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CHW63-Developing, Reviewing and Managing Personal Plans Policy

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Registration Number: {{org_field_registration_no}}

Developing, Reviewing and Managing Personal Plans Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} develops, implements, reviews and maintains accurate, person-centred and legally compliant personal plans for each individual receiving care and support at the service.

For the purpose of this policy, a personal plan means the plan required under Regulation 15 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. The personal plan sets out how the individual’s care and support needs will be met on a day-to-day basis, how they will be supported to achieve their personal outcomes, how identified risks to their well-being will be mitigated, and how positive risk-taking and independence will be supported where appropriate.

This policy also recognises the distinction between:

{{org_field_name}} will ensure that personal plans are developed in accordance with the Regulation and Inspection of Social Care (Wales) Act 2016, The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, the Welsh Government statutory guidance for service providers and responsible individuals, and relevant Care Inspectorate Wales expectations.

Personal planning will support individuals to receive safe, effective, dignified and person-centred care that protects, promotes and maintains their well-being, rights, independence, preferences, communication needs, cultural needs, Welsh language needs where applicable, and personal outcomes.

2. Scope

This policy applies to all staff involved in assessment, admission, care planning, delivery of care, review, documentation, auditing and governance of personal plans. This includes care staff, nurses, senior care staff, the Registered Manager, the Responsible Individual, administrative staff who handle care records, and any external professionals contributing to the individual’s care and support.

This policy applies to:

Where the service provides care and support to children, or to children who are looked after by a local authority, the service will ensure that the personal plan takes account of the child’s Part 6 care and support plan, health plan, personal education plan, placement plan and, where applicable, pathway plan. Where {{org_field_name}} is registered to provide services to adults only, this requirement will apply only if the statement of purpose is amended and CIW registration permits such provision.

3. Key Definitions

For the purpose of this policy:

Individual means the adult or child receiving care and support from {{org_field_name}}.

Personal plan means the provider’s plan required under Regulation 15 of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended. It sets out how the individual’s care and support will be delivered on a day-to-day basis.

Care and support plan means a plan prepared by the local authority under the Social Services and Well-being (Wales) Act 2014.

Provider assessment means the assessment required under Regulation 18, which must be completed within 7 days of the commencement of care and support.

Personal outcomes means the outcomes the individual wishes to achieve in day-to-day life. For a child, this includes the outcomes the child wishes to achieve or the outcomes that those with parental responsibility wish to achieve in relation to the child.

Representative means a person who has legal authority, or the consent of the individual, to act on the individual’s behalf.

Placing authority means the local authority or other relevant body responsible for placing a child, where applicable.

Service commissioner means the local authority or NHS body responsible for making arrangements with the provider for care and support to be provided to the individual.

4. Principles of Personal Planning

All personal plans must be developed and managed in accordance with the following principles:

5. Personal Plan Development Process

5.1 Before Agreeing to Provide Care and Support

Before agreeing to provide care and support, {{org_field_name}} must determine whether the service is suitable to meet the individual’s care and support needs and to support the individual to achieve their personal outcomes.

The determination must take account of:

The individual, the placing authority where applicable, and any representative must be involved in this process unless the individual is an adult, or a child aged 16 or over, and does not wish the representative to be involved, or the representative’s involvement would be inconsistent with the individual’s well-being.

Where the service can meet the individual’s care and support needs, written confirmation will be provided to the individual and/or their representative, where appropriate. Where the service cannot meet the individual’s care and support needs, this will also be confirmed in writing, with the reasons clearly recorded.

5.2 Initial Personal Plan

Once the service has determined that it can meet the individual’s care and support needs, an initial personal plan must be prepared before the individual begins to receive care and support.

Where the individual is in urgent need of care and support and there has not been time to prepare the personal plan before the service starts, the initial personal plan must be prepared within 24 hours of the commencement of care and support.

The initial personal plan must be based on the information available at the point of commencement, including the care and support plan, pre-admission assessment, health assessments, risk assessments, professional advice, the individual’s views, wishes and feelings, and any information provided by the individual’s representative or placing authority where applicable.

5.3 Content of the Personal Plan

Each personal plan must set out:

5.4 Provider Assessment within 7 Days

Within 7 days of the commencement of care and support, {{org_field_name}} must complete a provider assessment.

The provider assessment must assess:

The provider assessment must be carried out by a person who has the skills, knowledge, competence and training required to complete assessments. Where the individual has nursing needs, the assessment must be completed or overseen by a registered nurse with relevant skills. Where the individual has complex or specialist needs, specialist professional advice must be sought where required.

The provider assessment must take account of the individual’s care and support plan, any previous provider assessment, any health or professional assessments, the individual’s wishes and feelings, relevant risks, and the service’s admissions and commencement procedures.

Following completion of the provider assessment, the personal plan must be reviewed and revised as necessary.

5.5 Short Stays, Respite and Readmissions

Where the individual is admitted for respite, short stay or repeat admission, the service must review updated care and support plans, health information and risk assessments before each admission. The personal plan must be amended to reflect any changes before the stay begins, or within 24 hours where urgent circumstances apply.

6. Implementing Personal Plans

Staff must provide care and support in accordance with the individual’s current personal plan.

Staff must:

Where staff identify that the personal plan no longer meets the individual’s needs or does not support the individual to achieve their personal outcomes, this must be reported immediately to the person responsible for reviewing the plan.

7. Reviewing and Updating Personal Plans

Personal plans must be reviewed as and when required and at least every three months.

A review must also take place sooner where:

Reviews must include consideration of:

The individual, the placing authority where applicable, and any representative must be involved in the review unless the individual is an adult, or a child aged 16 or over, and does not wish the representative to be involved, or the representative’s involvement would be inconsistent with the individual’s well-being.

Following each review, the provider must consider whether the personal plan should be revised and must revise it where necessary. Any changes must be clearly recorded, dated, communicated to relevant staff, and shared with the individual and/or representative where appropriate.

8. Documentation, Records and Access to Personal Plans

{{org_field_name}} must keep a record of:

A copy of the personal plan and any revised personal plan must be provided to the individual. A copy must also be provided to any representative unless this is not appropriate or would be inconsistent with the individual’s well-being. Where a child is provided with accommodation as part of a care home service, a copy must be provided to the placing authority.

A copy of the provider assessment must be provided to the individual, any representative where appropriate, and the placing authority where applicable.

Personal plans and provider assessments must be provided in a format and language appropriate to the individual’s needs, age, level of understanding and communication requirements. This may include large print, easy read, audio format, translated information, visual aids, communication aids or support from an interpreter or advocate.

All records must be accurate, factual, contemporaneous, legible, dated and signed or electronically attributable to the person making the entry.

Records must be stored securely and managed in accordance with UK GDPR, the Data Protection Act 2018, confidentiality requirements and the organisation’s records management policy.

Personal plans must be accessible to authorised staff who need the information to provide safe and effective care, while maintaining confidentiality and information security.

9. Individual Involvement, Consent, Capacity and Advocacy

Individuals must be actively involved in the development, implementation and review of their personal plan.

Staff must support individuals to express their wishes, feelings, preferences, concerns and personal outcomes. Information must be provided in a way the individual can understand, taking account of language, communication needs, sensory impairment, cognitive impairment, mental capacity, age and level of understanding.

Where the individual has capacity, their consent must be sought in relation to care and support arrangements. The individual has the right to refuse care or request changes to their personal plan, and this must be respected unless there is a lawful basis to act otherwise.

Where there is concern that the individual may lack capacity to make a specific decision, the Mental Capacity Act 2005 must be followed. Capacity must be decision-specific and time-specific. Where the individual lacks capacity, decisions must be made in the individual’s best interests, using the least restrictive option and involving relevant representatives, attorneys, deputies, advocates and professionals as appropriate.

Where the individual lacks capacity and has no appropriate representative, referral for advocacy, including an Independent Mental Capacity Advocate where required, must be considered in accordance with statutory requirements.

Where arrangements may amount to a deprivation of liberty, the service must follow the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards requirements and must ensure that lawful authority is in place.

Individuals must be informed about advocacy services and supported to access advocacy where they wish to do so or where this is required.

10. Language, Communication and the Welsh Language

{{org_field_name}} will take reasonable steps to meet the language and communication needs of individuals.

The personal plan must record:

Where Welsh is the individual’s language of need or choice, the service will make reasonable efforts to support the individual to communicate and receive information in Welsh, in line with the service’s statement of purpose and the Active Offer principle.

Staff must ensure that communication support is used consistently and that any required aids or equipment are available, maintained and used appropriately.

11. Required Care Areas to Be Reflected in the Personal Plan

Where relevant to the individual, the personal plan must include clear guidance for staff on the following areas:

11.1 Personal Care and Dignity

The plan must describe the support required with washing, dressing, continence, oral care, grooming, bathing, privacy, dignity, gender preferences for care where possible, and any cultural or religious requirements.

11.2 Nutrition and Hydration

The plan must describe dietary needs, food preferences, allergies, texture-modified diets, swallowing risks, fluid requirements, nutritional screening outcomes, weight monitoring, fortified diet requirements, specialist advice and actions to take where intake is poor.

11.3 Medication

The plan must describe the support required with medication, including self-medication, administration, prompting, monitoring, known allergies, covert medication where legally authorised, “as required” medication protocols and escalation where medication is refused or concerns arise.

11.4 Mobility, Falls and Moving and Handling

The plan must describe mobility support, falls risks, equipment, transfer methods, moving and handling requirements, staff numbers required, physiotherapy advice and actions to reduce risk while promoting independence.

11.5 Skin Integrity and Pressure Care

The plan must describe skin integrity risks, pressure ulcer prevention, repositioning, equipment, monitoring, wound care, referrals and escalation where deterioration is identified.

11.6 Continence

The plan must describe continence needs, toileting routines, aids and products, dignity considerations, monitoring and referral requirements.

11.7 Communication and Sensory Needs

The plan must describe hearing, sight, speech, cognitive or sensory needs and how staff must support the individual to communicate and understand information.

11.8 Mental Health, Cognition and Emotional Well-being

The plan must describe dementia support, cognitive impairment, mental health needs, anxiety, distress triggers, calming approaches, meaningful activities, relationship needs and professional support.

11.9 Behaviour Support and Restrictive Practice

Where the individual may experience distress or behaviours that may place themselves or others at risk, the personal plan must include proactive, person-centred support strategies. Any restrictive practice, control or restraint must be lawful, necessary, proportionate, the least restrictive option, and used only to prevent harm. Any such use must be recorded, reviewed and considered as part of the personal plan review.

11.10 Social, Cultural, Religious and Spiritual Needs

The plan must describe how the individual will be supported to maintain relationships, community links, hobbies, activities, cultural identity, religious observance and spiritual well-being.

11.11 End-of-Life Care

Where appropriate, the plan must record the individual’s wishes and preferences for end-of-life care, advance statements, advance decisions, lasting power of attorney for health and welfare, DNACPR information where applicable, palliative care arrangements, family involvement and professional support.

12. Compliance, Governance and Monitoring

The service provider and Responsible Individual are responsible for ensuring that effective governance arrangements are in place to support compliance with legal and regulatory requirements. The Registered Manager is responsible for the day-to-day implementation, monitoring and quality assurance of personal planning practice within the service.

The Registered Manager must ensure that:

The Responsible Individual must maintain oversight of the quality and safety of care planning through governance systems, quality assurance processes, review of audits, visits to the service, feedback from individuals and staff, and the quality-of-care review process.

Personal plan audits must include checks on:

Where deficiencies are identified, corrective action must be recorded, allocated, monitored and reviewed for completion.

13. Staff Training and Competence

All staff involved in assessment, care planning, implementation or review must receive training and support appropriate to their role.

Training must include, where relevant:

Staff competence must be monitored through supervision, observation, record audits, appraisal, training records and feedback from individuals.

14. Related Policies and Procedures

This policy should be read in conjunction with:

15. Policy Review

This policy will be reviewed at least annually or sooner where there are changes to legislation, Welsh Government statutory guidance, CIW requirements, the service’s statement of purpose, operational practice, safeguarding learning, complaints, inspection findings, audit outcomes or best practice guidance.

Any changes to this policy will be communicated to relevant staff. Staff will be required to read and understand the updated policy, and additional training will be provided where required.

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.

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