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SL63-Developing and Managing Person-Centred Care Plans Policy

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Registration Number: {{org_field_registration_no}}

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.

{{org_field_name}} is registered with the Care Quality Commission to carry out the regulated activity of {{org_field_regulated_activity}} for {{org_field_service_users_bands}} in supported living settings.

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

4. Policy Statement

{{org_field_name}} is committed to ensuring that every person receiving Personal Care within our Supported Living service has an individual, current and person-centred care and support plan.

Care and support plans will be developed collaboratively with the person using the service and will reflect their:

Family members, friends, advocates and other representatives will be involved where:

A relative or person described as “next of kin” does not automatically have legal authority to make decisions on behalf of an adult.

Relevant health and social care professionals will be involved where their input is required to ensure that the person’s care and support is safe, appropriate and coordinated.

Care and support plans will:

5. Principles of Person-Centred Care Planning

Person-centred care planning within {{org_field_name}} will be based on the following principles.

6. Care Plan Development Process

6.1 Initial Assessment

Before {{org_field_name}} begins providing Personal Care, a comprehensive assessment will be undertaken to determine the person’s needs, preferences, strengths, risks and desired outcomes.

The assessment will be undertaken by a person with appropriate knowledge, skills and competence.

The person using the service will be actively involved in the assessment to the maximum extent possible.

Where appropriate and lawful, the assessment may also involve:

The assessment will consider, where relevant:

The assessment will distinguish between:

Where there is reason to doubt the person’s capacity to make a particular decision, capacity will be assessed in accordance with the Mental Capacity Act 2005.

The person’s own views, wishes and desired outcomes will be clearly recorded and will not be replaced solely by the views of family members or professionals.

The assessment will form the basis of the person’s individual care and support plan.

6.2 Developing the Care Plan

An individual care and support plan will be developed following assessment and before staff undertake care tasks that require person-specific instructions.

Where urgent support must begin before a full care plan can reasonably be completed, sufficient interim information, risk controls and instructions must be available to enable staff to provide safe and appropriate care. The full care and support plan must then be completed without unnecessary delay.

The care and support plan will be developed collaboratively with the person using the service and, where appropriate and lawful, relevant representatives and professionals.

The plan will include, where applicable:

The plan must clearly identify:

The person will be provided with the care-plan information in a format they can understand.

Where required, {{org_field_name}} will make reasonable adjustments, including:

The person’s involvement in and agreement with the plan will be recorded appropriately.

A physical signature is not required as the only evidence of involvement or consent. Where signatures are used, they may form part of the record, but other reliable evidence of participation, agreement, consent or lawful decision-making may also be recorded.

Staff responsible for delivering care must have access to the current care and support plan and must understand the instructions relevant to their role.

7. Managing and Reviewing Care Plans

7.1 Ongoing Monitoring

Care plans will be treated as active working documents and must reflect the person’s current needs, preferences, risks and support arrangements.

Staff providing care must:

Where a change is identified, immediate action will be taken where necessary to maintain the person’s safety and wellbeing.

Relevant changes will be communicated to staff who need the information.

The care plan will be updated without unnecessary delay where existing instructions no longer reflect the person’s current needs or circumstances.

7.2 Formal Care Plan Reviews

Each care and support plan will contain an agreed review date.

A formal review will take place at least every six months where this is the organisational standard adopted by {{org_field_name}}, and earlier whenever required by the person’s circumstances.

An earlier review will take place where relevant following:

The person using the service will be actively involved in each review.

Where appropriate and lawful, reviews may also involve:

a person lawfully acting on the person’s behalf;

family members or friends where the person wishes them to be involved;

an advocate;

care staff;

social workers;

healthcare professionals; and

other relevant agencies.

The review will consider:

The outcome of the review will be recorded.

Any required amendments will be made promptly and communicated to relevant staff before revised arrangements are implemented wherever practicable.

The updated care plan will record:

8. Consent, Mental Capacity and Decision-Making

{{org_field_name}} will ensure that people are supported to make their own decisions about care and support wherever possible.

A person will be presumed to have capacity to make a particular decision unless it is established otherwise.

Staff will not assume that a person lacks capacity because of:

People will be provided with information about proposed care and support in a way they can understand.

Reasonable steps will be taken to support decision-making, including where appropriate:

Consent will be treated as an ongoing process and may be:

Where a person has capacity, their decision must be respected, including where they refuse care, subject to any other lawful requirements.

Where there is reason to doubt capacity for a specific decision, an assessment will be undertaken in accordance with the Mental Capacity Act 2005.

Capacity assessments must be:

Where the person lacks capacity for the relevant decision, any decision made on their behalf must:

Family members and next of kin do not automatically have legal authority to make decisions on behalf of an adult.

Where another person is said to hold legal decision-making authority, {{org_field_name}} will verify the nature and scope of that authority, including where applicable:

Independent advocacy will be arranged or facilitated where appropriate, including statutory advocacy where the applicable legal criteria are met.

9. Deprivation of Liberty in Supported Living

{{org_field_name}} recognises that the Deprivation of Liberty Safeguards process used in hospitals and registered care homes does not provide the ordinary authorisation route for people living in Supported Living arrangements.

Where care arrangements may amount to a deprivation of liberty in Supported Living, {{org_field_name}} will:

Staff must not assume that restrictions are lawful merely because they are included in a care plan or considered necessary for the person’s safety.

10. Staff Responsibilities

10.1 Registered Manager

The Registered Manager is responsible for ensuring that effective systems are in place for the development, implementation, review and audit of person-centred care plans.

The Registered Manager will:

10.2 Key Workers and Care Coordinators

Key workers and care coordinators will, within the responsibilities delegated to them:

10.3 All Staff

All staff involved in providing care must:

Staff must not independently make significant changes to a person’s care arrangements outside their authority unless immediate action is necessary to protect the person from harm. Any emergency variation must be reported, recorded and reviewed promptly.

11. Governance, Record Keeping and CQC Compliance

{{org_field_name}} will maintain effective governance arrangements to monitor the quality and effectiveness of person-centred care planning.

The Registered Manager will ensure that care-plan records are:

Care-planning records will include, where applicable:

Quality assurance activity will include periodic audits of care plans.

Audits will consider whether:

Where a shortfall is identified:

This policy supports compliance with applicable requirements including:

The organisation will also have regard to:

12. Legal and Regulatory References

This policy is informed by the following legislation and regulatory guidance:

13. Policy Review

This policy will be reviewed at least annually and earlier where necessary following:

The Registered Manager is responsible for ensuring that this policy remains current and consistent with related organisational policies and procedures.

Changes affecting staff practice will be communicated to relevant staff and supported by appropriate briefing, training or competency assessment 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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