HCS13-Personal Care and Support Planning

Registration Number: {{org_field_registration_no}}

Personal Care and Support Planning Policy

1. Purpose

The purpose of this policy is to set out how {{org_field_name}} ensures that every person we support has a comprehensive, person-led personal plan that reflects their assessed needs, outcomes, preferences, and rights. We aim to promote independence, choice, safety, and wellbeing through support plans that are collaborative, meaningful, and regularly reviewed.

This policy ensures that our personal planning practice meets the requirements of:

The Health and Social Care Standards
Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011, specifically Regulation 5
Care Inspectorate’s Personal Planning Guidance (2021)
SSSC Codes of Practice for Social Service Workers and Employers (2024)

2. Scope

This policy applies to:

All individuals receiving care and support from {{org_field_name}}
All care staff, coordinators, supervisors, and management involved in planning, reviewing, or delivering care
Family members, legal representatives, advocates, and professional partners who are involved in the care planning process

It covers the entire support planning cycle—from initial assessment and plan development to daily implementation, ongoing review, and evaluation.

3. Related Policies

This policy should be read in conjunction with:

Person-Centred Care Policy
Risk Assessment and Management Policy
Equality, Diversity, and Human Rights Policy
Communication and Accessible Information Policy
Safeguarding Adults and Children Policy
Medication Management Policy
Quality Assurance and Continuous Improvement Policy

4. Policy Statement

At {{org_field_name}}, we believe that personal plans should be more than documents—they are the heart of our care delivery. Each plan is a living record that reflects the person’s identity, needs, wishes, choices, and outcomes. We are committed to ensuring that:

Personal plans are created with the individual, not for them
Plans are based on what matters to the person, not just what’s the matter with them
Staff are trained to understand the importance of planning and how to implement care effectively and responsively

We recognise that each person we support is unique, and their plan must reflect that uniqueness.

5. How We Manage Personal Care and Support Planning Effectively

5.1. Initial Assessment and Gathering Information

We begin every care relationship with a comprehensive initial assessment, which includes:

A conversation with the person (and family or advocate, where appropriate) about their needs, preferences, routines, and desired outcomes
Gathering background information from referral sources (e.g. social workers, district nurses)
Understanding physical, emotional, psychological, social, and cultural needs
Identifying communication needs, accessibility, sensory impairments, or language preferences
Discussing any risks and how the person wants them to be managed

This is done in a manner that is respectful, inclusive, and led by the individual’s pace and capacity. We follow Health and Social Care Standard 1.15: “My personal plan (sometimes referred to as a care plan) is right for me because it sets out how my needs will be met, as well as my wishes and choices.”

5.2. Creating the Personal Plan

Once the assessment is complete, we work collaboratively to develop a detailed personal plan. This document includes:

The individual’s preferred name and how they like to be addressed
Daily routines, dietary preferences, religious/cultural practices, and lifestyle goals
Support required with personal care, medication, mobility, nutrition, and social activities
Who is involved in care decisions (e.g. family members, advocates)
Communication support needs and preferred formats for information
Clear outcomes that the person wants to achieve (e.g. “I want to go to the park independently again”)

Every personal plan is tailored to the individual and written in language that they can understand, with easy-read or translated formats provided where needed.

Plans are signed and dated by the individual (or representative), the key worker, and the manager.

5.3. Delivering Care in Line with the Plan

Care staff are provided with up-to-date, accessible versions of personal plans and are trained to:

Understand the content of the plan fully before providing support
Refer to it during service delivery to ensure consistency
Adapt their approach sensitively based on the person’s needs that day
Document observations and changes in daily care records
Report concerns if the person’s needs appear to have changed

We ensure consistency in care delivery by using small teams of regular staff where possible, allowing stronger relationships and better knowledge of the individual’s preferences and needs.

Staff are expected to provide care in a way that is dignified, empowering, and aligns with the person’s expectations as detailed in their personal plan.

5.4. Reviewing Personal Plans

In accordance with Regulation 5(2)(b) of the 2011 Regulations, all personal plans are reviewed:

At least once every six months
As soon as reasonably practicable after a significant change in the individual’s circumstances
At the request of the person or their representative

Each review is a collaborative process, led by the person we support, and involving family members or professionals as appropriate. During reviews, we:

Revisit outcomes—what has been achieved and what remains important
Update health, wellbeing, or social needs
Reassess risks and preferences
Ensure the person is still happy with the staff team, timing of visits, and content of support

Review meetings are documented clearly, and resulting changes are updated promptly in the personal plan.

5.5. Promoting Outcomes and Choice

At {{org_field_name}}, we do not define success solely by completed tasks. Instead, we measure it by whether the person is achieving the outcomes that matter to them. Our staff are trained to:

Ask outcome-based questions (e.g. “What do you want to be able to do that you can’t do just now?”)
Offer choices at every opportunity—even in small tasks
Encourage independence wherever safe and possible
Enable positive risk-taking, in line with the person’s values

We respect the person’s right to say no, to change their mind, and to take supported risks. These decisions are recorded with care and reviewed for ongoing safety.

5.6. Confidentiality and Data Protection

All personal plans and assessments are treated as confidential and sensitive documents. We comply with UK GDPR and the Data Protection Act 2018, ensuring that:

Access is restricted to authorised staff only
Plans are stored securely (digitally or in locked cabinets)
People we support are informed of how their data is used, stored, and shared
Any third-party sharing (e.g. with district nurses) is done with the person’s consent unless there is a risk of harm

Our Data Protection Officer is {{org_field_data_protection_officer_first_name}} {{org_field_data_protection_officer_last_name}}, who monitors compliance and provides guidance to staff.

5.7. Training and Staff Competence

All staff are trained on:

The purpose and importance of personal plans
How to complete daily records that inform plan reviews
How to involve people meaningfully in planning and reviewing care
What to do if someone refuses support or shows signs of changing needs
Using inclusive communication techniques and involving people with cognitive, sensory, or language barriers

Supervisions include reflective discussions on how well staff are delivering care in line with plans. Observations and audits are conducted to ensure care practice matches the documented plan.

5.8. Audit and Quality Assurance

Our Registered Manager regularly audits personal plans to ensure:

They are completed to a high standard
They reflect individual needs and preferences
Reviews are timely and meaningful
Changes are actioned promptly

Findings from audits inform our Service Improvement Plan and individual staff development where required.

6. Roles and Responsibilities

Registered Manager: Oversees assessment and planning systems, conducts reviews and audits, and ensures staff follow best practice.
Deputy Manager: Supports creation and monitoring of personal plans and leads on scheduling reviews.
Key Workers / Care Staff: Deliver care in line with the personal plan, contribute to updates, and report changes in needs.
People We Support: Are central to all decisions about their care, and their voice is the most important in plan development and review.

7. Policy Review

This policy will be reviewed annually or earlier if:

There is a change in legislation or Care Inspectorate guidance
Feedback or inspection findings indicate a need for improvement
Internal audit identifies a gap or risk

Responsible Person: {{org_field_registered_manager_first_name}}{{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.