wellbeing, strengths and resources.
  • Incorporate self management strategies.
  • Involve the person from the beginning.
  • Involve informal carer, or independent advocate.
  • Focus on the future and the steps required to attain the person’s aspirations.

Care plans should be reviewed in turn with a rating and supporting evidence recorded on one data collection sheet per care plan. This means that if you review ten care plans you should have ten corresponding data collection sheets. Your rating should be justified by supporting evidence from the care plans. You may prefer for one person to review all care plans or to take a group approach.

Statement 1 Basic needs are routinely addressed

The team will look at the ten care plans seeking written evidence suggesting that basic needs are being routinely addressed. Basic needs include housing, nutrition, health, finance, safety, personal care and spirituality. Addressing these might for example involve negotiating with housing providers or organising a suitable place for the person to pray. Individuals attach their own importance to basic needs and they define them in their own terms. People using the service may have opinions about which basic needs to prioritise and these may differ from those of the people providing the service.

The score awarded reflects the presence or absence of evidence that basic needs are being addressed across the ten care plans, systematically and routinely.

Statement 2: Personalised self-set goals are routinely addressed

Personalised self-set goals spring from hopes and aspirations. They are proposed by the person and are a facet of autonomy. Such goals are salient to the person and any success in attaining them, however partial, tends to foster wellbeing and hope. In high scoring care plans it will be apparent that goals are being determined by the person. The team will look for written evidence across the range of care plans indicating that personalised self-set goals are routinely addressed. This could be for example a record of a logical sequence of actions designed to achieve the goals identified in the assessment. There could be written evidence that some goals have been broken into smaller sequential steps, and plans made to tackle these using a SMART objectives approach, i.e. actions are Specific Measurable Achievable Realistic And Time Limited.

It is possible that since assessment the person has new needs, aspirations and priorities and that these have generated new self-set goals that were not apparent at assessment. A recovery focused care plan would record and address these too, and include evidence of regular reviews to track progress and monitor priorities as they change and evolve.

Statement 3: Considerable variation between care plans

Considerable variation between care plans demonstrates that the recovery indicator 'personalised services are provided' is being addressed. The fact that the care plans are tailored to the unique needs and aspirations of the individual is evidence of a recovered oriented approach to care planning and delivery. A high score for this statement would be justified by evidence that the care plans were highly individualised, contained choices that are personal and tailored to individual needs and circumstances. The range of ten care plans would be varied and bespoke.

This statement varies from the others in that to reach a rating you are required to compare at least three care plans for the extent to which difference exists between them. In other words rather than reviewing a single care plan you are in fact comparing it with two others randomly selected for the extent to which variation exists.

Statement 4: Strengths are routinely integrated

Integrating the strengths of the person using the service into the care plan confirms that the recovery journey is a collaborative partnership utilising the individual's expert knowledge. A high score on this statement would be justified by written evidence of:

  • Specific strengths that are being mobilised and integrated.
  • How these strengths are being mobilised and integrated.
  • Strengths routinely integrated in support of recovery across the range of care plans.

Some strengths will have been identified at assessment but others will only become apparent through time. For example it might become apparent that the person has a sense of humour, a capacity for compassion, the ability to manage relationships, a desire for knowledge, or a spirit of resilience in the face of distressing circumstances. It is likely that the person may not recognise and value their own strengths so experiencing their skills, abilities and resources being integrated into the care plan can be therapeutic in itself.

Statement 5: Mainstream services and community integration are routinely addressed

There is a strong link between recovery and social inclusion therefore to score highly the range of ten care plans will contain clear evidence that they systematically and routinely support people to regain their place in the communities, engage with mainstream services, and take part in social, educational, training, volunteering and employment opportunities.

Statement 6: Informal carers are routinely fully involved

Where family or carers are willing to be involved and their involvement is welcomed by the person using the service, the care plan would reflect the ways in which they had been included and empowered to achieve this.

High scoring set of recovery focused care plans would show evidence of such things as:

  • Plans to support and involve carers
  • Each carer having been offered their own written care plan.
  • Clear description of the carers role in the recovery plan.
  • Carer included and invited to planning meetings.
  • Carers supported to be fully involved.

There would be specific reference to how carers were included, how they were kept informed of progress and that they were invited to meetings, case conferences and so on and there was evidence that this was in accord with the wishes of the person using the service.

Statement 7: Advance plans and self management plans are routinely integrated

Care plans scoring highly against this statement would record how and when the person's advance plans or self management plans had been integrated. There would be details of the content of these plans and advance statements and information about how they were to be utilised in various scenarios that could reasonably be planned for.

There would be a record of what kind of advance or self-management plan or WRAP (Wellness and Recovery Action Plans) was in place, where it was kept, how it was to be enacted, who would be involved in the event of incapacity, arrangements for contacting key individuals and so on. There would be evidence that such plans were regularly reviewed and updated in partnership with the individual.

If the person using the service did not know about WRAP it could be that the service appropriately introduced the concept to the person and supported them to develop and manage it.

Statement 8: Responsibilities are routinely shared

Care plans that rate highly against this statement will demonstrate evidence of shared responsibility in as many domains of care and recovery as is reasonable and possible. This collaborative approach to the recovery journey helps move away from the idea of the people using the service as passive recipients of treatment, and reinforces a sense of self efficacy and agency. There would be evidence that this was happening routinely across the range of ten care plans.

Scoring and rating

Each statement will be considered and the highest score of 5 awarded where there is clear evidence across the range of care plans that the service has met the aspirations of the statement.

A score of one would result if it was found that there was little or no evidence that the aspirations of the statement had been met.

Arriving at a fair score between 1 and 5 is a matter of judgement based on reflection, discussion, and the application of reasoning regarding the quality and quantity of evidence.

The N/A (not applicable) option would be recorded in services where the statement is not applicable or relevant to the service or the person using the service.