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When a care coordinator in Brighton asked her new client about his morning routine, she learned he'd been a professional footballer and had spent years in the Navy. He still wakes at 5am, takes tea at exactly 4pm, and goes to bed at 6pm sharp. That detail transformed his care plan from generic to genuinely useful.
That's what person-centred care planning looks like in practice. Not assumptions or standardised templates, but specific details that help carers understand what makes someone's day feel normal, safe, and worthwhile.
This guide walks through practical examples of person-centred care planning, including specific questions that work, a real-world care plan example, and how to adapt your approach for different conditions and needs.
What makes a care plan truly person-centred?
Most care plans capture what needs to be done "for" someone (medications, personal care tasks, mobility support) but miss what matters "to" them (how they like their morning routine, who they want to talk about, what makes them anxious).
The difference isn't cosmetic. When carers understand what matters to someone, they can:
- Build trust more quickly with new clients
- Spot changes in behaviour or mood earlier
- Reduce incidents caused by misunderstanding preferences
- Deliver care that feels like care, not just a service
A truly person-centred care plan pulls together everything that makes someone unique - their history, routines, preferences, and what matters most to them day-to-day. If someone has a long-standing Sunday family lunch, enjoys gardening every afternoon, or needs time alone to listen to their favourite music, all of this should shape how you plan and deliver their care.
Five essential areas for person-centred care planning
Based on work with care agencies, clinicians, and CQC guidance, these five areas help you capture what matters most:
1. Identity and how someone wants to be known
- What name do you like to be called?
- How do you prefer to be addressed? (He/Him, She/Her, They/Them, or another term)
- Is there anything about your background, culture, religion, or life experience that affects how you'd like to be cared for?
Why this matters: Someone's preferred name might be different from their legal name. Their identity might include cultural practices that shape when they eat, how they dress, or who can provide personal care.
2. People and relationships
- Who are the most important people in your life?
- How involved are your family members in your care?
- Are there people you'd prefer didn't visit?
- Do you have any caring responsibilities for others?
Why this matters: Understanding someone's relationships helps you recognise who might notice changes first, who can provide context about their habits, and whose involvement might cause stress rather than comfort.
3. Routines, preferences, and non-negotiables
- What does a good day look like for you?
- What time do you usually wake up and go to bed?
- Are there parts of your routine that must happen at a certain time or in a certain way?
- What are your strong likes and dislikes (food, drink, music, TV, conversation topics)?
- How do you like to spend your time?
Why this matters: Routines provide structure and predictability. Disrupting them can cause distress, especially for people with dementia, autism, or anxiety. Small preferences (like having the curtains open before breakfast) can set the tone for an entire visit.
4. History and what shaped them
- What work did you do?
- Where have you lived?
- What are you most proud of?
- Is there anything in your past that still affects you today?
Why this matters: Knowing someone's history helps carers start conversations, understand behaviour, and show genuine interest. An ex-teacher might appreciate being asked their opinion. Someone who grew up during wartime might have strong feelings about waste. Someone who served in the armed forces might have triggers related to loud noises or sudden movements.
5. Worries, fears, and what to avoid
- Is there anything that makes you anxious or uncomfortable?
- Are there tasks you find particularly difficult or upsetting?
- Is there anything you really don't want to happen?
Why this matters: Understanding someone's fears allows you to plan care that avoids triggering them unnecessarily. If someone is frightened of falling, explaining what you're doing before you help them move can reduce their anxiety. If someone with a learning disability finds certain textures distressing, you can plan meals accordingly.
Real-world example: A person-centred care plan in practice
Here's how these questions translate into an actual care plan:
Client profile: Mr. James Thompson
Identity & preferences:
- Prefers to be called "Jim" (not James)
- Former professional footballer, has an M.B.E.
- Spent many years in the Navy
- Lives with moderate dementia
Daily routine:
- Wakes at 5am (Navy habit - deeply ingrained)
- Breakfast at 6am - prefers toast with marmalade, strong tea
- Tea break at exactly 4pm (non-negotiable)
- Bed at 6pm sharp
Key relationships:
- Son visits every Sunday at 2pm
- Close relationship with neighbour who checks in daily
- Talks about his late wife frequently, especially in the evening
What brings him comfort:
- Reminiscing about his football career
- Listening to Radio 4
- Sitting in his armchair by the window
What causes distress:
- Being woken after he's gone to bed (will become very agitated)
- Changes to his routine without explanation
- Loud or sudden noises
Care implications:
- If carers are running late for the 5:30pm visit, they must arrive before 6pm or reschedule entirely
- Always greet him as "Jim" and ask about his football days to build rapport
- Keep conversations calm and give advance warning of any changes
- Never disturb him after 6pm
This level of detail isn't "nice to have"—it's essential for reducing distress, building trust, and ensuring the person feels truly understood. The same approach works whether you're supporting someone with dementia, a learning disability, physical disabilities, mental health needs, or complex care requirements.
How to use these questions in practice
Don't ask everything at once. Initial assessments should cover the essentials (identity, safety, immediate care needs). Use subsequent visits to build out the fuller picture.
Let care teams contribute. The best person-centred information often emerges during care visits, not in formal assessments. Make it easy for carers to add what they learn.
Good care is like building a friendship. When you first met your best friend, your first interaction didn't cement your relationship. Instead, you built your friendship over many tiny micro-interactions that slowly completed the picture. Good care is the same. Encourage your care teams to document every micro-interaction to build the complete picture of the people in your care.
Treat care plans as working documents. People's preferences and circumstances change. What brought someone comfort last month might not work today, especially for those with progressive conditions or fluctuating needs.
Be clear about impact. After each answer, ask: "How should this affect the way we care for you?" This helps translate information into action.
Respect boundaries. Not every client will want to answer every question. That's fine. The point is to offer the opportunity to be known, not to force disclosure.
Adapting your approach for different needs
While the five core areas apply to everyone, how you gather information and what you prioritise will vary:
For people living with dementia:
- Involve family members and carers who've known them long-term to fill in gaps
- Focus heavily on established routines and what triggers anxiety or comfort
- Update plans regularly as needs change and communication abilities shift
- Use life history as a foundation for meaningful interactions
For people with learning disabilities:
- Use accessible language and communication tools (pictures, symbols, easy-read formats)
- Take extra time to build trust before asking personal questions
- Involve family or advocates who know the person well
- Pay particular attention to sensory preferences and triggers
For people with mental health needs:
- Be sensitive to what topics might be difficult to discuss
- Ask about early warning signs that carers should watch for
- Document what helps during difficult periods
- Understand how their condition affects their preferences day-to-day
For people with physical disabilities:
- Focus on autonomy and what they can do (not just what they can't)
- Ask specifically how they prefer to be supported with mobility or personal care
- Understand their aids, equipment, and how they like them used
- Document their goals and what independence means to them
If you're looking for condition-specific care plan examples and case studies, organisations like Dementia UK, Mencap, Mind, and SCIE (Social Care Institute for Excellence) publish practical case studies showing how person-centred planning works across different contexts.
How digital care planning makes person-centred care easier
If information is trapped in paper files or buried in unread care plans, it won't change anything. The most effective care planning systems make person-centred information visible at the point of care - when a carer is about to knock on someone's door.
Digital care planning allows for:
Instant updates - If you receive new information, your care teams have the updated details immediately, allowing for streamlined continuity of care.
Accessible information - Care plans are at carers' fingertips whenever they need them, not locked in an office filing cabinet.
Team contributions - Carers can add observations and details they learn during visits, enriching the care plan over time.
Dynamic planning - As someone's needs change, the care plan can evolve in real time rather than waiting for annual reviews.
This is the difference between care planning as paperwork and care planning as a tool that improves people's lives.
How this connects to CQC compliance
Person-centred care planning directly supports all five CQC Key questions:
Safe - Documenting dislikes and worries helps you avoid situations that might trigger challenging behaviour or distress.
Effective - Capturing preferences about routine, culture, and religion ensures care is delivered in ways that work for each person.
Caring - Recording life history and interests gives carers talking points and ways to build genuine relationships.
Responsive - Understanding what matters to someone allows you to plan care around their goals, not just your schedule.
Well-led - Systematic person-centred planning demonstrates that your organisation values dignity, individuality, and continuous improvement.
The Care Quality Commission expects to see evidence that you're capturing this information and using it to shape care delivery.
Want to see how digital care planning can help you capture and use person-centred information more effectively? Book a demo or explore how Birdie's care planning features work.
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Published date:
September 1, 2023
Author:
Emma-Lee Curtis
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