Standard 5: Care is based on the assessed unique needs

The General Practice commits to:

To meet this standard the practice commits to:


Practice Guidance

5.1 Implement Personalised Care and Support Planning (PCSP)




5.1a Understand the role and optimum outcomes of Personalised Care and Support Planning (PCSP)
  • Objectives of Personalised Care and Support Planning (PCSP) agreed by practice team and recorded
  • Objectives need to cover:
    Medical plans, such as Emergency Health and Advance Care Planning
    Demedicalised (non-health) Wellbeing plans, such as mapping care and support networks to enable care preferences
  • Consider different needs for both:
    • Medical plans, such as Emergency Health and Care Planning
    • Demedicalised plans, such as mapping care and support networks to enable care preferences
  • Consider evidencing peer discussion to agree objectives of PCSP
    • Peer discussion / reflective reading on what makes effective PCSP.
    • Consider another practice, hospital or hospice system or invite external peer review
    • Consider use of PPI feedback to improve outcomes
  • Recognise the relevant legal framework in relation to o Valid consent
    • Capacity Assessments and Best Interest decisions
    • Advance Decision Making and Lasting Power of Attorney




5.1b Achieve consistent PCSP process for patients
  • Use a holistic PCSP template to identify and record the key medical and 'demedicalised' information for PCSP
  • Holistic PCSP template used relevant to age, diagnosis, cultural and psychosocial needs
  • Offer sensitive conversations on items in minimum dataset and record on PCSP template
  • Use of PCSP recorded for people on Practice Register
  • The practice team have constructed a process map of PCSP
  • Offer copy and/or access (if available) of PCSP to patient
5.1c Achieve consistent quality of PCSP

The recorded plan, including EOLC dataset, once started is completed and regularly reviewed and updated, in a timely manner and includes:

  • Medical plans including assessment of pain, other physical symptoms and emergency health and care planning.
  • Demedicalised plans, such as mapping care and support networks to enable care preferences.
  • Assessing and reviewing mental capacity.
  • Benefits guidance, e.g. DS1500.
  • Sensitive involvement and communication with patients, families and carers.
  • DNACPR documentation, where appropriate.
  • Holistic needs, including: practical, communication & disability, psychological, social, spiritual and cultural needs.
  • Date and place of death recorded within 2 weeks of death.
  • Evidence continuous improvement of assessing, documenting and reviewing mental capacity.
  • Evidence documentation of relevant and sensitive communication with patients, families and carers.
  • Consider recommendations for DNACPR discussions to be part of the PCSP journey and ideally not to be done in isolation.
  • Consider using common assessment tools to identify and assess needs.For example, SNAP tool - Support Needs Approach for Parents
  • Consider how to ensure patients' pain and/or other physical symptoms will be effectively controlled.
  • Consider how to ensure decision-making is shared with the patient and those important to them.
  • Consider how to meet the communication and information needs of patients' with disabilities and sensory loss, in line with NHS England's Accessible Information Standard 




5.1d Achieve person-centred care
  • Goals of care are recorded and commenced early.
  • How care is aligned to those goals recorded.
  • Information on self-management and enhanced care models available to patients and their carers.
  • Evidence that conversations about goals of care commence early to optimise opportunities to align care to those goals.
  • Consider how the practice evaluates sensitive and compassionate communication.
  • Consider how patients have an opportunity through early identification to benefit from self-management and enhanced care models.
  • Evidence family and carers are involved in planning patient-centred care
  • When patients lack capacity, ensure an understanding of how to make best interest decisions and involving LPAs and Court of Protection deputies, as appropriate.
  • Reflect how the practice minimises non-beneficial or burdensome care in partnership with the patient and those important to them.
  • A toolkit on PCSP for patients not necessarily at EOLC  

Next: Standard 6: Quality Care during the last days of life >

QI 5: Continous Improvement

The practice has identified areas for improvement from their process map (see 5.1b). They then use the 3 questions from the Model for  Improvement, which are:

  1. What are we trying to accomplish?
  2. How will we know if a change has made an improvement?
  3. What changes can we make that will result in an improvement? One of these changes at a time are taken into a Plan-Do-Study-Act cycle. Guidance on Model for Improvement and PDSA cycles can be found on the Quality Improvement page.

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