Person-Centred Care Planning: What Good Looks Like

Person-centred care means planning and giving care around the individual: their needs, preferences, history and what matters to them, rather than around the routine of the service or their diagnosis. In England it's a legal requirement. CQC's Regulation 9 says care must be appropriate, meet people's needs and reflect their preferences. The care plan is where you show it.

What person-centred care means

The Health Foundation's 2014 guide Person-centred care made simple sets out four principles:

• Dignity, compassion and respect: the person is treated as a person, not a task.
• Coordinated care: support from different people and services joins up.
• Personalised care: support fits this person, not a standard package.
• Enabling: the person is supported to do what they can for themselves.

NHS England describes personalised care and support planning as conversations in which the person takes part, focused on what matters to them and their whole life, not just their condition. That's the test. A plan that could be swapped between two residents with the same diagnosis isn't person-centred.

The rules across the UK

England. Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires providers to assess needs and preferences with the person, design care to meet them, involve them in decisions as far as possible and make reasonable adjustments. CQC's guidance adds that assessments should be reviewed regularly and whenever needed. Regulation 17 requires an accurate, complete and contemporaneous record for each person.

Wales. Care Inspectorate Wales regulates services. Under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, providers must prepare a personal plan with the individual and review it as and when required, and at least every three months.

Scotland. The Care Inspectorate regulates services. The care services regulations require a written personal plan, made after consulting the person within 28 days of the service starting, and reviewed at least every six months or sooner if they ask or their needs change significantly.

Northern Ireland. RQIA inspects against minimum standards set by the Department of Health. For residential care homes, the standards expect each resident to have an individual, up-to-date care plan, with the resident encouraged to take part in drawing it up.

Wherever someone may lack capacity to make a decision about their care, care planning in England and Wales must also follow the Mental Capacity Act 2005. Our guide to Mental Capacity Act principles and DoLS covers the basics.

What is a care plan?

Two documents get called a care plan. If the council arranges someone's support, it writes a care and support plan after a needs assessment. The NHS explains this in its guide to care and support plans. Your service then writes its own care plan, which sets out exactly how your team will give that support, day to day. This guide is about the second one.

What a care plan should contain

There's no single national template. A useful plan normally covers:

• About the person: their history, family, interests, and what a good day looks like to them.
• What matters to them: routines, preferences, likes and dislikes, faith and culture.
• Communication: how they express themselves, and how best to give information and offer choices.
• Each area of need: personal care, mobility, eating and drinking, continence, health conditions, medicines, sleep, emotional wellbeing. For each one: what they can do, what support they want, and how to give it.
• Risks: what the risk is, the person's view, and the least restrictive way to manage it.
• Capacity and consent: which decisions they make themselves, and any best interests decisions.
• Outcomes: what the person wants to achieve, written so you can tell whether it's happening.
• Who was involved, and when the plan will next be reviewed.

How to write a person-centred care plan

Write for the agency carer on their first shift who has never met the person. They should be able to read the plan and support the person the way the person wants.

Poor: "Needs assistance with personal care."

Better: "Margaret prefers a bath to a shower, in the evening before bed. She washes her face and arms herself if you hand her the flannel. She feels the cold, so warm the bathroom first and have her dressing gown ready."

Poor: "Can be aggressive."

Better: "Tom may shout or push your hand away if he feels rushed in the morning. Tell him what you're about to do before you do it, and give him time to answer. If he says no, leave it and offer again ten minutes later."

A few habits that help:

• Use the person's name, and their words where you can ("I like to be up early").
• Say what the person can do before what they can't.
• Replace vague words such as "assist", "monitor" and "encourage" with what staff actually do. "Encourage fluids" becomes "offer tea in his own mug when he wakes, mid-morning and mid-afternoon".
• Write outcomes that are SMART: specific, measurable, achievable, realistic and time-bound. "Walk to the garden with one carer and her frame, three afternoons a week, by the end of the month" can be checked. "Improve mobility" can't.

Good daily notes feed good plans. Our record keeping training helps staff write notes that are accurate and useful.

Involving the person and their family

Regulation 9 expects the person to be involved in assessing, planning and deciding on their care as far as possible. In practice, that means:

• sitting down with the person at a time that suits them, rather than writing the plan in the office and asking for a signature
• asking family and friends what they know about the person's history and preferences, with the person's agreement
• using easy read, pictures or objects of reference where they help
• involving an advocate where someone has no one else to speak for them
• recording who took part, and what the person said, in their own words where possible

Reviewing care plans

Set your review frequency in your care planning policy, and make sure it meets the rules for your nation: at least every three months in Wales and at least every six months in Scotland. In England, CQC expects regular reviews and a review whenever needs change.

Also review the plan when something changes: after a hospital stay, a fall, a new diagnosis, or when the person or their family say something isn't working. Ask the person whether the plan still feels like them, check progress against each outcome, and update what's out of date.

How Kasorb can help

Our care planning training helps staff write and review person-centred care plans that are clear, specific and useful on shift. It covers what care planning is for, the law and standards that shape it, best practice in the care planning process, working with the multidisciplinary team, person-centred care planning, reviewing your own policy and documentation, and writing SMART outcomes with case studies. It runs on-site or live online as a half day, and two sessions in one day cost no more, so half the team trains while the rest cover the floor. Your trainer has used these skills for real; send your care plan templates in advance and they'll use them in the session. Certificates are emailed the next day.

This guide summarises the law and guidance; it isn't legal advice.

FAQs

What is person-centred care in simple terms?

Person-centred care means support is planned and given around the individual: their needs, preferences, history and what matters to them. The person is involved in decisions about their care as far as they can be, rather than fitting into the routine of the service.

What should a care plan include?

A care plan should describe who the person is, what matters to them, how they communicate, each area of need and how staff support it, risks and how they're managed, capacity and consent, the outcomes the person wants, who was involved and when it will be reviewed.

How often should care plans be reviewed?

In Wales, personal plans must be reviewed at least every three months, and in Scotland at least every six months. In England, CQC expects regular reviews and a review whenever needs change. Your care planning policy should set the frequency for your service.

Is person-centred care a legal requirement?

In England, yes. Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires care to be appropriate, meet people's needs and reflect their preferences. Wales, Scotland and Northern Ireland have their own regulations and standards on planning care with the person.

What does a good care plan example look like?

Instead of "needs assistance with personal care", a good plan says how the person likes it done: for example, a bath in the evening, washing their own face if handed the flannel, and a warm room first. That detail lets a new carer get it right.