E: support@e-carehub.co.uk



Personal Plans and Support Arrangements in Care Services (Scotland) Policy


[This policy template can be adapted for both care homes and care at home services in line with the relevant national health and care standards, My Support, My Life, which apply to all social care services.]

This policy sets out the values, principles and procedures underpinning {{org_field_name}}’s approach to personal plans in line with the requirements of the health and social care standards for Scotland, My Support, My Life (2017), particularly under:

• Standard 1: “I experience high-quality care and support that is right for me”, which includes:
a) 1.14: My future care and support needs are anticipated as part of my assessment
b) 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
• Standard 2: “I am fully involved in all decisions about my care and support”, which includes:
a) 2.17: I am fully involved in developing and reviewing my personal plan, which is always available to me.

This policy should be read and used in relation to the policies on Healthcare (Scotland) and Medication Management in Care Homes (Scotland).

The policy also helps to answer key question 5: “How well is our care and support planned?” of the applicable Quality Framework used by inspectors to make their assessments against the national health and social care standards.

Policy Statement

People who use services need to be assured that the service provided will meet their needs and preferences. Care service staff, therefore, need to work with a person to produce a personal plan setting out needs, preferences and the way in which these will be met to the person’s satisfaction.

The person receiving care always has a copy of the plan written in suitable language and presented in an accessible format.

People who use services have the right to ask at any time for a review of their needs, to participate in the review, to involve anyone else they choose in the review, and to be helped in this process if necessary.

Care service staff, with the person’s agreement, might need to involve or contact other services also involved about any changes in the person’s personal situation or health.

Contents of the Personal Plan

{{org_field_name}} makes available in every case an individual plan which provides the outline of the care to be delivered in line with the national care standards and regulations. It includes:

The plan is drawn up on the basis of a thorough assessment of the new person receiving cares’ needs, abilities and aspirations.

The assessment covers all aspects of the new person receiving cares’ health, personal and social care needs. The personal plan then sets out in detail the actions to be taken by care staff to meet all the identified needs.

It include objectives for care, how the care is to be provided, statements of responsibility for staff and others and appropriate timescales.

The plan meets all appropriate clinical and best practice guidelines in respect of any healthcare matters included in the personal plan.

{{org_field_name}} recognises that it is important to promote and maintain the person’s independence. Its staff must always show respect for the individual and maintain or improve through their care the person’s sense of dignity, identity and self-esteem.

It also recognises its duty of care to keep the person safe from avoidable harm, which it exercises through its risk assessments and management of identified risks. The personal plan therefore includes full risk assessments and risk management plans where needed.

The person who uses the services is always central in the procedures for planning their care. The person who uses the services must, therefore, sign or otherwise signify active consent to the plan of care and to the attendant risk assessments.

In instances where the person who uses the services, because of mental incapacity, is unable personally to take responsible decisions, every possible step is taken to comply with mental incapacity law requirements. The process can include the involvement of relatives, friends, advocates or other representatives who can unequivocally represent the person’s interests in the planning process.

{{org_field_name}} makes available relevant managerial, care and other staff as appropriate to assist in producing and carrying through the plan of care.

Subject to the person who uses the services’ permission and to recognised standards of confidentiality, it might involve others who may have a part to play. It is for the person who uses the services to specify which relatives, friends or others they wish to be involved in drawing up and implementing the plan.

{{org_field_name}} regularly reviews with the person who uses the services and others involved the outcomes achieved, purpose, strategies, responsibilities, timescales and risks, which have been identified in the personal plan. The plan is revised in line with the review.

{{org_field_name}} is committed to open and transparent recording of its actions on the personal plan. All records relating to a person’s plan are written in readily comprehensible language and kept in a secure place, which is, however, accessible to the person who uses the services.

Summary of Procedures

Formulating the personal plan

  1. The personal plan is drawn up on the basis of the needs assessment. It identifies the purpose and goals which the person who uses the services identifies and which {{org_field_name}} is expected to achieve in line with the written agreement.
  2. The personal plan might embrace some or all aspects of the person’s welfare.
  3. For each assessed need, {{org_field_name}} discusses with the person who uses the services its plan to address that need and how it will implement the plan with reference to its goals, actions to be taken, timescales, allocation of staff responsibilities and any partnership arrangements.

Risks and risk assessment

  1. {{org_field_name}} helps each person assess the risks involved in any proposed activity, weighing the benefits and possible adverse effects, and coming to a measured conclusion.
  2. All risk assessments and following risk management plans are recorded in the personal plan.

Planning and meetings

  1. {{org_field_name}} holds regular meetings with the person who uses the services on their personal plan. The first planning meeting takes place before or very shortly after the needs assessment has been completed and an agreement reached to provide a service.
  2. At the first meeting, {{org_field_name}} discusses the purpose and goals of the service and how they will achieve them. The person who uses the services/legal representative is asked for their formal consent to the plan by signing the care plan and attendant risk assessments.


  1. The personal plan of care is always readily accessible to the person who uses the services and the care staff.
  2. It is routinely consulted by staff and others who have legitimate access as a guide to the work they need to carry out.
  3. The manager/key worker (where used) continue to monitor the work with the person who uses the services to make sure that all other care staff are implementing the agreed plan and the work is in line with the written agreement.


Where the service agrees to provide a service in an emergency, and where no pre-service assessment and personal planning has been possible, it will develop a provisional plan within 24 hours of the start of the service.

The plan will then be developed and reviewed with all concerned by the end of the first week after the start of service, and further reviewed by the end of the first month (if still applicable).


  1. In addition to the regular monitoring of the plan on a day-to-day basis, {{org_field_name}} arranges formal reviews monthly, wherever practical.
  2. Reviews involve at least the person who uses the services, the manager and key worker (where there is one) where the progress of the plan is discussed.
  3. Reviews critically consider the appropriateness of the original goals, the feasibility of the agreed plan, the outcomes to date, implications of any risks taken, the responsibilities allocated and the timescales set.
  4. Reviews take into account any new information which is available and any significant changes in the person’s needs, abilities and aspirations.
  5. {{org_field_name}} makes sure that the person who uses the services is in full agreement with any modifications or additions made to the plan.
  6. Reviewing the plan of care is a continuing process of counting achievements, setting new goals and adjusting the care. It will often be done in partnership with other agencies and professionals.
  7. After each review, the other stakeholders involved in the care are always briefed on changes which require their action or attention.


  1. Each person has a file, which contains at least:
    a. a page with basic information (name, age, etc)
    b. the initial assessment documentation
    c. the first plan of care
    d. risk assessments
    e. records of reviews of the plan.
  2. The records are always written in a style and language which the person who uses the services/representative understands.
  3. The records are kept securely, where practical, in the person’s accommodation with authorised access for care staff who need to record their work, and for management and administrative purposes. People who use services have access to their care plans in line with data protection laws and the service’s access to records policy.
  4. When changes are required to the person’s care and support they will be made on the care plan with retention of the previous information.
  5. Corrections/amendments (eg because of recording errors) made to the care records should be signed by the person making them with, where appropriate, the agreement of the person who uses the services. There should be a brief explanation as to the reasons for the correction/amendment. The changes should then be verified by a line manager.
  6. All care and support plans, including those that are kept electronically, must comply with data protection law.


All new staff receive training as part of their induction programme on person-centred care and support planning and {{org_field_name}}’s approach to this.

Care service staff are expected to develop their knowledge and skills in line with their roles and responsibilities for care planning, eg as key workers/care co-ordinators/managers. Their training is tailored to their specific learning needs and qualifications pathways.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Copyright ©2024 {{org_field_name}}. All rights reserved

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