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Assessment of needs, care plan and provided care

Provision of care and rights

Assessment of needs, care plan and provided care

Overall, all countries have provisions related to the need to document some personal, social and health related information about the resident and develop an individual care plan. In some countries, the required information and the care plan tend to focus more on medical and nursing issues, whereas in other countries this seems to take a more holistic approach (please see table 14 for details). Differences can also be observed in relation to the expected involvement of the resident and his/her family in drawing up and reviewing the care plan. In Romania and Northern Ireland (National Standards for nursing homes), there are references to staff training in or having the necessary skills to develop care plans for the residents.

The personal and medical care that should be provided in residential care facilities is overall well described in the relevant legislation or National Standards, in particular in relation to nutrition and hydration needs. The type and amount of food and drinks provided should be nutritionally balanced and suited to the residents’ needs. In the majority of the cases, it is stated that residents should receive information about the daily menus or that the menus should be displayed. In some cases, such as Belgium (Wallonia) and Northern Ireland, the menu should offer residents a choice of meal at each mealtime. In Wales and Scotland, it is specified that food (including liquidised meals) should be presented in a way that is appealing and attractive. Some countries have specific details of the times when meals should be provided (e.g. Belgium Wallonia, Poland, UK Wales). The National Standards in Ireland and in the UK make reference to the religious or cultural dietary needs of residents, and in Scotland, it is stated that meals should reflect the resident’s food preferences. In Scotland, it is also stated that residents can have snacks and hot and cold drinks whenever they like and that they can decide where (e.g. in their own room or in the dining room) and when to eat. The latter is also the case in Ireland.

Likewise, the social care that should be provided in the residential care facility is overall well described, and in general in all countries, there are references to opportunities to participate in social events, entertainment and activities provided by the residential care facility and to maintain links with family and friends. The legislation or National Standards in Belgium (Flanders), the Czech Republic, Germany, Greece (private facilities), Finland, Italy, Latvia, Poland, Portugal and Slovakia make reference to the provision of rehabilitation services in residential care settings. In the UK (Scotland), the resident can continue to receive any health-care service (e.g. physiotherapy) that he/she was receiving at home and should have opportunities to participate in physical activities in or outside of the facility. Whilst the majority of the legislation and National Standards state that the residential care facilities should promote and maintain the contact of residents with family, friends, volunteers and the community at large (e.g. visits and/or participation of these people in activities and in daily life), the legislation in Belgium (Flanders) specifically requires the involvement of family members, carers and volunteers in the management of the facility.

On the other hand, only a handful of countries have provisions in relation to the transition of residents to hospital and on the management of behaviours that challenge. In Belgium (Flanders), Finland, Netherlands and the UK (England and Northern Ireland nursing homes) provisions exist for the prevention of unnecessary hospitalisations and for ensuring that if the transfer is necessary, this occurs in a coordinated manner. In Northern Ireland, when residents with confusion or dementia are transferred to hospital, documentation such as ‘This is Me’ must accompany the patient. The appropriate transfer forms and documentation should also be with the resident on their return to the residential care facility.

In Germany, behavioural problems are mentioned in the LTCI but these are not linked to dementia. In Malta, an administrative policy and procedure regarding the use of sedatives and antipsychotic medication for the management of behavioural and psychological manifestation of mental health problems should be in place. These policies and procedures have to be available to residents and their legally appointed substitute decision maker. In the Netherlands, the Quality Frame states that staff should be able to recognise challenging behaviours and seek appropriate help. The most detailed descriptions are found in the National Standards in Ireland and Northern Ireland (nursing homes). Please see attached page (entitled "Management of behavious that challenges") for further details.

Table  14: Assements of needs and care plans



Who is involved?


Belgium (F)

The individual care and guidance plan for each resident should include at least the following information:

  • Personal details,
  • Attending physician,
  • Person(s) to be notified in case of an emergency,
  • Personal characteristics, life history,
  • Individual needs or wishes,
  • Agreement on the care offered,
  • Coordination of care services,
  • Agreements on leisure and social activities.

The care plan should support the greatest level of personal autonomy and self-responsibility.

The care and guidance plan should be approved by the resident (or family member / carer).


Belgium (W)

Each resident has an individualised record of care. This should include the medical, paramedical and nursing care, and physiotherapy. It should contain details of how this care will be implemented and any observations or remarks from the staff who implemented it. It should slao include the date of medical visits, medication prescribed and dosage, care required, the examination/tests that were required and diet.




Each resident should have an individualised plan of care which includes the medical care, nursing care and care provided by allied health professionals.

The care should also include social work and therapy (i.e. speech therapy, work therapy). The plan should contain details of how the care will be implemented and by whom.

The resident and his/her  family

The care plan is reviewed regularly according to the needs of the resident.


The individual needs of each resident should be assessed in particular, the nursing and medical care needs, treatment and evaluation.  The biography of each resident with key life facts provided by the family of the person with dementia should be available to the staff.

The professionals (nurses, social workers) involved in developing the care plan should evaluate it on a regular basis and modify the individual care plan if it is necessary in collaboration with GP and with approval of resident and family members.

The care plan should be revised regularly by the professionals (nurses, social workers) who were involved in developing it.


A file with the resident’s personal data and history should be kept. Each resident should receive a medical evaluation and a care plan should be developed.



Czech Republic

The individual needs of each resident should be assessed, in particular the nursing and medical care needs, treatment and evaluation. Regarding social care, the “goals” of care must be set in a care plan and evaluated.

Professionals involved in developing a care plan should evaluate it annually and modify it if necessary.

Annually or when any changes in the resident´s health status occurs.


The service plan must be based on the assessment of the older person’s functional capacity and the social and health care services that are needed to support the person’s wellbeing, health, functional capacity and independent living and to ensure good care of the person.

The older person (and if necessary, his/her family members, other people close to him/her, or the legal guardian) must discuss the plan. The person’s views must be recorded in the plan.

When important changes occur in the older person’s functional capacity that affect the person’s service needs.


The following information has to be documented for each resident (article113 LTCI)

  • care history including relevant biographical information,
  • care plan,
  • care report,
  • proof of implementation.

Staff of the institution, residents themselves, family caregiver or legal guardian.

Ongoing process.


Public hospices and private facilities should have a personal file for every resident which should include an assessment of the resident’s needs.

In private facilities, a personalised therapeutic program should be developed and reviewed every 6 months, there should be a weekly report of every activity.

In hospices, changes are monitored on an ongoing basis and taken into account.


Every six months.


The individual care plan should contain:

  • assessment of the resident’s physical and mental health,
  • necessary tasks to improve or maintain the resident’s heath status and their timing,
  • other elements of support/ care.

The professionals involved in developing the care plan should evaluate it annually and modify the individual care plan if necessary.

The professionals involved in developing the care plan should evaluate it annually and modify the individual care plan if needed.


An individual assessment is carried out for all residents initially and the care plan is developed and continually assessed. Individual care plans are based on holistic ongoing assessments which identify personal, health, social and recreational goals, where appropriate.

The cognitive ability of residents is assessed and they receive the necessary care and support to maintain a good quality of life.

Residents’ participation in the care planning process is central to supporting them to identify their goals, needs and preferences and what supports need to be put in place by the service to ensure that their needs are met.

Residents can expect that their care plan will change as their circumstances and /or need for support changes.


An individual care plan should be drawn up for all residents. The individual plan should indicate the objectives to be achieved, the content and modalities of the intervention and how it will be evaluated.




An individual social care or social rehabilitation plan in accordance with the functional condition of the resident should be developed. The plan shall include the following:

- a definition of the problem to be solved;

- the purpose of the social rehabilitation or social care;

- the tasks of the social rehabilitation or social care; and

- the evaluation of the social rehabilitation or social care.




An individual social care plan is provided to residents, it should contain detailed information about the person's contacts and family, information from his/her doctor about his/her health status, information about his/her social needs, the measures to be taken, provided services, expected results and follow-up actions and a brief description of the implementation process and of any changes made to the plan.

If possible, the resident and his/her legal representatives, family members/ relatives should be involved in the development, implementation and monitoring of the plan.

The plan should be reviewed not less than once a year or when there is a change in the residents’ situation.


A resident’s plan of care generated from a comprehensive assessment shall be drawn up with the involvement of the resident and close relatives and/or representative. This plan shall provide the basis for the care to be delivered. The individual plan of care shall set out in detail the action that needs to be taken by care staff to ensure that all aspects of the resident's health, personal, spiritual and social care needs are met. It shall be based on the outcome of the initial and ongoing assessments, including results from the Barthel 20 index.

Involvement of the resident and close relatives and/or representative. It shall be recorded in a style accessible to the resident, and agreed and signed by the resident and/or representative if applicable.

To reflect changing needs, the individual plan of care shall be reviewed and updated by nurse in charge or his/her delegate at least once every three months, or after any significant change in the resident’s general medical, psychological, behavioural, or social condition. The advice of other health professionals shall be sought as the case dictates. An annual routine multidisciplinary review is advocated.


A care and living plan is written shortly after admission in the care facility. It contains: the living situation, mental well-being and autonomy, physical well-being and health.


The plan is reviewed and adapted regularly as required.



The municipality has to prepare an individual plan for patients and users in need of long-term and coordinated services according to the Health and Care Services Act. The Ministry may, in regulations, provide further information on the patient and user groups that the duty includes and make demands on the contents of the plan.

Individual support plans should be developed between resident, the carers/family and staff.

Any necessary changes are made after discussion with the resident and his/her family.


Residential care facilities should set up therapeutic care teams, consisting mainly of the staff providing direct care to the residents. They are responsible for drawing up and implementing the individual support plans. An individual support plan should be ready in 6 months from the day of admission.

Individual support plans have to be developed and implemented in cooperation with the resident (if such cooperation is feasible according to resident’s health and /willingness to participate in this task).



An individual care plan for each resident should be developed according to the project of life and the potential of each resident. For this, an assessment of their needs has to be carried out.

The resident and the family must be involved.

As the individual plan must always be updated, it shall change as the person's circumstances and /or need for support change. There is no deadline foreseen in the legislation but the internal regulation may establish deadlines to review the individual plan.


The care and support provided to residents must be based on the evaluation of the individual needs and personal situation of each beneficiary. The resident should be assessed in terms of biopsychosocial status, health status and degree of autonomy preserved, communication capacity, family and social relationships, education level, socio-economic situation, special treatment needs and recovery / rehabilitation needs, educational, cultural and spiritual needs, possible risks, possible addictions as well as vocational assessment.

The residential care facility must have specialised personnel able to draw up the care and intervention plan. A multidisciplinary team consisting of at least 3 specialists in the field of medicine, social work and psychology should draw up the plan. The resident or his/her legal representative should receive a copy of the individual plan, presented in an accessible form (easy to read, Braille, audio format, etc.)

The residential care facilities must monitor the resident’s situation and the implementation of the plan. The plan has to be updated  within 3 days of completion of a re-assessment of needs,


Residential care facilities should have an individual assessment and care plan for each resident

The social worker, resident and relatives.

The plan is reviewed when the situation of the resident changes.


The services and care provided should be according to the resident’s needs and wishes.

The resident, his/her legal representative and staff should be involved in developing the plan.


Revised every six months.


The canton of Zurich does not have detailed requirements concerning this. The Health Department examines in each case if the care plans are sufficient for the concrete needs of the residents (e.g. the needs for people with dementia have to be respected).  In other cantons specific requirements exist (e.g. Berne).




There are forms that have be filled at the admission stage, covering very detailed information including personal, mental and physical health and social information, functioning in activities of daily living, etc. The Care Technician Evaluation Form includes:

  • Personal information,
  • List of medicines prescribed,
  • Health history,
  • General evaluation of functioning /level of independence,
  • Recommendations of the rehabilitation team,
  • Determination of care needs,
  • Care Plan,
  • Habits and hobbies,
  • Social activities / programme planned.

The Care Plan is drawn up according to the assessment at admission, especially taking into account the Initial Care Technician Evaluation Form.

The plan is reviewed based on the annual check-up and treatment plan which is written and signed by the doctor, if necessary, other revisions can be made on the Nurse Observation Form.

UK (England)

The things which a registered person must do, include:

  • carrying out, collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment of the service user;
  • designing care or treatment with a view to achieving service users’ preferences and ensuring their needs are met;
  • enabling and supporting relevant persons to understand the care or treatment choices available to the service user and to discuss, with a competent health care professional or other competent person, the balance of risks and benefits involved in any particular course of treatment (…)

Each person using a service, and/or the person who is lawfully acting on their behalf, must be involved in an assessment of their needs and preferences as much or as little as they wish to be. Providers should give them relevant information and support when they need it to make sure they understand the choices available to them.

Assessments should be reviewed regularly and whenever needed throughout the person's care and treatment. This includes when they transfer between services, use respite care or are re-admitted or discharged. Reviews should make sure that people's goals or plans are being met and are still relevant.


Care homes

An individual comprehensive care plan is drawn up as the assessment of the resident’s needs is carried out, and includes details of:

  • Any personal outcomes sought by the resident,
  • The daily care, support, opportunities and services provided by the home and others,
  • How specific needs and preferences are to be met if the resident is from a specific minority group,
  • How information about the resident’s lifestyle is used to inform practice,
  • The resident’s agreed daily routine and weekly programme,
  • The management of any identified risks,
  • Strategies or programmes to manage specified behaviours,
  • Directions for the use of any equipment used to assist the delivery of care.

Residents are encouraged and enabled to be involved in the assessment process but when a resident is unable or chooses not to be involved, this is recorded. The resident’s representative, where appropriate, and relevant professionals and disciplines are also involved.

A copy of the care plan is made available to the resident in a language and format suitable for them.

The initial assessment details obtained at the time of referral are revised as soon as possible and at the latest within one month of the resident’s admission. The care plan is kept up-to-date and reflects the resident’s current needs. Where changes are made to the care plan, the resident, or their representative where appropriate, the member of staff making the changes and the manager sign the revised care plan. When a resident or their representative is unable to sign or chooses not to sign, this is recorded.


Nursing homes

Prior to admission an identified nurse employed by the home, visits the prospective resident and carries out and records an assessment of nursing care needs. This assessment includes information received from other care providers including family members as appropriate. Each resident’s health, personal and social care needs are set out in an individual care plan which provides the basis of the care to be delivered and is re-evaluated in response to the resident’s changing needs. An initial plan of care based on the pre-admission assessment and referral information is in place within 24 hours of admission. A detailed plan of care for each resident is generated from a comprehensive, holistic assessment and drawn up with each resident.

All residents have a named nurse who has responsibility for discussing, planning and agreeing the nursing interventions. This is done in partnership with the resident and their relatives and includes their values and preferences in terms of physical safety and promoting independence and how emotional, social and psychological needs will be met alongside the physical and other healthcare needs. The care plan is written in a suitable format and so as to be accessible to and understood by the resident and their relatives. Staff are trained in developing care plans.

Re-assessment is an ongoing process that is carried out daily and at identified, agreed time intervals as recorded in care plans.

UK (Wales)

Each resident’s health, personal and social care needs, are set out in an individual plan of care. The plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The plan meets relevant clinical guidelines produced by the relevant professional bodies concerned with the care of older people, and includes a risk assessment, with particular attention to prevention of falls.

The plan is drawn up with the participation of the service user, recorded in a style accessible to the service user; agreed and signed by the service user whenever capable and/or representative (if any).

The service user’s plan is reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care and actioned.

UK (Scotland)

The personal plan should include:

  • what the person prefers to be called,
  • personal preferences as to food and drink, and any special dietary needs,
  • social, cultural and spiritual preferences;
  • leisure interests,
  • any special furniture, equipment and adaptations that the person may need,
  • who should be involved in reviews of the person’s care,
  • any special communication needs the person may have,
  • what communication arrangements need to be put in place if the person’s first language is not English,
  • individual health needs and how these should be met (where appropriate they take account of the person’s ethnic and cultural background),
  • when, and in what circumstances, friends, relatives and carers will be contacted,
  • the person’s arrangements for taking any medication, including any need to inform professionals,
  • an independent person to contact if the person wants to make a complaint or raise a concern,
  • any measures of restraint which staff may have to use for the person’s own safety or for the safety of others.

Staff should develop with the resident a personal plan which provides details of his/her needs and preferences and sets out how they will be met, in a way that is acceptable for the resident. The person should receive a copy of his/her personal plan.

The personal plan should be reviewed with the resident every six months, or sooner if the resident wants or if his/her needs have changed.


Management of behaviour that challenges


The residential care setting’s procedures for managing and responding to residents’ behavioural and psychological symptoms and signs of dementia, promote positive outcomes for the resident. They are based on staff knowing and understanding the resident’s usual conduct, behavioural and psychological symptoms and signs of dementia and means of communication, and having an awareness of and ability to adapt the environment in response to behavioural and psychological symptoms and signs of dementia.

Each resident with a cognitive impairment who exhibits symptoms that cause them significant distress, or who develops behavioural and psychological symptoms and signs of dementia, is assessed at an early opportunity to establish aggravating factors or underlying causes. They are continuously assessed thereafter if the distressing symptoms, or the behavioural and psychological symptoms and signs of dementia persist. Early interventions that may prevent an escalation of such behaviour or distress are used and recorded in their individual care plan and evaluated as to their effectiveness.

Where a resident’s behavioural and psychological symptoms and signs of dementia places them or others in imminent danger, short-term, proportionate and non-dangerous restraint measures may be taken by staff without prior formal assessment. Precipitating factors and behavioural and psychological symptoms and signs of dementia are clearly recorded in a restraint register, along with any actions taken.

Northern Ireland (nursing homes)

A specific documented behaviour support plan for the management of behaviour that challenges is drawn up and agreed with residents, their relatives and relevant professionals and are regularly reviewed for effectiveness. The plan identifies activities that can have a positive and preventative effect to minimise episodes of distress.

Residents with behaviours that challenge and their relatives have the support they need to ensure they can take an active part in these reviews. Proactive and preventative strategies are always considered and evidenced within documentation as the first option. Restrictive interventions are evidence-based, proportionate and the least restrictive option required.

All staff receive regular training (and ongoing updates) that is appropriate to the level and type of behavioural challenges within the home. Training is delivered by a suitably competent professional or trainer. Induction covers initial information on behaviour that challenges.



Last Updated: Thursday 30 January 2020