CARE AND SUPPORT PLAN

Jayne Oates

April 202
 Customer details
Title Mrs
First name Jayne
Surname Oates
Address 1 42 Church Road
Address 2
City Hauxton
County Cambridge
Postcode CB22 5HS
Country Cambridgeshire
Tel 01223 872 143
Email lee.hill@me.com
Mobile 07973 104686
DOB 22/03/1974
Doctor Dr Kathleen Farrierr
Surgery Harston Surgery
Surgery tel 01223 810 230
Sex Female
Next of kin Lee Hill - partner
Next of kin tel 07812068558 – call first instance
Other relevant people Mr Norman Oates – Father - 07490234987
Mrs Linda Oates – Sister -
Allergies No know allergies
Diagnosis Multiple Screlosis
Approximate date of diagnosis Jayne was diagnosticated with MS in 2011
 Care visits

Visit name Mon Tue Wed Thu Fri Sat Sun

Day service
10
1 10
1 10
1 10
1 10
1
Care visit, 08:00-18:00
Weekend service
81
Care visit, 09:00-17:00 18
Summary

Jayne lives with her partner Lee in a privately owned bungalow in Hauxton, the
bungalow is suited for her needs.

Jayne loves to do some of the gardening and carers will help Jayne to do still little bit
now. Jayne used to play a lot of sport but she loved Hokey, she even play ed for England and
she was very good at it. She went to Canada to play Hokey . She like to read about healthy
food and does some of the cooking or baking with the carers at this present time.

Jayne is living with a disgnosis of Multiple Screlosis with no know allergies. (see
appendix for multiple screlosis details)
Jayne is at hight risk of falls as she is now immobile and unable to weight bear.
Jayne has full mental capacity and cand express what she wants but not always
communicate what she would like to be assisted with. The carers will need to ask questions to
make sure that Jayne can express her choice.
She is incontinent, and due her condition detreating she can not be aware and this is
why it is so important to make sure that the carers will check Jayne’s pad.
She has two hoists, one is full body hoist for all transfers around the house, and
another one is fix hoist in her bedroom for all transfers in her bedroom and uses a wheelchair
to mobilize around the house. Jayne has two wheelchairs, one is manual and another is
electric wheelchair which it gave before independence to Jayne outside of the property , but
now is in unable to use the remote control, she crash obstacles in her way and this is not safe
for her.

Jayne’s muscles seize and lock up at night, for this reason she requires 2 carers at all
times be careful around her legs as she does not have much feeling in her legs.

She has a recliner chair in the living room which she uses during the day or one in the
garden is there is nice weather for it.

She has been provided with a hospital bed, following the falls caused by muscle
spasms. Jayne has pain and spasms and needs massaging in the morning and in the evening to
alleviate the discomfort of these.

She has deteriorating ability to swallow and has episodes of asprating on her saliva,
she must be monitored for this at all the time. Jayne requires full support to eat, due to risk of
choking. If Jayne is choking , please position one care staff on each side, tip Jayne forward
and strong tap on the back to help Jayne spit out the saliva. Jayne can not be left on her own
at all. She always have to have one carer with het at all the times.
 1 Level of Understanding
What care and support needs do I currently have?

I am fully able to understand what is said to me and I can have a conversation with my partner,
family, friends or carers, if I am not tired.
I would like to be fully involved in my care and support planning along with any decisions that
need to be made about me.
I do have some memory loss – I can recall things from a long time ago very easily. Sometimes I
forget names of people I don’t know well but don’t have a problem with familiar people such as family
and friends.
I know what time it is, and what date it is as long as I have the big clock by my side.
I know my way around the home and grounds but would need help with my wheelchair and
guidance anywhere else.
I have a Lasting Power of Attorney plan set up so my can help with any
decisions regarding my health and finances if I am ever unable to do so myself

What are my desired outcomes?

I would like people to remember I am able to make my own choices and decisions and
help/support me make them if I ask.
I want to continue to make my own choices and decisions in as many areas of my life as possible
and for as long as possible.

How do I want staff to support me to achieve my desired outcomes?

Please remember that I like to make my own choices and decisions in every area I can, so do not
make assumptions or choose for me.
Please assist me to make choices, by clearly describing.
 2 Communication
What care and support needs do I currently have?
My name is Jayne. I speak English and I am able to make my feelings and needs known without
problems. I can ask for staff assistance without any problems, but most of the time I am quiet and I
need the carer to ask question about my needs.

Sometimes is possible to have speech difficulties, which are caused by MS. Therefore my speech
can sound slurred, can be very quiet or I may run out of air when I am talking.

What are my desired outcomes?

I want to be able to communicate as well as possible. This helps me feel connected.

How do I want staff to support me to achieve my desired outcomes?

Please talk clearly to me.
Please make sure that you tell me about all activities and events that are happening because I do
find it hard to remember all of this.
 3 Mobility
What care and support needs do I currently have?

I had several falls in the past, sometimes because of spasms or contractures or if I have lost my
balance as a result of reaching for something.

I am now immobile and unable to weight bear. I have Sidhil Portable bedhead hoist and mobile
full body hoist for all transfers and uses a wheelchair to mobilize around the house.

Two care staff to assist me with moving and handling needs with the aid of full body hoist.

I have recliner chair in the living room which I use during the day. I have been provided with a
hospital bed, following to my falls caused by muscle spasms. When I have muscle spasms I will need
the carer to lightly press on top of leg to prevent the shake and this will stop. Usually happenes in the
morning when I sit on the commode.

I use the be hoisted from my bed to the commode for shower, with 2 carers.

When I need to use the toilet, I need to be hoisted on my bed, then from bed to be hoisted on the
commode, and transferred to the bathroom. After, I need to be hoisted back to bed, get dressed, hoisted
on the commode, and from the commode, into the lounge on my recliner chair.

I really enjoy going out for trips and visits and use my own wheelchair for this. I need one carer
to push the wheelchair.

What are my desired outcomes?

I want to enjoy activities within the home and go out on trips and visits as I enjoy this very much.

How do I want staff to support me to achieve my desired outcomes?

Please remember that I can't do things for myself, so I need you to be patient with me and warn
me if I'm not in the right position with my head or hands when using the hoist.
 4 Personal Care
What care and support needs do I currently have?
I have my morning routine, which I would like to be followed.

In the morning I would like the carer to check if I am sleeping, If I am sleeping please let me to
sleep, If I am awake, I would like to say “Good Morning” to me, and to ask me how I am. Normal I
like to stay more in bed, until 11am. I would like the carers undress my low part of the body, so take
off my trousers and pull up/night pad, the apply sling and please hoist me in the commode by using
green loop on my legs. You will need to put commode next to the bed and another carer going behind
to support me to sit correctly on the commode and the second will use the remote control and lift my
legs so I do not get hurt. Please cover my lower part with towel and wheel me in the bathroom. Leave
me in the bathroom with the door half open, around 10-15 min to let me do what I need to do and then
ask me if I am ready for the shower. In this time, please make my bed and get ready my clothes in
bedroom.

Please wheel me in shower and give me a shower every day, and every other day I would like the
carera to wash my hair. When I shower I would like the carer to put towel on my body and after, I
would like to give me the tooth brush with tooth paste ( they are in the small cabinet in the bathroom,
and my toothbrush head is with yellow), and I will brush my teeth. Please help me if I can’t press the
button. I will need sometimes help brushing my teeth as I can only brush one half, so politely ask me I
need help brushing my teeth. After you take me back in my bedroom, please use the hoist and I would
like the carers to help me dry my body very well to prevent pressure sore. Please put my pull up pads. I
would like the deodorant on every morning, please, as this is important to me. I would like you to ask
me what I would like to wear for the day and the help me dress. Usually I have bra, trousers and T-
shirt. Before you put my socks on, I would like to put cream on my leg and massage them as this help
my circulation.

After all this, I would like you to apply a dry sling on my body and help me to be hoisted in to my
electric chair. Please take me in the kitchen and give me my breakfast, what my partner has already
gotten for me. If if it's cereal, i'll need your help because I can't coordinate my hands anymore to
handle the spoon. I would like to have my tablets what Lee has got ready for me. After this, please let
the tea to cool down a little bit, and then help me to drink me cup of tea.

After this morning routine, please ask me what I would like to do as I can sometime choose listen
to radio, go in the garden. Please make sure that I have my personal phone with me at all the time.
 What are my desired outcomes?

I would like to be clean, nice dressed in outfits that I choose. I want to be have my hair
brushed, and wearing my favorite perfume.
I would like the staff to respect my dignity and ensure my privacy at all times during
personal care.

How do I want staff to support me to achieve my desired outcomes?

I need help and support from 2 carers with most aspects of personal care and to ensure that
doors and blinds are closed when it is taking place. I am a very private person.
I would like staff to wash and dry my face. I need help with washing and drying other areas.
I would like carers to check my finger nails and assist me to keep them neat, clean and
short.
I would like the carers to help me to have a shower every day and hair wash every other
day.
 5 Continence Care
What care and support needs do I currently have?
I am unable to use the toilet, because I lost my feelings. During the day I use to wear pull
up pads, and during the night I use normal pads. I had urine infections, which made me feel
uncomfortable.

Most of the time my pad is wet, but sometimes I can use and the commode.

I don’t feel if I need to go to the toilet, or if I am wet, for that I need a pad check during
the day. I would like the carers to check/change my pad between 1:30pm – 2:00 pm, depending
on what we are doing.

I would like the carers to take me back to my bedroom and hoist me back to my bed.
Please take my trousers off. If the pad is wet, please change this, if is dry, please hoist me on
the commode and let me to sit there for 5-10 min. Please wipe my private area with wet wipes
to prevent any infections am I am prone to this. Please put my trousers back on and hoist me on
the commode, and transfer me into the lounge, then use the full body hoist to put me on my
comfy chair. Because most of the time it is possible to be tired, please ask me if I want to sleep
or if I want to watch tv.

I suffer from constipation, it is possible for 5 days to pass without having bowels open. If
5 days pass without my bowels open, please tell my partner to give me tablets, Senna. If I don't
make it the next day, please tell him to give it to me again, and so on until I can have bowels
open.

What are my desired outcomes?

I would like help to avoid constipation.

I would like staff to help me prevent another urine infection.

I always want staff to maintain my dignity with my toileting needs.

How do I want staff to support me to achieve my desired outcomes?

I always want to feel private when using the commode in the bathroom, so always like the
bathroom/bedroom door shut , but not full due to risk of drowning.

I would like the staff to ensure that my pads are discreetly stored in my bedroom.

I would like the staff to help with my incontinence quickly and discreetly. At these times I
would like to be clean down below and make sure I am dry so my skin doesn’t get sore.

I would like the care staff to count my days without bowels open, and to help me with this
problem. If I have not had a bowel movement for 5 days then I would like the staff to tell my
partner to take advice because I don’t want to be uncomfortable.
I know I need to drink fluids to reduce the possibility of a urine infection. I would like
staff to be vigilant to look for signs that I may be getting a urine infection and to report this to
my partner quickly.
 6 Oral Care
What care and support needs do I currently have?
I would like to give me the tooth brush with tooth paste ( they are in the small cabinet in the
bathroom, and my toothbrush head is with yellow), and I will brush my teeth. Please help me if I can’t
press the button. I will need sometimes help brushing my teeth as I can only brush one half, so politely
ask me I need help brushing my teeth.
After I brushed my teeth, I have a green plastic cup, and a plastic box which I use to rinse my
mouth. Please give me to hold the cup with half water in, and I will rinse 3 times. Every time I use to
split in the plastic box.

What are my desired outcomes?

For me to continue to be able to maintain my oral health and hygiene.

For any problems to be addressed and treated promptly by my dentist.

How do I want staff to support me to achieve my desired outcomes?

I would like the staff to put toothpaste on the soft toothbrush and to hand it to me so that I can
brush my gums and mouth.
I would like the staff to check my upper and lower teeth each morning, ensuring that they are
clean.
 7 Nutrition and Hydration
What care and support needs do I currently have?
I like a varied diet and I prefer to eat small meals throughout the day rather than large platefuls
of food.
I like ham, cheese and tomato sandwiches, fruits and soup for lunch.

I enjoy most food, particularly roast. I like to drink cups of tea with no sugars. I need lots of
encouragement in relation to drinking fluids as I am aware that this will help me to avoid a urine
infection. Most of the time I like water, but sometimes I like apple juice, orange juice or pineapple
juice.
I am able to make decisions and choices in relation to the foods that I eat.

Due to my health condition, I need help to eat when using fork and knife. If I have sandwich for
lunch, I can eat on my own.

I also find it difficult to pick up full mugs and glasses, so I would prefer to help me with my
drinks.

I prefer to eat my breakfast in the kitchen or in the garden if weather is nice, and my lunch into
the lounge.

Because I have my breakfast around 12pm, I can have my lunch around 3pm. Sometimes, I
decline the lunch, but I can have a snack, like yogurt, biscuits, chocolate, or ice-cream.

What are my desired outcomes?

For me to enjoy a healthy, varied and nutritious diet and for me to remain as independent as
possible.
To use my diet to increase fluids so that I avoid repeated urine infections and have regular bowel
movements.

How do I want staff to support me to achieve my desired outcomes?

I would like staff to ensure that I have barley water to hand throughout the day.

I would like the staff to ensure that they help[ me with my drinks.

I would like the staff to present me with smaller sized meals and to offer me choices in relation
to what I eat.
I like small snacks mid-afternoon.

I would like the staff to ensure my food is cut into bite sized chunks prior to putting it in front of
me.
 8 Skin Care
What care and support needs do I currently have?

I have no special needs with the skin, sometimes the skin on the face is dry, and please apply a
little cream, which you can find in the bedroom in the cosmetic bag. And if I sit outside in the garden,
please put the umbrella to protect me from the sun, and apply sunscreen on my face and hands, which
you can find in the bathroom in the cabinet, because I risk to get red very quickly.

What are my desired outcomes?

For my skin to remain healthy and not to get any sores.

How do I want staff to support me to achieve my desired outcomes?

I would like the staff to monitor the condition of my skin while helping me with personal care
and report any concerns.

I like to wear winter socks, because I am always cold on my feet.

During the day, when I am on electric chair, or on my comfy chair I would like to have my legs
up, to prevent my feet getting purple.
 9. Social Interests and Activities
What care and support needs do I currently have?
I would like to be offered the opportunity to help in the home’s garden and enjoy arranging
flowers.

When I was young I used to play a lot of sport but I loved Hokey, I play even for England and I
was very good at it. I went to Canada to play Hokey.

I like watching Countdown, Pointless, Garden Rescue, Escape to the County, Money for Nothing,
The repair shop, a lot of sports, I like to watch Hokey, Footbal, Snooker or Tennis.

I like to read about healthy food and I like to do some of the cooking pr baking with the carers at
this present time.

What are my desired outcomes?

For me to join in with things that I enjoy and spend my time as I choose.

How do I want staff to support me to achieve my desired outcomes?

I would like help to join in with activities I’m interested in. I need staff to tell me when outings
are planned.

I would like the staff to chat to me.

 10 Night Time Support
What care and support needs do I currently have?
I would like the carers to help me to get ready for night around 4:45pm – 5:00pm. I will need the
carers to hoist me from the recliner chair to the wheelchair then take me to my room.

I would like the carers to undress me and put my top of the pyjamas on when I am on wheelchair.

Then, please hoist me to my bed by using the hoist next to my bed.

I would like the carers to persuade me to use the commode again in this time. I will usually say
yes so I need the carers to hoist me on to the commode, take me in the bathroom and give me a few
minutes. (10-15 minutes) and then I would like to hoist me back to my bed, clean me very well and put
a night pad on, and my pyjamas trousers.

Then I would like carers to apply cream and massage on my feet, and do some exercises with my
legs, that help my with my blood circulation. After hoist me on the commode and transfer me into the
lounge.

I would like carers to hoist me in to my recliner chair and offer me a glass of water and assist me
with this please, as I need to be hydrotreated during the day. Usually after this I will stay with my
partner for the rest of the evening and the carers are free to go home.

What are my desired outcomes?

For me to be dry, clean, and comfortable for the rest of the evening.

How do I want staff to support me to achieve my desired outcomes?

I would like to be helped to the commode, assisted with undressing and getting ready for bed.

I would like carers to help me to be comfortable on my recliner chair.

 11 Emotional Support
What care and support needs do I currently have?
I sometimes get a little anxious if I don’t know what is happening or when I am in new situations,
and I may need reassurance.

I come from a nice family who were very open and affectionate with each other and I still enjoy a
hug.

I like spending time with my partner, my father or my sister. Sometime my auntie is visiting me
aswell.

I like seeing friends from school, or from University, and have a lot of chat. They are visiting me
once a year.

What are my desired outcomes?

To continue to spend as much time as possible with my family.

To feel safe and happy.

To be offered the opportunity to join in the things that I wish to.

How do I want staff to support me to achieve my desired outcomes?

I want to be reassured when I am feeling anxious.

I like a hug if I am feeling down and always appreciate the opportunity to talk about things.

Please involve me in what is going on around me as I find this reassuring and interesting.

I would like help to take part in regular activities and visits.

I want to be able to see my family as often as possible and for them to be made welcome when
visiting.

Please spend time talking to me as I enjoy hearing about other people’s lives, what is going on in
the world, or sharing a joke.
 12 Expressing
Sexuality???????????????
What care and support needs do I currently have?

I always like to dress smartly, clean and comfortable, because I spend all day sitting on my
electric chair or recliner chair.

It is important for me to have my hair clean and brushed.

What are my desired outcomes?

To continue to take care of my appearance.

To feel confident in my hygiene and appearance.

How do I want staff to support me to achieve my desired outcomes?

I would like staff to support me with my daily personal hygiene and I like to feel clean and smell
nice. I enjoy wearing my perfume.

I would like staff to help me decide what to wear. I may need them to describe the choices
available each day in my clothing as I really enjoy this.
 13 Spiritual and Cultural Well-
Being?????????????
What care and support needs do I currently have?

What are my desired outcomes?

How do I want staff to support me to achieve my desired outcomes?

 14 Health Care
What care and support needs do I currently have?
I live with my partner Lee in our owned bungalow in Hauxton, and the bungalow is suited for
my needs.

I am diagnostigated with Multiple Screlosis with no known allergies.

I am unable to walk, and I loose my feelings, I need help with almost everything.

Sometimes I feel pain on my legs, but it helps me some massage.

I have prescribed tablets from GP, and from Neurologist, but my partner is getting ready
everything for me.

What are my desired outcomes?

For my various health conditions to continue to be monitored and controlled.

To continue to do things I enjoy despite my health conditions.

To be pain free.

How do I want staff to support me to achieve my desired outcomes?

I would like the staff to ensure that I take all prescribed medication prepared by my partner.

I would like the staff to speak with my partner to make sure that I attend all appointments and
I would like him to attend them with me.

I will tell staff if I am in pain and need extra medication to stop this.

I would like to see my doctor when I feel unwell.

 15 Medication Management
What care and support needs do I currently have?

I am prescribed a number of tablets by my doctor, but my partner take care of ordering and
collecting every month.

I need help taking my tablets and I am happy for the staff to administer my medications for
me.

Tablets what I take: Solifencin, Vitamin D3, Sertaline, Madofnil????????

What are my desired outcomes?

I want my health conditions to be managed as well as they can be by taking the tablets that I
am prescribed by my doctor.

I would like to see my doctor when it is necessary and to have my tablets reviewed.

How do I want staff to support me to achieve my desired outcomes?

I would like staff to help me take my tablets.

 16 Mental Health
What care and support needs do I currently have?

I have full mental capacity and I can express what I want but not always communicate
what I would like to be assisted with. The carers will need to ask questions to make sure that I
can express my choice.

I am a happy lady who enjoys company and activity but I am also quite private.
I like to see my family regularly as that makes me very happy.

What are my desired outcomes?

To remain happy.

To have my occasional anxieties and upset dealt with in a private, low key way without too
much fuss.

How do I want staff to support me to achieve my desired outcomes?

I want to have the opportunity to enjoy being in company and being involved with the
activities.

I would like staff to reassure me when I am anxious .

I love a hug if I am feeling down, especially from my partner.

 17 End of Life Preferences
What care and support needs do I currently have?

Not know, not ready to talk about this yet.

What are my desired outcomes?

How do I want staff to support me to achieve my desired outcomes?

Appendix
Multiple sclerosis (MS) is a condition that can affect the brain and spinal cord, causing a wide
range of potential symptoms, including problems with vision, arm or leg movement, sensation or
balance.

It's a lifelong condition that can sometimes cause serious disability, although it can occasionally be
mild.

In many cases, it's possible to treat symptoms. Average life expectancy is slightly reduced for people
with MS.

It's most commonly diagnosed in people in their 20s, 30s and 40s although it can develop at any age.
It's about 2 to 3 times more common in women than men.

MS is one of the most common causes of disability in younger adults.

Symptoms of multiple sclerosis

The symptoms of MS vary widely from person to person and can affect any part of the body.

The main symptoms include:

 fatigue
 difficulty walking
 vision problems, such as blurred vision
 problems controlling the bladder
 numbness or tingling in different parts of the body
 muscle stiffness and spasms
 problems with balance and co-ordination
 problems with thinking, learning and planning
Depending on the type of MS you have, your symptoms may come and go in phases or get steadily
worse over time (progress).

Muscle spasms, stiffness and weakness

MS can cause your muscles to:

 contract tightly and painfully (spasm)

 become stiff and resistant to movement (spasticity)
 feel weak
Mobility problems

MS can make walking and moving around difficult, particularly if you also have muscle weakness and
spasticity.

You may experience:

  clumsiness
 difficulty with balance and co-ordination (ataxia)
 shaking of the limbs (tremor)
 dizziness and vertigo, which can make it feel as though everything around you is spinning
Pain

Some people with MS experience pain, which can take 2 forms.

Pain caused by MS itself (neuropathic pain)

This is pain caused by damage to the nervous system.

It may include:

 stabbing pains in the face

 a variety of sensations in the trunk and limbs, including feelings of burning, pins and needles,
hugging or squeezing
Muscle spasms can sometimes be painful.

Musculoskeletal pain

Back, neck and joint pain can be indirectly caused by MS, particularly for people who have problems
walking or moving around that puts pressure on their lower back or hips.

Problems with thinking, learning and planning

Some people with MS have problems with thinking, learning and planning, known as cognitive
dysfunction.

This can include:

 problems learning and remembering new things – long-term memory is usually unaffected
 slowness in processing lots of information or multitasking
 a shortened attention span
 getting stuck on words
 problems with understanding and processing visual information, such as reading a map
 difficulty with planning and problem solving – people often report that they know what they
want to do, but can't grasp how to do it
 problems with reasoning, such as mathematical laws or solving puzzles
But many of these problems aren't specific to MS and can be caused by a wide range of other
conditions, including depression and anxiety, or even some medicines.

Mental health issues

Many people with MS experience periods of depression. It's unclear whether this is directly caused by
MS or the result of the stress of having to live with a long-term condition, or both.

Anxiety can also be a problem for people with MS, possibly because of the unpredictable nature of the
condition.

In rare cases, people with MS can experience rapid and severe mood swings, suddenly bursting into
tears, laughing, or shouting angrily for no apparent reason.

Bladder problems

Bladder problems are common in MS.

They may include:

 having to pee more frequently

 having a sudden, urgent need to pee, which can lead to unintentionally passing urine (urge
incontinence)
 difficulty emptying the bladder completely
 having to get up frequently during the night to pee
 recurrent urinary tract infections (UTIs)
These problems can also have a range of causes other than MS.

Bowel problems

Many people with MS also have problems with their bowel function.

Constipation is the most common problem. You may find passing stools difficult and pass them much
less frequently than normal.

Bowel incontinence is less common, but is often linked to constipation.

If a stool becomes stuck, it can irritate the wall of the bowel, causing it to produce more fluid and
mucus that can leak out of your bottom.

Again, some of these problems aren't specific to MS and can even be the result of medicines, such as
medicines prescribed for pain.

Speech and swallowing difficulties

Some people with MS experience difficulty chewing or swallowing (dysphagia) at some point.

Speech may also become slurred, or difficult to understand (dysarthria).