The Complete Guide To A Care Plan

Elderly person signing that they took part in the creation of their care plan

What is a care plan?

The care plan is a legal document outlining, in an accessible way, the services and support to be provided to the client/patient. 

It states what the aims and objectives are, how to treat each issue the patient has, as well as who is doing what, where and when. It will also contain all personal details that may be required in an emergency. This document should be assembled and agreed upon with all parties concerned.

How do I get a care plan?

To create a care plan you first need to understand person-centred care (thinking and planning). This means acknowledging a person in their entirety, allowing for all aspects of their life and wellbeing, as well as all external parties, involved in their care, to be accounted for. Above all, it should allow for the individual (where they have the capacity) to make their own health care choices.

For those who are unable to exercise this decision making, (eg; has dementia or other degenerative/mental health disorders) decisions are deferred to the person with Lasting Power of Attorney (LPA), and a different process should be followed. – Seek guidance from The Mental capacity Act, 2005.

At this time it’s important to still work with person-centred care in mind, by working with individuals involved in care who should take the person’s history and best interests into consideration.

Involving people in decisions about them

Involving people in decisions about their care is essential to the principles of the Mental Capacity Act (MCA), and should be evident in every care and support plan. Research on mental health and wellbeing demonstrates that involvement leads to improved service outcomes and enhances mental wellbeing. By that knowledge, people who use the services and their carers are experts by experience. By bringing their knowledge and ideas, they give a fresh perspective on how their particular needs for care and support can best be met.

Supporting people to be involved in decisions about their care and treatment should be reflected in the management, policies and care practice of each service. Meaningful involvement is based on a sharing of power between the person using the service and the provider. Involving people in designing their care plans means:

  • having a conversation among equals who are working together to help one of them make a decision about their care and support
  • The person is considered as a whole in all aspects of their life
  • That the plan belongs to the person, keeping them in control
  • The care plan is only implemented or shared with others if the person gives consent (where they have the capacity to do so).

These are identified as key elements in person-centred care planning for people with long-term conditions. They are, however, equally applicable to care planning for all adults in need of care and support.

Person-centred thinking: 

Involves viewing the person as a whole, accounting for their mental health needs, physical needs and family/social needs. You must personalise the care plan to fit them. This involves listening to the client, acknowledging their beliefs and needs, thinking together, working cohesively alongside other health professionals and caregivers as needed, sharing ideas and regularly getting and implementing feedback. 

This is about the client having as much control as possible. This mode of care gets patients involved in their care and is proven to result in much improved health outcomes.

Person-centred planning: 

Similarly to the way you think planning involves, looking at how the person wants to go about care, and circumstances that the person currently lives, as well as their goals for the future and for their health. 

Acknowledge and accommodate for their values, beliefs and interests. Know what is important to them and what support they feel they require. Once all information has been gathered the planning process can begin, allowing for input from all parties needed or wanted in the patient care, when everyone in their care team is in agreement, the plan can be implemented.

Evaluations, reviews & monitoring: 

This should take place on a regular basis to check that all needs are still being met, and the care plan is up to date with patient needs. If there are any immediate changes to the patient’s condition the care plan will need to be adjusted to accommodate for their new needs.

Person-centred care and support plans

Each person’s needs and choices will be unique to them. This means that everyone involved must do all they can to help the patient convey their personal aspirations and goals, and the support they need. Creating the care plan with the person or their chosen representative will keep the focus on what is important to that individual and will enable their care and support to reflect this.

Designing a Mental Capacity Act compliant care and support plan requires a cultural shift from ‘traditional’ models of care planning to person-centred care planning.

The key differences between the two are summarised in the table below.

Traditional care planningPerson-centred, MCA-compliant care planning
The professional assesses the person’s needs.The care and support plans are developed with the person. The conversation is led by the person who knows best about their needs and preferences.
Care planning follows a medical model of disability.Care planning follows a social model of disability.
The focus is on what the person is unable to do.The focus is on goals and aspirations, what the person would like to achieve with their care and support.
There is a static view of the person’s ability or capacity.Care planning explores potential for change, opportunities to develop capacity and ability.
The professional writes the care plan with little or no input from the person or their representative.The person is supported to express how they would like their care and support to be delivered. The professional provides information about what the service can offer. They agree what will be in the care and support plan. A copy of the plan is made available to the person and/or their representative.
Emphasis is on protecting the person from risk.The emphasis is on safe care that respects a person’s right to take risks that they understand.
The process takes place when it is convenient for the professional.A care planning conversation takes place at a time when the person is most or more likely to have capacity.
Power is with the professionals.Power is equally shared.

MCA-compliant care and support plan

Promoting involvement may mean orientating the person to the decision. For example, helping to orientate a person with dementia to the time and place relevant to the decision and filling in the gaps of their understanding. It might also include helping someone who is depressed to hold onto positive values that were important to them when they were not so depressed. Ongoing work to reduce the effects of mental health conditions and maintain independence and control is vital to maximising a person’s capacity.

Actively involving other people who are part of the person’s life will usually improve their care and support. Linking into a person’s existing support network will bring together all the information about them, so that their care and support are tailored to meet their specific needs and preferences. This will help to improve the client’s experience and promote their wellbeing. Rather than merely responding to problems as they arise.

Being truly “person-centred” is about recognising people within the full context of their lives and how they live them. Not just focusing on their health conditions. The person’s wishes, thoughts and feelings should be routinely prioritised together with input from families and carers. 

Care planning is a conversation between the person and the healthcare provider about the impact of their condition. How they can be supported to best meet their health and wellbeing needs in a ‘whole-life way’ should also be discussed. The care plan is owned by the individual, and shared with others with their consent.

Producing a shared written record of how the person will be cared for tells them (and others whom they wish to involve) what to expect. Providing this information clearly maintains the accountability of the service provider, and enables people to raise any concerns about the care plan or its delivery.

How to write a care plan

After discussing what should be included in the plan, all persons involved should work on writing the care plan. A care plan that is written by one person alone in an office may include all the key elements, but is not likely to be effective in practice.

Whereas a plan which is written in partnership with the person and those who are contributing to the plan, can be more effective due to the familiar and comfortable language that would be used.

What is included in my care plan?

A care plan should include the following:

  • Times when the care is required
  • Any nutritional needs
  • Personal hygiene needs
  • Allergies
  • Specific conditions or health problems to be monitored as well as actions to mediate these.

The Human Rights Act, 1998 and The Equality Act, 2010. They are both UK legislations that set out the rights for every individual. 

There is also the Care Act 2014. Which was introduced to educate on support and planning for the care of vulnerable individuals.

Crisis and contingency plans

Crisis and contingency plans must be based on the individual circumstances of the person. However, If no risks are identified, a contact card will be sufficient. The contact details provided must have 24/7 availability, so that someone can always get in touch with the correct people. Crisis plans should also set out the action to be taken if the patient becomes very ill, or their health is deteriorating rapidly.

The plan must include:

  • Who the patient responds best to and how to contact them
  • Previous strategies that have been successful in similar situations
  • Early warning signs and relapse indicators
  • Contingency plans should help to prevent a crisis developing when, at short notice, the Co-ordinator is not available or part of the care plan cannot be provided.
  • Information about who to contact if the Co-ordinator is not available
  • A contingency for any key elements of the care plan.

What to think about when creating a care plan

  • What the person would like to achieve with their care and support, their goals and aspirations for the future.
  • Include what is important to the person. About how they live their life now; what they enjoy doing, their interests and their likes and dislikes. As well as who is important to them, who they like to see, and their preferred routines. (such as when they like to get up and go to bed, whether they like a bath or a shower, etc.).
  • Details of key life events and dates to assist with chronological orientation.
  • How best to support and involve the person in decision-making.
  • Essential information for continuity of care and for use in emergencies.
  • Roles and responsibilities so that the person receives coordinated care and support to meet their needs.
  • Where a person lacks capacity to express their choices: how their families and others who are interested in their welfare have been consulted.
  • What outcome the person wants and any other options considered.
  • The associated benefits and risks of each option.

When should my care plan be reviewed?

Your care plan has to be reviewed regularly. Needs can change over time, and you may have to make changes to the care you receive.

The first review should happen within a few months of the start of your care and then regularly once a year.

You can request a review of your care plan anytime. Should you see a sudden change in your situation, call the adult social services at your local council.

What if I’m not happy with my care plan?

If you wish to complain about your needs assessment or care plan, you should get in touch with the main contact that was assigned to you in your care plan.

Should you still have issues that cannot be resolved this way, you can contact the local government or social care ombudsman. This is an independent advice service which looks into complaints about councils, local public services and social care providers.

There are many resources online to assist you with better understanding of the process of planning care. 

Check out the following guidance tools online: 

Continence care planning

Care and support statutory guidance 

Core care standards

Author: James

I founded and manage PrimeCarers, a Platform that connects Private Clients with Private Carers near them.