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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Developing and Managing Care Plans Policy

1. Purpose

This policy ensures that care plans at {{org_field_name}} are developed, implemented, reviewed and quality-assured to provide safe, effective and person-centred care in line with the CQC Single Assessment Framework (five key questions and Quality Statements) and the Fundamental Standards.

Care planning under this policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including (but not limited to) Regulation 9 (person-centred care), Regulation 11 (need for consent), Regulation 12 (safe care and treatment), Regulation 16 (complaints), Regulation 17 (good governance/records), Regulation 18 (staffing/training) and Regulation 20 (duty of candour).

This policy must also be read and applied alongside the Care Act 2014 (involvement, wellbeing and advocacy principles), Equality Act 2010 (reasonable adjustments and non-discrimination), Human Rights Act 1998, and data protection legislation (UK GDPR and Data Protection Act 2018).

Where a person may be, or becomes, deprived of their liberty, we will follow the current Deprivation of Liberty Safeguards (DoLS) process under the Mental Capacity Act 2005 (noting that Liberty Protection Safeguards are not in force yet and remain subject to national consultation/implementation steps).

2. Scope

This policy applies to all staff responsible for the assessment, development, review, and implementation of care plans at {{org_field_name}}. It covers all aspects of care planning, including risk assessment, consent, collaboration with families and healthcare professionals, and documentation.

3. Related Policies

• Person-Centred Care Policy (CH07)
• Mental Capacity and Deprivation of Liberty Safeguards Policy (CH39)
• Safeguarding Adults from Abuse and Improper Treatment Policy (CH13)
• Confidentiality and Data Protection (GDPR) Policy (CH34)
• Risk Management and Assessment Policy (CH18)

4. Policy Statement

{{org_field_name}} is committed to developing and maintaining care plans that reflect the individual needs, preferences, and rights of people we support. Care plans will be comprehensive, regularly reviewed, and updated to reflect changes in health conditions, risks, and personal choices.

5. Principles of Care Planning

Care plans at {{org_field_name}} must be:

• Person-centred: Tailored to the unique needs, preferences, and goals of each individual.
• Holistic: Addressing physical, emotional, psychological, and social needs.
• Evidence-based: Incorporating best practices and guidelines from regulatory bodies.
• Collaborative: Developed with input from people we support, their families, advocates, and healthcare professionals.
• Regularly reviewed: Ensuring care remains relevant and responsive to changes in condition.
• Legally compliant: Adhering to legislation, including consent and data protection laws.
• Accessible and inclusive: We will make reasonable adjustments and provide information in accessible formats (including communication support) so people can understand, participate and make informed choices about their care.
• Least restrictive: Any restrictions must be necessary, proportionate, the least restrictive option, time-limited where possible, clearly recorded in the care plan, and reviewed.
• Outcome-focused: Care plans must clearly record the person’s goals/outcomes, what matters to them, and how we will measure whether the plan is working (including the person’s own view).

6. Initial Assessment and Care Plan Development

• A comprehensive initial assessment must be conducted before a care plan is developed.
• A care plan (or interim care plan in an emergency admission) must be in place before or on admission, so staff have clear instructions to deliver safe, personalised care from the outset. A full, detailed care plan must be completed as soon as practicable and no later than 72 hours after admission, unless there is a documented reason and immediate risks are controlled.
• Information gathered includes:
  • Personal history, preferences, and daily routines.
  • Medical conditions and medication requirements.
  • Mobility, nutrition, hydration, and personal care needs.
  • Mental health, emotional wellbeing, and social interaction preferences.
  • Communication needs and sensory impairments.
  • Risks, including falls, choking, skin integrity, and self-neglect.
  • Mental capacity (decision-specific) and how the person will be supported to decide (communication/adjustments).
  • Consent preferences (including consent to share information with family/professionals).
  • Equality, culture, religion and protected characteristics, and any reasonable adjustments needed.
  • Pain assessment/management, continence, oral health, sleep, and emotional wellbeing.
  • Escalation planning (what to do if the person deteriorates), including who to contact and when.
  • End of life preferences/advance care planning where appropriate (e.g., preferred place of care, DNACPR/ReSPECT if used locally, and who should be involved).
  • Maintaining relationships/visiting preferences and how these will be supported (where relevant to the person’s wishes).
• The assessment should involve the person we support, family members, and relevant professionals.
• The care plan must be agreed upon with the person we support, ensuring they understand and consent to their care arrangements.

7. Risk Management within Care Planning

• Every care plan must include a detailed risk assessment to identify potential hazards.
• Risk management strategies must be documented and regularly updated.
• Where restrictive practices are considered, they must be lawful, necessary and proportionate, and the least restrictive option. The rationale, alternatives tried, review frequency and stop-conditions must be clearly recorded in the care plan and risk assessment. Where the arrangements may amount to a deprivation of liberty, we will follow the current DoLS process and keep the authorisation status and any conditions clearly recorded within the care plan. We recognise that Liberty Protection Safeguards are not currently in force and will update our processes if/when national implementation changes.
• All risks must be communicated to staff, and mitigation strategies should be clearly outlined.

8. Consent and Decision-Making

• Care plans must be developed with the full involvement and consent of the person we support.
• If an individual lacks capacity to consent, decisions must be made in their best interests, following the Mental Capacity Act 2005.
• Consent must be reviewed regularly, and any changes in capacity must be documented and acted upon appropriately.
• Consent must be obtained and recorded in line with Regulation 11 (Need for consent). Where the person may lack capacity for a specific decision, we will complete and record a decision-specific mental capacity assessment, and where required, a best interests decision with evidence of consultation with relevant people (family, attorneys/deputies, advocates and professionals as appropriate).
• Where there is no appropriate family/friend to consult, and the decision is serious (e.g., accommodation, major medical treatment, safeguarding restrictions), we will consider referral for an Independent Mental Capacity Advocate (IMCA) in line with the Mental Capacity Act framework.
• Any person acting lawfully on the individual’s behalf (e.g., Health and Welfare LPA or Court-appointed Deputy) must be identified, verified, and recorded within the care plan.

9. Care Plan Implementation

• Staff must be trained on the contents of each care plan to ensure accurate implementation.
• Care plans should be accessible to all relevant staff while maintaining confidentiality.
• Staff must follow the care plan precisely, adapting only when necessary and documenting any deviations.
• Any concerns, changes, or incidents affecting a person’s care must be reported and reviewed immediately.

10. Reviewing and Updating Care Plans

• Care plans must be reviewed whenever needs change, and as a minimum at least every six months, and sooner following any significant event (e.g., hospital admission/discharge, fall, safeguarding concern, medication change, new diagnosis, weight loss, change in mobility/cognition/behaviour, or following feedback/complaints).
• A first review must take place within 1 month of admission (or sooner if risks/needs indicate), to confirm the plan is accurate, outcomes-focused and being delivered consistently.
• Reviews should involve the person we support, family members (where appropriate), and professionals such as GPs, nurses, or therapists.
• Care plans should be updated if:
  • There is a significant change in health, mobility, or mental wellbeing.
  • A new risk is identified.
  • A different approach to care is required due to feedback or concerns.
• A multi-disciplinary approach must be used for complex cases.

11. Care Plan Documentation and Confidentiality

• Care plans must be accurately documented in a structured and readable format.
• Records should be securely stored, in line with GDPR and Data Protection Laws.
• Access to care plans must be restricted to authorised personnel only.
• Staff must record all interventions, changes, and reviews in real time.
• Any breaches of confidentiality must be reported to the Data Protection Officer.
• Records relating to care planning must be accurate, complete, legible and contemporaneous, with clear dates/times and the author’s identity, and must be stored, retained and shared in line with UK GDPR and the Data Protection Act 2018 (including lawful basis, data minimisation, access controls and audit trails). These record standards form part of our compliance with Regulation 17 (Good governance).

12. Involvement of Families and External Professionals

• Family members and advocates should be encouraged to contribute to care planning.
• Healthcare professionals, including GPs, dietitians, physiotherapists, and speech therapists, should be consulted where appropriate.
• Decisions affecting a person’s care must be discussed transparently, ensuring they align with the individual’s best interests.

13. Training and Staff Responsibilities

• All care staff must complete mandatory training on care planning.
• Staff should be trained in risk management, communication techniques, and consent processes.
• The Registered Manager is responsible for overseeing care plan compliance and staff training.
• Keyworkers and team leaders must ensure care plans are followed and updated as needed.
• Staff must communicate effectively with colleagues to ensure continuity of care.
• Staff will receive learning disability and autism training appropriate to their role in line with the Oliver McGowan statutory Code of Practice and CQC expectations under Regulation 18 (Staffing).

14. Quality Assurance and Compliance

• Regular internal audits must be conducted to ensure care plans meet CQC requirements.
• Care plans should be checked for accuracy, completeness, and effectiveness.
• Feedback from people we support and their families should be actively sought and incorporated into reviews.
• Non-compliance with care planning processes must be addressed through staff training or disciplinary procedures if necessary.

14.1 CQC Single Assessment Framework evidence

Our care plan audits and governance processes will be structured to evidence the CQC Single Assessment Framework, drawing on multiple evidence categories (including people’s experiences, staff feedback, partner feedback, observation and process/outcome measures). We will maintain an audit schedule that includes: (a) admission care plan completion timeliness, (b) review compliance and triggered reviews, (c) evidence of involvement/consent, (d) risk management and restrictive practice recording, and (e) outcomes achieved and learning from complaints/incidents.

15. Complaints and Feedback

This section supports compliance with Regulation 16 (Receiving and acting on complaints) and our complaints process will be accessible, including providing communication support and reasonable adjustments where needed.

• Individuals and their families must have clear access to a complaints procedure regarding care planning.
• Complaints must be investigated promptly, and any necessary changes to care plans should be made.
• Feedback should be used to improve care planning processes.
• Outcomes of complaints and feedback must be clearly recorded, shared with relevant staff, and where appropriate result in updated care plans, revised risk assessments, and governance learning.

16. Duty of Candour (Regulation 20)

Where a notifiable safety incident occurs and/or where an omission or error in care planning may have contributed to harm, {{org_field_name}} will act in an open and transparent way with the person (and/or their representative) in line with Regulation 20 (Duty of candour). This includes: providing an explanation of what is known at the time, offering an apology, documenting all actions and communications, and ensuring learning is reflected in the person’s care plan, risk assessments and service governance.

17. Policy Review

This policy will be reviewed annually or sooner if changes in CQC regulations, best practices, or operational needs require an update.

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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}}
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