Person Centred Care Planning Explained

Providing care that is person centred is a recognised requirement by all of the UK’s national regulators. We have covered what person centred care is elsewhere. This blog gives us the chance to dig into exactly what person-centred care planning is, what a person-centred care plan could look like, with some examples of a personalised care plan.

Person centred care means putting the person who is in receipt of care services at the centre, shaping support around the individual’s needs, preferences and experiences, rather than around routines, convenience or efficiency.

It also means that each person is involved as much as possible with the creation of their care plan and any decisions taken about their care. Family, friends or other advocates should be involved where appropriate.

Likewise, a person’s religious, ethnic and cultural values should be considered. We should avoid taking a "one size fits all" approach, while at the same time not applying stereotypes or putting people into unhelpful buckets. 

We should also help people to recognise and build on their strengths as part of care provision, instead of simply focusing on what they need help and support with.

As people’s preferences change, their care and care plans should be flexible and responsive to these changes.

Following the values of person-centred care we can think about how the care plan creation process also works in a person-centred way.

The care plan should be a shared document, but the direction of ownership should be firmly in the hands of the person receiving care, not the care agency. The way a care plan is put together can have a big influence on how much the person receiving care feels a sense of ownership.

In turn this can impact how effective care is. If the person realises they own their care plan, they may be more likely and more comfortable to ask for changes, or raise concerns. This can help improve the quality of care, satisfaction, empowerment and overall better outcomes for the person and the care service.

The process of writing care plans can be made more person focused by:

Incorporating the words they use and recognise. Avoid translating and replacing their terminology and interpretations into jargon and abbreviations.

These might make sense to your colleagues but they then become detached from what the person being cared for was trying to communicate. They can become detached from and lose a sense of ownership over their own care plan.

A well-executed person-centred care planning process delivers measurable benefits for individuals, care teams, and organisations alike.

For the individual, it means feeling genuinely heard and valued. Person-centred care empowers clients to meet their emotional, social, and practical needs, enhancing their quality of life and confidence in the service they receive. People who participate in shared decision-making are more likely to adhere to treatment plans, and those supported to manage their own care are less likely to need external or hospital services.

For care teams, it builds trust and improves outcomes. Working in a person-centred way maintains an individual's identity and self-esteem, and improves their wellbeing. Promoting person-centred values also reduces the risk of negative, unfair, or harmful treatment and neglect.

To embed best practices, care providers should ensure that person-centred planning is not a one-off exercise. It is not just asking a person their needs and preferences at the start of care delivery - rather, it is a cyclical process of active listening, regular adjusting, and continuous improving.

Best practice covers every aspect of the service: initial assessments, writing care and support plans, the complaints process, and the overall relationship between staff and service users.

Setting goals and objectives is a crucial part of person-centred care planning. While we may have our own ideas about what a person should want, in the end it is entirely up to them. We can help them with examples and ideas but should not force them and certainly not dismiss any of their aims if we feel they are not important, it is not our life after all!

Consider what people may have enjoyed doing in the past, but do less of now. This is usually a good place to start, restore independence and improve quality of life. Again, without imposing, only suggesting.

Similarly, we should not have a cookie cutter set of goals for the people we support - that is not a person-centred approach.

If we feel a goal is not realistic now, we might to work with the person to put some intermediary goals in place to build towards the larger objective.

It’s important to adopt the same focus to using people’s own words and phrases when setting goals and outcomes.

People should feel a sense of ownership over their care plan. It’s important that they understand care isn’t something being prescribed to them, and that they have a voice and a choice in how support is delivered, what they want our help with, as much as is safely possible. This sense of involvement shouldn’t end once the plan is written, but should continue through every review and any changes that are made. Creating person-centred care plans isn’t a tick-box exercise, but a commitment to shaping care that is unique, meaningful and truly personalised for every individual.

Technology plays an increasingly important role in making person-centred care planning more effective, consistent, and efficient, both for care providers and the people they support.

Digital care plans replace paper-based records, eliminating the risk of outdated or misplaced information. With cloud-based care planning software, care teams can access up-to-date plans in real time, from any device and at any point of care, ensuring every interaction is informed by the individual's latest preferences, goals, and needs.

Automated alerts and reminders help care workers stay on top of review schedules, ensuring no care plan goes unreviewed for too long. This supports a truly cyclical approach to person-centred planning, rather than a static, tick-box exercise.

Reporting and analytics tools give managers greater visibility across their service, making it easier to identify where care plans may need updating, spot trends, and demonstrate compliance with CQC standards.

Family and individual portals can give service users and their loved ones direct access to care plans, enabling greater transparency and encouraging active participation in the planning process.

The right technology does not replace the human relationships at the heart of person-centred care. Instead, it removes administrative burden, so care teams can spend more time doing what matters most.

There may be times when a person’s preferences around their care cannot be met, and when this happens it should always be the exception, not the norm. In these moments, it’s essential that we take the time to explain, discuss and agree the way forward with the person, helping them explore the next best alternative together. They should have a clear understanding of why a particular preference can’t be supported, so they can make informed choices and maintain a sense of ownership over their care. This openness not only builds trust but reassures the person that their wishes remain at the heart of every decision. Even when compromises are needed, they should still feel heard, respected and involved in shaping their care experience.

An example of a personalised care plan could include (but not be limited to) the following areas:

• Detailed personal information
• Mental health details and history
• Medical history
• Communication (preferences, difficulties, needs)
• Social support
• Environmental risks
• Nutritional preferences and requirements
• Interests and activities

Each of these areas will usually act as groupings, under which there are a number of sub-topics, and not all will be applicable for everyone.

Each of these areas should include:

• What the situation now and how the person is experiencing it
• The persons goals, aims and desired outcomes are in this area
• How we will support them with their outcomes based on how they would like to be supported
• How aspects of this area might link to other areas of the care plan

Care plans will likely form part of your auditing processes. When auditing be sure to build in criteria to assess whether your service has a person-centred approach in place, and whether the care plans used are person centred. Here are some examples of the lines of auditing you may want to follow:

• Does the person understand the care plan and how care will be delivered? Has this understanding been affirmed and recorded?
• Has the person been involved, and continue to be involved in meaningful ways, in designing their care?
• Is the care plan written in language familiar and personal to the person?
• Are there any sections duplicated from another person’s care plans (there shouldn’t be!)
• Are care plans made available to the person receiving care, in a format they can easily use/access and understand (language and ease of use)
• Has the care plan been reviewed and changed according to changing needs/preferences?
• Have family, friends or other advocates been involved with the production of the care plan where appropriate?
• Does the care plan adjust to promote people’s independence?
• Does the care plan have personalised goals and outcomes and how we will try to achieve those together?
• Is there clear evidence of the person’s involvement, input, control and ownership over their care plan?

This article was written to give you more information on the fundamentals and what is care planning. You can find more of the underlying guidance of what the CQC looks for in person centred care planning here.

If you are providing care for elderly people one of the most frequent challenges you might face in person-centred care planning is maintaining person-centred care planning for people that have dementia.

When caring for older people, one of the most common challenges is maintaining truly person-centred care planning for those living with dementia. It can be difficult to balance safety, dignity and personal choice, especially as needs change over time. To offer support in navigating these situations, Dementia Partnerships have created a helpful guide designed specifically for this purpose.

Most providers of social care have transitioned or are transitioning to electronic care planning. This is being pushed for by regulators, government, clients and providers themselves for good reason.

Using this technology makes care planning less labour intensive, more efficient, easier to evidence, link to other relevant processes, more secure and easier to report on. It can also make person-centred care planning easier to implement and maintain. To find out more view our care planning software or contact us here.