A support plan should give a clear and consistent picture about the person’s needs and how these needs should be addressed. The person has the right to be involved in the drafting of them as far as they have mental capacity to do so.

It is important to remember that it is a working document and therefore needs constantly updating so that it can address a person’s changing needs, it ensures people are working (with instructions on how to do so) to support a person in the agreed and coordinated ways. The support worker has an important role in informing the care coordinator if a person’s needs/condition have improved or deteriorated so that the support plan can be reviewed to ensure that care and support is provided in a way that meets their needs and is effective in achieving their chosen outcomes.

Why the changing needs of an individual must be reflected in their support plan

People’s needs are not always static/stable and may fluctuate for example:

• If someone has a condition such as multiple sclerosis, motor neurone disease or mental illness (the plan should differentiate between the type of support the person needs when the condition is in remission and when it is not).
• A person might wish to change the support they have according to the time of year (i.e. to tie-in with the weather, or season of sporting activity).
• Medication might affect what the person can or cannot do due to possible side effects (this can also affect a person’s usual eating and drinking habits). If someone experiences side effects from their medication inform your line manager who will contact the prescriber for advice
• Services need to be able to respond promptly if someone’s support needs increase so as not to put them at risk or to cause delays
• A person may lack capacity at one time to make a particular decision but may be able to another time.
• If the needs documented in the plan are not accurate, it is inflexible and does not reflect the person’s needs.
• There is a need to document contingencies for foreseeable crises (the person might require additional support or a different approach might be needed.)

Use to answer question 5.2b of the Care Certificate