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squaresStep 2: assessment, care planning and review

The second step on the route to success is about the early assessment of a resident’s needs and
wishes as they approach the last year of life. The aim is to establish their preferences and choices
as well as identify areas of unmet need. It is important to explore the physical, psychological,
social, spiritual, cultural and environmental needs and wishes of each resident.

Time: Half day
Aim: The care home representative will understand holistic assessment and
its relevance to advance care planning. They will explore systems to discuss,
record, review and share assessments appropriately




By the end of the session the Care Home Representative will be able to:

• Recognise the importance of holistic care planning

• An awareness of assessing a residents mental capacity

• Produce an action plan to implement a system to support advance care planning

• Develop further the Care Home End of Life Care Policy.


This workshop should be followed with mandatory supporting education.  More information can be found here


Supporting Documents:


Attendance register  PDF

This basic register can be used at any events and workshops to keep a record of delegates.


The Routes to SuccessPDF

The programme is based on the Routes to Success and this document can provide further background to the programme. 


Holistic Assessment Guide PDF

This document provides guidance for holistic common assessment of the supportive and palliative care needs of adults requiring end of life care. 


Step 2 case study PDF

This learning aid provides a case study which can be used alongside the work plan for Step 2.


Step 2 care plan PDF

This tool is used alongside the work plan for Step two. 


Mental Capacity Act (2005) - Two stage test of capacity PDF

This guide, produced by the Care Quality Commission, contains information about the Mental Capacity Act (2005) and the two stage test of capacity (see page 5).


Best Interests at End of Life PDF

This document contains practical guidance for Best Interests Decision Making and Care Planning at End of Life.


Support sheet 12 PDF

This support sheet provides information on the Mental Capacity Act (2005).


Support sheet 13 PDF

This support sheet provides information on best interest decision making.


Planning for your future care - A guide PDF

This booklet provides a simple explanation about advance care planning and the different options open to people approaching the end of life.


Capacity, care planning and advance care planning in life limiting illness: A Guide for Health and Social Care StafPDF

This document provides guidance around advance care planning for health and social care staff. 


Support sheet 3 PDF

This support sheet provides information on Advance Care Planning.


Support sheet 4 PDF

This support sheet provides information on Advance Decisions to Refuse Treatment.


Support sheet 18 PDF

This support sheet provides information on the Preferred Priorities for Care (PPC).


North West End of Life Care Register PDF

This useful tool can be used to register and track individuals who may require end of life care.  (Copy without examplePDF)


Step 2 To Do list  PDF

This provides a checklist of actions which should be completed before the next workshop.


Evaluation form  PDF

This evaulation form can be used to allow delegates to provide any feedback.  This feedback will help facilitators to continually develop and improve the delivery of the programme. 










End of Life Care
Downloads   End of Life Care Strategy:PDF 
Downloads   Best Interests at end of life:PDF
Downloads   Advance Care Planning:PDF
Downloads   Preferred Priorities for CarePDF
Take a look in our library for a wide selection of documents and resources.