Care Planning - Everything You Need To Know

A care plan, also known as a support or nursing care plan, is a document created for a person that is receiving healthcare, personal care, or other forms of support. 

Care plans are almost always created following an assessment of a person's care needs and a risk assessment (both involving the person receiving care and sometimes their family or other advocates). The information from these processes then feeds into the building of the care plan.

The care plan may be consulted by GPs, pharmacists and others, to gain information on a person to assist with their healthcare. However, the primary use of a care plan is in the delivery of ongoing health and social care services.

In health and social care, a care plan is crucial to ensuring a client gets the right level of care in line with their needs, and goals and in a way that suits them. It guides health and care professionals as they deliver care to a person and is their primary source of information when doing so.

For example, when a person is delivering home care services they will check the care plan to understand what they need to do during a visit to the service user, any medication that needs to be given, any preferences the person has and any other important information, for example around risks and hazards that they should be aware of in order to deliver care safely and to the highest standards.

A care plan should not simply be about giving people medicines, giving them some food and getting them out of bed and in front of the TV. A key principle of care planning is to assist them in being as independent and having as much control over their life as possible.

A care plan should enable care providers to understand a person's health and needs better while making sure their care is safe, person-centred and working towards outcomes the person has agreed on.

The process of creating a care plan begins with those processes that create the information foundations for the care plan. These include:

• Care needs assessment - what is the person's current situation, including their mental and physical health. What do they need support with and why. In the UK this will typically be carried out by the local authority.
• Risk assessment - Assessment of possible risks and hazards, to both the service user and people providing care or support. This can include aggressive behaviour, fire risks, trip hazards etc. Risks will be assessed for their likelihood to occur and the severity of harm that could be caused. Controls/preventive steps to avoid these risks will be recommended and implemented. Risk assessments are 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. It should be put together 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 it should not be the sole source of information.

Talking with the person you are going to support about their goals, what they used to do but can no longer do, what makes them energised and positive and so on can all make a real difference in producing a care plan that works to deliver better outcomes.

In short, do not prescribe care to people, produce a care plan together that they own with you and are aware of that ownership.

Creating a care plan is a structured, collaborative process, one that places the individual at the centre of every decision. It typically unfolds like this:

Step 1: Carry Out a Care Needs Assessment

The process begins with a thorough assessment of the individual's current situation, covering their physical health, mental wellbeing, personal history, daily routines, and lifestyle preferences. In the UK, this is typically led by a health or social care professional, such as a social worker or nurse, and often involves input from the individual's family or advocates. The goal is to build a complete picture of what the person needs and why.

Step 2: Conduct a Risk Assessment

Alongside the needs assessment, a risk assessment is carried out to identify any potential hazards or vulnerabilities for both the individual receiving care and those delivering it. This might include risks such as falls, medication management, or behavioural considerations. Each risk is evaluated for its likelihood and potential impact, with preventive measures put in place accordingly.

Step 3: Set Goals and Agreed Outcomes

With the assessment findings in hand, the next step is to define clear, person-centred goals. These should reflect not just clinical needs, but what matters most to the individual, their preferences, aspirations, and what a good quality of life looks like for them. Goals might relate to independence, social engagement, physical health, or emotional wellbeing.

Step 4: Build the Care Plan Collaboratively

The care plan itself is then created in full consultation with the person receiving care and, where appropriate, their family or representatives. It sets out what support will be provided, how and when it will be delivered, and who is responsible for each element. The plan should be written in clear, accessible language and signed off by all parties involved.

Step 5: Put the Plan Into Action

Once agreed, the care plan is shared with everyone involved in delivering support, from care workers and healthcare professionals to family members. Each person should understand their role and be equipped to deliver care consistently and in line with the individual's preferences.

Step 6: Monitor, Review, and Update

A care plan is never a finished document. It should be reviewed regularly, typically within the first few weeks of care starting, and at least annually thereafter. If the individual's needs, health, or circumstances change at any point, the plan should be updated to reflect this. Ongoing monitoring ensures that care remains safe, effective, and truly person-centred.

Once a care plan has been put together and circulated to the relevant people, that is not the end of the care planning cycle. Typically in social care, the care plan will be reviewed in the first few months of the care/support service starting, to check for any adjustments that are needed. It will then usually be reviewed every year.

The best care plans, from the top-performing care providers, are responsive care plans. This means they adapt to any relevant changes in the service user's needs, preferences, risks, environmental or other changes that might affect how a person's care should be delivered.

This is not just about making changes when a person's condition worsens and they need more intense care for example. It is also about identifying new opportunities to deliver care in a better way or strengthening newfound independence.

A care plan is essential, it provides a detailed and effective personalised outline of care to be provided, that helps improve service users’ quality of life and ensure their safety.

It’s important that the care planning process makes sure that the client gets the right level of care long-term, that the agreed care plan adjusts as their care needs and personal preferences change, and that their needs are known by all relevant stakeholders.

Benefits of a care plan include:

• It captures and records conversations, decisions and agreed outcomes in a way that makes sense to the service user.
• It outlines the description of the person, what elements make their plan achievable and effective and importantly, what matters to them.
• It should always be proportionate, coordinated and adapt to the person’s needs. Flexibility is key, as it may need to be changed to make more sense for a person’s health condition, situation and care and support needs.

Different organisations will have their own care plan layouts, with different sections they have determined are necessary to deliver the best care they can.

Although care plans will have a set structure, they must be person-centred. The care plan must be tailored to the person, using language they understand, with their preferences, their priorities and goals. Always avoid an overly standardised cookie-cutter approach.

Care plans should include:

• What the assessed needs are
• Strengths and wishes of the client
• Cultural and ethnic background, gender, sexuality, and any disabilities
• What type of support do they need
• Who needs to provide care
• When the care and support should be provided to the service-user
• Detailed records of care provided
• Acknowledgement of any differences and disagreements
• Details of family members that need to be kept updated
• Any costs of the services

Depending on what support the person needs, their care plan could include everything from personal assistants visiting them each week to home adaptations to make them more independent.

Information from risk assessments and other documentation relevant to providing the person's care may also be included, referenced or extracted into the care plan where useful.

It’s key that the care plan production process follows the principles of person-centred care.  Regulators across 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.

Similar guidance has been issued by the Care Inspectorate Scotland, Care Inspectorate Wales and RQIA.

When creating a care plan the care needs and personal preferences of the client are the first things to think about. Their care relies on the person/people providing it being properly and comprehensively informed of this, to ensure that care is safe, and supports them in living a fulfilled life. In a separate bloggy colleague has covered the principles of person-centred care planning so please familiarise yourself with that too.

Care plans need to be reviewed regularly as standard, at a minimum of once a year, to ensure they are still supporting the provision of the best possible care and align with a person’s needs and preferences.

Care plans also may need to be reviewed when a change occurs that may impact a person’s care plan, such as an incident, a worsening of health, other changes in care needs or a change in the person’s preferences. Substantial changes in a person’s care need will require a full reassessment before a new or revised care plan is written for them.

Generally, a good care plan will contain information similar to what’s outlined in this handy example from Hertfordshire Care Providers Association.

Good care plans in health and social care will typically share the following characteristics:

• Detailed 
• Well-structured/organised and clear
• Can be fully understood by both service users and care professionals 
• Are 'owned' by the person receiving care
• Regularly reviewed and updated
• Flexible to the individual needs and preferences of the person
• Responsive to changing needs, circumstances and preferences
• Help the person receiving care to maintain independence so far as possible, and/or progress towards agreed outcomes
• Secure (the care plan will contain sensitive information)
• Easily accessible to relevant stakeholders
• Has a single, latest 'master' version used by all stakeholders

Many social care providers now use digital care records as part of a software package. These systems often contain pre-built templates, which you can then build and adapt to better fit your care services.

The benefits of digital versus paper care records are numerous. They enable information sharing and updating in a way paper simply cannot, giving everyone a one shared version of the record, instead of multiple, sometimes contradictory ones.

Moving away from paper also means moving away from hours of additional admin for different team members, which is hugely important in a sector that is beset by staffing issues and cannot really afford to spend scarce resources paying people to scan and file, instead of caring and responding to clients.

The Department of Health & Social Care’s recent policy paper 'People at the heart of care: Adult social care reform’ stated that:

All professionals involved in providing care have access to the right digitised information at their fingertips to provide safe, outstanding quality care.

And

Digital technology is also making the provision of social care more efficient for the workforce. E-rostering solutions can reduce administration demands for care managers. Similarly, digital social care records can improve transfers of care and handovers between shifts by ensuring staff have up-to-date information about people’s health and care needs. They also enable more joined-up, timely and accurate data.

The Department went on to announce that “by March 2024, we will ensure that at least 80% of social care providers have a digitised care record in a place that can connect to a shared care record.”

Find out more about digital care planning software that is part of a comprehensive care management system, for providers of domiciliary, residential and many other forms of social care.

Or for more information about how Access can support and streamline your care business with software including digital care planning contact us here.