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Registration Number: {{org_field_registration_no}}

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Developing and Managing Person-Centred Care Plans Policy

1. Purpose

The purpose of this policy is to establish a robust framework for developing and managing person-centred care plans that reflect the unique needs, preferences, and aspirations of individuals supported by {{org_field_name}}. This policy ensures compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Care Act 2014, and CQC fundamental standards, supporting high-quality, safe, and responsive care delivery.

2. Scope

This policy applies to all employees, including care staff, managers, and any professionals involved in the assessment, planning, and review of care plans. It covers the entire lifecycle of a person-centred care plan, from initial assessment to ongoing review, modification, and transition planning.

3. Related Policies

• Person-Centred Care Policy (SL07)
• Dignity and Respect Policy (SL08)
• Consent to Care Policy (SL09)
• Safeguarding Adults from Abuse and Improper Treatment Policy (SL13)
• Risk Management and Assessment Policy (SL18)
• Mental Capacity and Deprivation of Liberty Safeguards Policy (SL39)

4. Policy Statement

{{org_field_name}} is committed to ensuring that each individual has a personalised care plan developed in partnership with them, their families, and relevant professionals. Care plans will be dynamic, regularly reviewed, and tailored to support independence, dignity, and well-being while ensuring that risks are managed proportionately.

5. Principles of Person-Centred Care Planning

• Individuality and Choice: Care plans must reflect the unique identity, preferences, and goals of the individual.
• Partnership and Inclusion: Care planning must be a collaborative process, involving the individual, their families, and multidisciplinary professionals where appropriate.
• Dignity and Respect: The person’s views, wishes, and choices must be central to decision-making.
• Continuous Review: Care plans must be reviewed regularly to ensure they remain relevant and effective.
• Risk Proportionality: Any risks associated with care delivery must be assessed and balanced against the individual’s rights to choice and autonomy.

6. Care Plan Development Process

6.1 Initial Assessment

• A comprehensive initial assessment must be conducted upon entry into the service.
• The assessment should gather information on:
  • Personal history and background
  • Health conditions and medical needs
  • Social and emotional well-being
  • Cultural and religious preferences
  • Communication needs
  • Daily living skills and independence level
  • Mobility and physical needs
  • Preferred activities and hobbies
  • Medication and treatment requirements
• The individual (or their legal representative if they lack capacity) must be involved in every step of the process.

6.2 Developing the Care Plan

• Based on assessment findings, a personalised care plan must be created within seven days of admission.
• The care plan must include:
  • Clear goals and outcomes tailored to the individual.
  • Details of required support, including personal care, mobility, nutrition, and social interaction.
  • Identified risks and strategies for mitigation.
  • Medication management plans where applicable.
  • Emergency contacts and escalation procedures.
  • Consent documentation, ensuring the individual agrees with the care plan.
  • Contingency planning in case of unexpected events.
• The care plan must be signed by the individual (or legal representative) and the key worker.

7. Managing and Reviewing Care Plans

7.1 Ongoing Monitoring

• Care staff must document daily observations related to the individual’s well-being.
• Any significant changes in health, behaviour, or circumstances must be immediately reported and recorded.
• Staff must work closely with healthcare professionals to adapt the care plan as required.

7.2 Formal Care Plan Reviews

• Care plans must be reviewed at least every six months or sooner if:
  • The individual’s needs change significantly.
  • A safeguarding concern arises.
  • A serious incident or hospitalisation occurs.
  • The individual or their family requests a review.
• Reviews must involve:
  • The individual and their representative (if applicable).
  • Care staff involved in their daily support.
  • Healthcare professionals where necessary.
  • Any external agencies providing care (e.g., district nurses, social workers).
• Outcomes of the review must be recorded, with any updates documented and shared with relevant parties.

8. Supporting Individuals with Decision-Making

• All individuals should be supported to make their own choices regarding their care.
• If a person lacks capacity, decisions must be made in line with the Mental Capacity Act 2005, following best interests principles.
• Independent advocates should be involved where appropriate to ensure individuals’ voices are heard.
• In cases requiring Deprivation of Liberty Safeguards (DoLS), the appropriate legal processes must be followed.

9. Safeguarding and Risk Management

• All staff must be trained to identify safeguarding concerns and report them promptly.
• Risk assessments must be proportionate, supporting independence while ensuring safety.
• Individuals must be informed of any risks in their care plan and given the opportunity to discuss their preferences.

10. Staff Responsibilities

10.1 Registered Manager

• Oversees the implementation and compliance of person-centred care planning.
• Ensures all care plans are up-to-date and reviewed in a timely manner.
• Provides ongoing training to staff on care planning procedures.

10.2 Key Workers

• Develop, update, and maintain individual care plans.
• Liaise with healthcare professionals and families to ensure holistic care planning.
• Support individuals in achieving their care plan goals.

10.3 All Staff

• Adhere to the care plan in daily support.
• Report any changes in the individual’s condition.
• Document daily observations accurately.

11. CQC Compliance

This policy aligns with the following CQC regulations:

• Regulation 9: Person-Centred Care – Ensuring care plans are tailored to individual needs and preferences.
• Regulation 10: Dignity and Respect – Ensuring individuals are treated with respect and their choices are prioritised.
• Regulation 11: Need for Consent – Ensuring individuals or their representatives provide informed consent.
• Regulation 12: Safe Care and Treatment – Ensuring appropriate risk management and medication planning.
• Regulation 13: Safeguarding Service Users from Abuse and Improper Treatment – Ensuring individuals are protected from harm.
• Regulation 17: Good Governance – Maintaining accurate records and conducting regular care plan audits.

12. Policy Review

This policy will be reviewed annually or sooner if legislative changes, CQC regulations, or operational requirements necessitate amendments.

For further guidance, contact {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, Registered Manager at {{org_field_email}}.

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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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