Care plan template

Why a care plan helps

A written care plan brings together the most important information about a person with dementia: their history, current support, preferences and goals. It is invaluable for hand-offs (between family members, carers, hospital staff, care home staff) and as a memory aid for the family.

The template

1. About the person

• Name (and preferred name);
• Date of birth and age;
• Address;
• Phone number;
• Photograph;
• Brief summary of who they are: occupation, hobbies, religious or cultural identity, family relationships.

2. Diagnosis and history

• Primary diagnosis (with ICD-11 code) and severity;
• Date of diagnosis;
• Other significant medical conditions;
• Allergies and intolerances;
• Previous mental health history;
• Family history of dementia.

3. Current medications

• Each medicine, dose, timing, indication;
• Any recently stopped medicines;
• Who manages the medication (self, carer, paid carer);
• Dosette box or other dispensing aid in use.

4. Key contacts

• GP (name, practice, phone);
• Memory clinic consultant;
• Pharmacist;
• Social worker;
• Admiral Nurse if relevant;
• Lasting Power of Attorney holders (health and finance);
• Next of kin and family members involved;
• Solicitor;
• Faith community contact (if relevant).

5. Cognitive and functional status

• Latest ACE-III or Mini-ACE score with date;
• Activities they manage independently;
• Activities they need help with;
• Walking, mobility, balance;
• Continence;
• Communication abilities and preferred ways to communicate;
• Hearing aid and glasses status.

6. Behavioural and psychological symptoms

• Any current behavioural symptoms;
• Triggers identified;
• What helps;
• What to avoid;
• Any specific situations the person finds difficult.

7. Daily routine

• Wake time and morning routine;
• Meal times and food preferences;
• Activity programme through the day;
• Rest and nap pattern;
• Evening routine and sleep time;
• Anything that helps with sundowning;
• Night-time arrangements.

8. Care arrangements

• Who is the primary carer;
• Other family or friends involved;
• Paid carers (agency, schedule);
• Day services or Memory Cafe attendance;
• Respite arrangements.

9. Preferences and values

• Things the person enjoys;
• Things the person dislikes;
• Music and food preferences;
• Religious or spiritual practices;
• Cultural considerations;
• Pets and important relationships.

10. Future preferences

• Where the person would prefer to be cared for;
• Views on residential care;
• Advance Decision details (if any);
• ReSPECT recommendations (if any);
• End-of-life preferences (place, treatments, who to be present);
• Funeral wishes;
• Organ donation preferences.

11. Review

• Date plan completed;
• Date of next review (suggest every 6 to 12 months, or after any significant change);
• Who has copies (GP, family members, care provider).

How to use the template

Complete the template with the person while capacity allows. Use it as a working document; update at the review intervals and at significant transitions (hospital admission, change in carers, move). Share copies with people involved in care.