Care and Support Plan (CSP) Template
- Thread starter John_Lobb
- Start date
1. Care and Support Plan (CSP) Guidance for Clinicians
| Main NG206 Guidelines | NG206 1.5 Assessment and Care and Support Planning by an ME/CFS Specialist Team |
| Symptom and Medicines Management | NG206 1.12 Symptom Management for People with ME/CFS |
| Information and Support Needs | NG206 1.6 Information and Support |
| Support for Activities of Daily Living | NG206 1.17.6 Severe and Very Severe Access to Care and Support NG206 1.8 Access to Care and Support NG206 1.6.8 Accessing Social Care |
| Adaptations / Living Aids to Improve or Maintain Independence | NG206 Aids and Adaptations |
| Education, Training or Employment Support Needs | NG206 1.9 Supporting People with ME/CFS in Work, Education and Training |
| Self-Management Strategies, Including Energy Management | NG206 1.11.2 Energy Management |
| Physical Functioning and Mobility | NG206 1.12.5 Physical Functioning and Mobility NG206 1.12.9 Orthostatic intolerance |
| Nutrition and Hydration | NG206 1.17.10 Dietary Management and Strategies NG206 1.17.11 Follow CG32 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition |
| Guidance on Managing Flare-Ups and Relapses | NG206 1.14 Managing Flare-Ups in Symptoms and Relapse |
| Safeguarding – Concerns & Assessments | NG206 1.7 Safeguarding |
| Details of the Health and Social Care Professionals Involved in the Person's Care, and Who to Contact | NG206 1.10 Multidisciplinary Care |
| Care & Support Plan – General | NG206 1.17.4 Risk assess each interaction with a person with severe or very severe ME/CFS in advance to ensure its benefits will outweigh the risks (for example, worsening their symptoms) to the person. NG206 1.5.3 Recognise that the person with ME/CFS is in charge of the aims of their care and support plan. NG206 1.5.4 Give the person and their family or carers (as appropriate) a copy of their care and support plan and share a copy with their GP. |
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2. Care and Support Plan (CSP) Example Case Study
| Patient Name | Fred |
| Assigned Clinician | Clinician X - Specialist Nurse (ME, CFS & LC Service) |
| CSP Date | 28/08/2025 |
| CSP Version | V1 |
| CSP Next Review Date | 28/11/2025 |
| Symptom and Medicines Management | Fred is on a 20mg Amitriptyline nightly to help with sleep. He takes self-prescribed paracetamol and ibuprofen for his muscle pain and headaches. He wants these reassessed as they are not very effective. |
| Action | Clinician X to arrange GP home visit to review medications. |
| Information and Support Needs | Fred needs medical information to be provided in writing as he finds it difficult to concentrate and remember outcomes of consultations. Fred needs medical care to be provided accessibly, wherever possible with home visits, or where suitable, by phone or email. |
| Action | Clinician X to alert GP practice and ask for relevant RAFs to be added |
| Support for Activities of Daily Living | Fred lives alone. He is currently provided with a carer with half an hour on alternate weekdays paid for by social services to help with household tasks, preparing meals and showering. This is not sufficient. He needs daily help of at least an hour. |
| Action | Clinician X to contact social services alerting them to Fred's increased needs and asking for him to be reassessed. |
| Adaptations / Living Aids to Improve or Maintain Independence | Fred's home is unsuitable, with no grab rails and narrow doorways, making it difficult for him to use his manual wheelchair which he needs to use on bad days. |
| Action | Clinician X to contact the local authority OT service to arrange a home adaptations assessment. |
| Education, Training or Employment Support Needs | Fred has been unable to work because of his severe ME/CFS for five years. He needs help with reapplying for benefits likely to be required within the next year. |
| Action | Clinician X to arrange provision of medical and care reports and assistance with filling in benefits applications when needed. Draft reports to be prepared in advance. Fred to alert Clinician X as soon as DWP contacts him. |
| Self-Management Strategies, Including Energy Management | Fred needs to pace his activity. He is struggling with this as he needs to do some hobbies to occupy himself and finds them tiring as they require him to sit up and use his arms and hands and coping on his own with household and personal care takes him beyond his energy envelope leading to frequent crashes. He finds having to explain his needs to ever changing carers exhausting. He needs more, and more consistent, care from people who understand his sensory and exertion limitations. |
| Action | 1. Clinician X to contact the care agency and provide them with information about the needs of people with ME/CFS, including Fred's specific needs. 2. Clinician X to provide Fred with a heart and step monitor and leaflets explaining their use to help him with pacing physical activities. Clinician X to check how this is going in 3 months’ time by email. 3. Fred to investigate more activities, eg non stressful games he can do online on his phone to use when lying down, and audiobooks and podcasts, and try to cut back and pace his sitting up hobbies, breaking into shorter sessions. |
| Physical Functioning and Mobility | Fred needs a motorised wheelchair, as he finds the manual one exhausting. He needs to be accompanied by a carer when he needs to go to appointments that can't be done at home such as dentist. Fred’s symptoms of postural orthostatic tachycardia syndrome (POTS) upon standing have improved following a trial of Ivabradine. |
| Action | Report this need when making OT assessment appointment. Clinician X will request that Fred’s GP add Ivabradine to his repeat prescription, with clinical review scheduled in six months. If Fred’s POTS remains inadequately managed at clinical review, Clinician X will consider referral to a specialist PoTS service. |
| Nutrition and Hydration | Fred lives alone and needs help preparing meals. He does not currently get this help every day and reports that he has been struggling to maintain his weight. He is concerned about his recent minor weight loss due to nausea and unappetising processed food and needs a dietician assessment and advice on ways to eat more healthily on his tight budget when he can't prepare meals. Fred’s diet is very restricted due to food intolerances which his carer does not understand |
| Action | Clinician X to arrange a dietetic assessment by a dietician with a special interest in ME&CFS. Dietician to monitor Fred’s weight at each review. Dietician to work with Fred and Fred’s carer to agree a meal plan |
| Guidance on Managing Flare-Ups and Relapses | Living alone makes coping with flare ups difficult as he cannot always get out of bed to fetch food or use the bathroom. |
| Action | Clinician X to alert OT assessors and social services assessors of this problem. |
| Safeguarding - Concerns & Assessments | In February 2025 Fred’s symptoms were confused by social services with signs of abuse and neglect. As a result Fred has lost trust in health and social care services. Fred feels he was not believed. |
| Action | Clincian X to arrange for specialist training in ME&CFS for those in contact with Fred for his social care needs. Fred to be informed when this training has taken place. Fred advised to contact the specialist ME&CFS team as soon as possible if a further safeguarding concern is raised. |
| Details of the Health and Social Care Professionals Involved in the Person's Care, and Who to Contact | |
| Coordinator | Name: Clinician X Phone Number: Email Address: |
| GP | Name: Phone Number: Email Address: |
| Social Services | Name: Phone Number: Email Address: |
| Care Agency | Name: Phone Number: Email Address: |
| Dietician | Name: Phone Number: Email Address: |
| OT | Name: Phone Number: Email Address: |
| Emergencies NHS 111 for out of hours advice, 999 for medical emergencies. |
| Details of the Other Individuals Involved in the Person's Care, and Who to Contact | |
| Name: Phone Number: Email Address: |
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3. Care and Support Plan (CSP) Blank Template
| Patient Name | |
| Assigned Clinician | |
| Date | |
| Version | |
| Next Review Date |
| Symptom and Medicines Management | |
| Action |
| Information and Support Needs | |
| Action |
| Support for Activities of Daily Living | |
| Action |
| Adaptations / Living Aids to Improve or Maintain Independence | |
| Action |
| Education, Training or Employment Support Needs | |
| Action |
| Self-Management Strategies, Including Energy Management | |
| Action |
| Physical Functioning and Mobility | |
| Action |
| Nutrition and Hydration | |
| Action |
| Guidance on Managing Flare-Ups and Relapses | |
| Action |
| Safeguarding - Concerns & Assessments | |
| Action |
| Details of the Health and Social Care Professionals Involved in the Person's Care | |
| Name: Phone Number: Email Address: Name: Phone Number: Email Address: Name: Phone Number: Email Address: Name: Phone Number: Email Address: | |
| Emergencies: NHS 111 for Out of Hours Advice / 999 for Medical Emergencies. |
| Details of Other Individuals Involved in the Person's Care | |
| Name: Phone Number: Email Address: Name: Phone Number: Email Address: Name: Phone Number: Email Address: |
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MrMagoo
Senior Member (Voting Rights)
Hi
Could you explain where this came from, and when, and your reason for posting it please? I have an interest in this and we’ve had a few other threads, I’m not immediately seeing what this thread is about or why it’s happened today.
There was criticism a while back of a care and support plan designed by a clinician from BACME. I had a look at the guidance on care and support plans in the NICE guideline and wrote a hypothetical example of a care plan based on the NICE headings about a patient I called Fred and posted it on our thread discussion. I wanted to demonstrate the idea that care and support plans should be about the medical, care and practical needs of the pwME, it should be written by a clinician, probably a specialist nurse with the pwME and focus on what Fred needs and who is going to ensure he gets his needs met it accessibly.
John Lobb contacted me to ask if he could use the example as the basis of designing a care and support plan for use in their local NHS ME/CFS service. This is the result, I suggested it be shared on the forum.
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MrMagoo
Senior Member (Voting Rights)
So this is an example we’ve generated here - it’s a S4ME guidance, example and template? Or an NHS version? Sorry it’s still not clear.
Which area is it that has a specialist nurse?
MrMagoo
Senior Member (Voting Rights)
I think it needs some kind of title as tow where it’s from/owned as otherwise how would anyone know?