Setting

This audit is relevant to community drug and alcohol teams (CDATs).

Background

For over a decade, care planning has been used in structuring the treatment and management of patients within substance misuse services. The central role of care plans and their use has been set out in guidelines and recommendations from the National Treatment Agency (NTA).

Standards

Standards for this audit were obtained from NTA documents and were as follows:

ᐅ All patients entering treatment with substance misuse services should have a written care plan.

ᐅ Patients should be involved in the construction of this care plan.

ᐅ The care plan should be signed by both key worker and patient.

ᐅ The care plan should be regularly updated and reviewed (the NTA recommends a review 3 months after the initial care plan and reviews every 3–6 months for subsequent care plans).

ᐅ Within the care plan, information about the following four domains should be included:

Method

Data collection

All cases open to each CDAT at the time of audit were identified according to primary substance of use (illicit drugs or alcohol) and by key worker. Then 10% of each CDAT's cases were selected randomly (using systematic sampling to ensure cases selected were not weighted in favour of any individual key worker).

The case notes of the selected cases were examined for the following:

ᐅ a care plan present in the notes

ᐅ the care plan signed by both the key worker and patient

ᐅ the date the care plan was last updated

ᐅ a clearly identified ‘treatment plan’ documented in the care plan

ᐅ all four domains included in the care plan

ᐅ an ‘aim’ and ‘plan of care’ documented in each of the four domains.

Data analysis

After preliminary data analysis, clarification was sought from key workers in a random sample of cases to establish whether domains missed had been considered for that client but not documented or had been omitted entirely.

Resources required

People

This audit can comfortably be undertaken by one person in a CDAT managing around 1000 patients. If more than one professional documents care plans, then they should be involved in data collection.

Time

Based on this size of audit, data collection takes approximately 20–25 hours.