Care Plans: What You Need To Know

What is a care plan?

A care plan is created for a person receiving healthcare, personal care or any other forms of support. It outlines why the person is receiving care, including their assessed health and care needs, their personal details, medical history and what care and support will be provided for them with details of how, when and who will provide each element of care.

“People using a service have care or treatment that is personalised specifically for them. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.” (You can read the full regulation here)

Why are care plans important?

A care plan is essential as it provides a detailed and personalised outline of care to be provided, which helps improve the person’s quality of life. A care plan should be created for everyone in social care who needs support, from those needing simple assistance with day to day tasks to those that need round the clock supervision and medical care.

Benefits of a care plan:

It is individual to the person; no two care plans should be the same.
It provides a record of conversations, decisions and agreed outcomes in a way that makes sense to the person receiving the care.
It provides a description of the person, what matters to them and how the care provided can make their plan achievable and effective.
It is adaptable to the person’s needs and should be reviewed and changed where required to continuously give an accurate insight into the person’s health conditions, situation, and care and support needs.

When are care plans created?

Care plans are usually created following an assessment of a person’s care needs and a risk assessment that involves both the person receiving care and sometimes their families. This information then provides the foundations for building the care plan.

The care plan may also be consulted by the person’s GP, pharmacists and other health care professionals to provide additional information that will assist with the person’s healthcare to deliver ongoing health and social care services.

The care planning process makes sure that the person is given the right level of care, and that the agreed care plan adjusts as their needs and personal preferences change, so it is important to follow the care planning process to ensure continuity of care.

What is a care plan in health and social care?

A care plan is fundamental in health and social care to ensure the person needing support gets the right level of care in line with their needs and goals and in a way that is individual to them. It provides information and is a source of guidance for health and care professionals delivering care.

For example, when a care professional is delivering care home services they will check the care plan to understand what they need to do for the person on a day to day basis, and to assist the person in being as independent and having as much control over their life as possible – as well as any medication requirements and any specific preferences the person has. It also provides other important information like risks that they should be aware of in order to deliver care safely and to the highest standards.

A care plan enables care providers to understand a person’s health and needs, whilst providing safe, person centred care to provide the outcomes the person has agreed on.

The care planning process

The process of creating a care plan begins with a care needs and risk assessment that creates the information foundations for the care plan:

Care needs assessment – a care needs assessment looks at the person’s current situation, including their mental and physical health to understand what they need support with and why. In the UK this is typically conducted by the local authority.
Risk assessment – the risk assessment considers any possible risks and hazards, to both the person themselves and people providing care or support, such as any aggressive behaviour, trip hazards etc. All risks are assessed for their likelihood to happen, and the severity of harm that could be caused if they did. Preventive steps to avoid these risks will be recommended and implemented. This assessment is typically carried out by the organisation that will deliver care, rather than the local authority or other body.

Once these processes are complete the care plan can be created in full consultation with the person who is being cared for or supported. The needs assessment will be used to determine how best to meet the person’s care needs, but is not sole source of information, as talking with the person who will be receiving the support about their goals, what they enjoy doing (and not doing) helps to deliver better outcomes and ensures the plan stays person centric in its approach.

Understanding the personal preferences of the care recipient

Every individual is unique, and by focusing on their preferences, personal preferences, and building a trusting relationship, it is possible to create a care plan that truly supports and empowers them.

A good care plan follows the principles of person-centred care. Regulators in the UK highlight how important person-centred care is with the CQC stating:

“Providers must make sure that they take into account people’s capacity and ability to consent, and that either they or a person lawfully acting on their behalf, must be involved in the planning, management and review of their care and treatment.”

Care recipient preferences and needs, along with their assessed health, play an important role in developing a successful care plan and it’s vital to take the time to listen actively and observe their behaviour to grasp what they value and require for their well-being. Building trust and rapport with the care recipient is key in this process. By establishing a strong connection, the care plan can ensure a safe space is created for them to express their needs openly and honestly. This trust helps in understanding their preferences better, leading to a more personalised care plan that caters to their individual requirements.

Understanding their daily routines, likes, dislikes, and any specific requests they may have help to ensure the care provided is individual to them and their needs. By being attentive and responsive to these needs and personal preferences, the care plan should not only meet their requirements, but also enhance their quality of life.

Reviewing the care plan

The care plan process does not finish once the care plan has been created and shared, as it should be reviewed in the first few months of the care starting to check if any adjustments are needed, and after this it should be checked (at minimum) once a year.

Ideally, the care plans should be treated as responsive, meaning that they are adapted in a timely manner to reflect any changes in the person’s needs, likes and dislikes, risks and changes in their environment as they arise to make sure the right care is continuously delivered.

If substantial care plan changes are needed, a full reassessment should be completed before a new or revised care plan is created.

If you would like to know more about care plans and how we use care plans to provide person-centred care please contact us.