Introduction

Decent Care is committed to pursuing the rights and principles of equality, independence, choice and inclusion that underpin a person-centred philosophy. The individual planning process is a person centred and inclusive approach to support participants to develop and maintain their skills and capacity and to have a lifestyle based on their interests and aspirations.

Scope

This policy applies to all Management and team members who are involved in the planning of participant supports.

Principles

Goal Planning is an important component of Decent Care support process to ensure that each participant can achieve success in their chosen activities. The “About Me and My Supports” is a holistic and collaborative process that explores participants aspirations and defines their chosen activities. Goal plans are developed based on the information sourced from the About Me and My Supports Form, whilst identifying individual participant risk. Goal plans are reviewed on a regular basis to monitor outcomes as well as review and manage any risks.

Policy

Individual planning and review processes aim to support people to move toward a more positive lifestyle through enhancing decision-making opportunities and facilitating social integration, participation, and inclusion in the community. The planning process also provides information to maintain safety and continuity of support in the event of natural disaster.

The “About Me and My Supports” provides information about all plans associated with the care of the participant as well as a guide to supporting participant needs and personal preferences. This includes where relevant:

• My Safety Plan (formerly the risk and vulnerability assessment)
• My Goal Plan that includes personal goals and health-related goals (including goal activity risk assessment)
• Mealtime Management Plan
• Behaviour Support Plan
• SDA Agreement
• Medication Management information
• Emergency and Disaster Management Plan (where participant has been identified as reliant on Decent Care’s supports and services)

All participants are provided with a copy of the plans and relevant team members are familiarised and have ongoing access to them, as a support referral point.

Procedure

Goal Planning, risk management and review process
The intake procedure provides the basis for all planning (see Intake and Transition Policy and Procedure) and serves as the “About Me” component of the “About me and My Supports”. The About me and My Supports Form provides information about the participant and indicates further planning requirements. The following steps should be taken when conducting support planning with participants:

1. Review the incoming transition form to identify previous supports and transition plan.
2. Review the About Me and My Supports Form and ensure all plans that are identified as required are included in the participant’s file
3. Considering the plans that do apply, commence the goal planning process including any health goals that have been identified. This is undertaken in collaboration with the participant, inviting them to include an advocate in the process.
4. Support the participant with access to current and accessible information about appropriate and accessible resources and services to help them make informed decisions and choices
5. Identify risks associated with goals and developing management strategies to remove or minimise the impact of the risk. Risks are reviewed regularly to ensure effectiveness
6. Explaining the risks and consequences in the choices being considered
7. Incorporate flexibility into the planning, development and review steps to capture the ongoing changing needs of participants and their families/carers, including their health needs, sexuality and self-protection requirements
8. On completion, ask participant if they would like a copy of the About Me and My Supports Form, Goal Plan and Emergency Plan. Once this has been provided to them, ask them (or their support person) to sign to acknowledge offer of the copy or receipt.
9. Enquire with participant if they would like the goal planning documents shared with family, support network or other providers. If yes, the consent form must be signed
10. Where appropriate and with the participant's consent, developing and maintaining linkages through collaboration with other providers by sharing information to help meet the participant's needs
11. Adjust the support delivery in a reasonable way and continuously monitoring to ensure it is fit for purpose and the participant's health, privacy, quality of life and independence is supported
12. The goal plan document is shared with all Decent Care team members who are involved in the participants supports. This includes ensuring each team member is trained to respond to emergencies, including how to distinguish between urgent, and non-urgent health situations
13. All goal plans and risk assessments are reviewed annually, or sooner if the participant circumstances change, or they request an update.

Planning Process

About Me and My Supports (Mandatory inclusion)

The About Me and My Supports includes:

• Contact details
• Communication requirements
• Preference for worker
• Likes/dislikes
• Living arrangement
• Daily routines
• Cultural background
• Support network
• Health and check-up review
• Mealtime support needs
• Medication support needs
• Specialised support requirements

My Goal Plan (Mandatory Inclusion)

The Goal Plan is developed in collaboration with the participant and with the participants consent their support network. Goal plans must:

• Be reflective of the funding provided by NDIS
• Be in line with the participants wants, needs and preferences
• Include health care plans where identified as required in the intake and assessment process
• Include a risk assessment of the goal planning activities
• Include review timeframe

My Communication Plan (where relevant)

Where the participant has specific communication needs, the Communication Plan provides guidance to team members to ensure they are aware of, and able to communicate in the most appropriate and effective method. This may include

• Communication aids
• Specific gestures
• Interpreter services
• Written communication
• Other

Medication Documentation (where relevant)

Where a participant has identified they require medication administration support, a medication consent form and Health Record from their GP will be requested. This information must be no more than 3 months old Refer to Medication Management Policy and Procedure

My Mealtime Plan (Where relevant)

Where swallowing challenges are identified in the My Safety Planning Assessment or About Me and My Supports Form, a mealtime assessment will be undertaken by appropriately qualified health practitioners and team members will receive training in each individual plan. Refer to Mealtime Management Policy and Procedure

My Behaviour Support Plan (Where relevant)

Where Behaviour Support needs have been identified that includes a regulated restrictive practice, a registered NDIS Specialist Behaviour Support Practitioner must develop an appropriate Plan and the restrictive practices within the plan be authorised by state. Refer to Implementing Behaviour Support Plans Policy and Procedure

SDA Tenancy Agreement

Where housing is provided under an SDA Agreement, a tenancy agreement will be developed in collaboration with the participant and with their consent their support network. Refer to SDA Policy and Procedure

My Emergency Management Plan (Mandatory Inclusion where the participant has deemed themselves as reliant on Decent Care for daily needs)

Each participant is assessed for vulnerability and reliance of Decent Care for their daily needs in the My Safety Assessment in case of an emergency or disaster. See also Emergency Management Policy and Procedure.

The Emergency Management Plan outlines the following:

• Emergency contact details and formal and informal supports
• Protocols for each participant about how to respond to medical emergencies for them
• Systems for escalation in an emergency (both medical emergency and disaster management emergencies)
• How services and supports may be affected in emergency or disasters
• General information regarding Decent Care’s emergency and disaster management plan

Progress notes

Team members must record progress notes each time they provide support to a participant. Progress notes should reflect a participant's progress towards their goals and record the events that occurred each time they received support, including any out of the ordinary events.

Safe Environment
Decent Care is committed to maintaining high safety standards at all times through:

• Ensuring participants are familiar with their support workers by undertaking a “meet and greet” process and ensuring a match prior to ongoing visits. All team members are issued with ID cards to ensure they can be recognised as a representative of Decent Care.
• Where a participant is working with other providers, Decent Care will seek consent to work collaboratively with the network to identify and manage participant risks and to correctly interpret their needs and preferences.
• The communication plan provides a process for participants to express any emerging safety or health related concerns to their support team
• The Emergency Plan provides escalation information to team members (see Emergency Planning Policy and Procedure)
• Each team member has training (including refresher training), in infection prevention controls standard precautions including hygiene practices, respiratory hygiene and cough etiquette See also infection control policy and procedure
• Infection prevention and control standard precautions are implemented throughout all settings.
• Each team member who provides supports directly to participants undertakes training (including refresher training) in the use and disposal of Personal Protective Equipment (PPE)
• PPE is available to each team member, and each participant who requires it.

Planning Principles

Person at the centre

Participants are central to planning and decision-making to achieve their preferred lifestyle. The participant chooses the level of participation in planning according to her or his preference and ability and is encouraged and supported to have as much control as possible over the whole planning process.

Considering culture

Planning takes into consideration the culture, language, religious beliefs and priorities of all people. Planning with a participant is undertaken about social customs and traditions and the individuals own culture and beliefs.

Inclusion of others

In accordance with the person's wishes and consent, their personal support networks and other supporting service providers are actively included in the planning and review process. The inclusion of others in the support planning process aims to encourage the ongoing involvement in the person's life, and to encourage and assist growth of the participant's networks and community engagement.

Personal priorities and strengths

Intake processes include the identification of the persons strengths, including their personal networks and interests. This information is utilised to develop a capacity building approach and instil confidence in the self-delivery of the plan.

Dignity of risk

Each participant's right to the dignity of risk in decision making is supported. When needed, each participant is supported to make informed choices about the benefits and risks of the options being considered

Continuous process

Planning with the person at the centre is a continuous process of listening, learning and further action and is not a one-off event. Person-centred planning assumes that people with disability have futures, and that their aspirations will change and grow with their experiences.

Consultation

Decent Care operates within a learning culture and supports that each person is the expert in their own lives. Whilst the policy draws on the expertise within Decent Care, the policy will evolve with consultation with team members, participants and their families, carers and advocates.

Training

All team members are trained in intake, assessment, goal planning, review and risk management processes as part of the induction.

Responsibilities

The Managing Directors are responsible for:

• Approving and monitoring the implementation of this policy and recording any changes within the Policy Version Control Register.
• Reviewing intake practices for consistency with the policy and procedure

Program Managers are responsible for:

• Ensuring all team members are provided with training in participant goal planning and risk assessment processes.
• Ensuring consistency between participant needs and associated plans
• Ensuring all team members are privy to the goal plans and support plans of each individual of which they are supporting
• Ensuring all intake and planning processes are undertaken with participants in line with this policy and procedure
• Ensuring Goal Plan Risk Assessments are undertaken and reviewed as necessary

Team members are responsible for:

• Ensuring activities that are undertaken are in line with the individual’s goal plan
• Monitoring the risks associated with Goal Plan activities
• Ensuring progress notes reflect the participants activities and any other observations

Definitions

Person-Centred Approaches

designing and delivering services and supports based on what is important to a person.

Person-Centred Planning

discovers and actions what is important to a person in a way aimed at helping people who want to make some changes in their life. It is an empowering approach to helping people plan their future and organise the support and services they need.

Support Pathway

the steps that a participant and their family or carers develop to help achieve their goals and the positive outcomes in their lives.

Related policies and documents

• Participant Welcome Pack
• Complaints and Feedback Policy
• Implementing Behaviour Support Plans Policy and Procedure
• Emergency Management Policy and Procedure
• Intake and Transition Policy and Procedure
• Medication Management Policy and Procedure
• SDA Policy and Procedure
• Privacy and Confidentiality Policy
• Informed Decision-Making Policy.