In this post, you'll learn what you need to know to write a personalised care plan.
What is a person centred care plan and how do you make one?
Does a care plan need to be person centred?
What are the benefits of using a person centred planning approach?
Can software help you create person centred care plans?
If you’ve ever wondered about any of the above - you’re in the right place.
“People using a service have care or treatment that is personalised specifically for them. Providers must work in partnership with the person, make any reasonable adjustments and provide support to help them understand and make informed decisions about their care and treatment options, including the extent to which they may wish to manage these options themselves.”
(You can read the full regulation here)
So what does that mean for you?
If you’re a care provider, you need to ensure that your care plans are person centred.
People might also use terms such as patient-centred, family-centred, user-centred, individualised or personalised, but they all mean the same thing.
What is a personalised care plan?
A personalised care plan is simply a record of the outcomes of a care planning discussion between an individual and their health or social care professional.
You may already be working with certain plans that schedule treatments or medication, but a truly personalised care plan should include other information such as SMART goals, preferences and personal information.
The most important aspect of a care plan is the initial discussion, as this will help you to build the complete picture.
Care plan templates
There is no national template for care plans, because a care plan should be a fluid document that is adapted to every individual. However, there are key domains to care planning that can be considered which may help local organisations and staff in developing local care plans.
Every care plan should include:
- Personal details
- A discussion around health and well being goals and aspirations
- A discussion about information needs
- A discussion about self care and support for self care
- Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes
- Any actions agreed
- A review date
The Health Foundation has identified a framework that comprises four principles of person-centred care:
- affording people dignity, compassion and respect
- offering coordinated care, support or treatment
- offering personalised care, support or treatment
- supporting people to recognise and develop their own strengths and abilities to enable them to live an independent and fulfilling life.
We’ll talk about a few ways to incorporate these principles into care planning below:
Ensure personalised care plans aren’t one-size-fits-all
It’s perfectly acceptable to use a care planning template for every person you care for, as long as they are used as a starting point, and not a complete document. Using a pre-existing care plan template helps to save time and can help you make sure you’ve not forgotten anything. But, in order to make sure they’re person centred, they need to focus on the goals and priorities of each person, with outcomes to match.
Paper care plans (and care delivery recorded on paper) is soon to be replaced by digital means, with the CQC and NHS driving the digital change. If you’re thinking about making the switch to a care planning software solution, here’s an example of how we create person centred care plans at Birdie - using guide templates for you to expand on.
Check out the benefits of digital vs paper care planning, here.
When you use Birdie to plan your care, you'll find a number of categories for you to fill in.
In each category, you'll be asked a number of questions about your care recipient’s level of independence so you can create a person centred care plan which fully understands their needs. You can also record any risks that you may observe in order to decide whether further assessments are needed.
From there, you can add tasks which will help the client achieve those outcomes. You can add your own notes to each one, which make them really person centred, and you can see in real time when they’ve been completed.
Focus on what the person can do
When planning for home care, you’ll need to specify whether or not a person can physically do something, so your team can assist appropriately. But in order to make a care plan person centred, you’ll need to speak with your clients to gauge what they can do, and what they would like to do. Whilst it may be clear that they cannot walk unaided, they may get great satisfaction from choosing how they dress, or the activities they enjoy. By focusing on their strengths, you can build a care plan that helps to support their goals.
“Recognise that people have preferences, aspirations and potential throughout their lives, and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.”
Keep everyone involved
Person centred care planning means making sure that everyone has a say - and treating everyone involved in the care of a person as an extended team member (yes, even the person you’re caring for!)
Treat the people who use your services with empathy and respect; ask them about their wishes, their likes and dislikes and factors that will influence the care you provide.
Agree on mutual expectations and be sure to review these frequently, involving all parties in any decisions.
A great example comes from our partner agency, Harino Care. Tracey the Registered Manager told us:
“For example one of the tasks would be a normal assist wash in the mornings, but we would make that person-centred, by saying ‘the bowl is in the kitchen, please use the yellow flannel for the top. Mrs Smith prefers to use X bubble bath’
You should also ensure that wherever possible you’re respecting the privacy of those you care for. If you use paper care plans, kept in a person’s home, this means some potentially private information is available to any visitors to their home. Speak to your clients and ask them what they’re happy to share - and if you can, use a home care planning software like Birdie, to ensure that sensitive data is never left out in a person’s home.
Ask for feedback (and action it!)
Asking for feedback can seem like opening a can of worms. With so many people involved in a single person’s care, there will be many opinions that need to be respected. But, if you’ve created a person-centred approach to care planning from the start, this step should be relatively pain-free.
If you receive feedback that highlights improvements or requests, be sure to communicate what you’ll do to action it.
You should also be in regular contact with the people you care for, to offer them the opportunity to direct and discuss their care. Find out what’s working for them, what they’d like more of and how you can support it. This helps to maintain a person-centred approach and ensures they are always in control of their care.
If you need some guidance on how to have an effective conversation, check out some tips, here.
Strive for continuity of care
It’s not always possible to assign your care team to the same people all the time. But, wherever possible you should strive to ensure the person is supported by the same home care worker(s) so they can become familiar with them.
You should also be actively trying to ‘match’ your team members to the people you care for, taking into account: the person's care and support needs, and the care workers' skills, and if possible and appropriate, both parties' interests and preferences.
Birdie provides in depth reports that allow you to see the percentage of visits to a client by one carer, so you always have visibility over your care continuity and you can make changes weekly (when you receive your report). If you’re interested in knowing more about our data and analytics service at Birdie, you can watch our on-demand webinar where we spoke with our partner agency Caring Crew about the impact of data on care planning, or you speak with our team by booking a free demo, here.
The key takeaway to write a care plan
It’s important to remember that although person centred care planning can stem from a number of activities, it needs to be integrated into everything you do at your home care agency.
The idea of person centred care planning is underpinned by the philosophy of doing things ‘with’ people, rather than ‘to’ them. You need to be flexible to meet people’s needs and work with people and their families to find the best way to provide their care.
If you stick to the above principles with your care planning, you can expect to score highly when you’re inspected by the CQC. You can see the CQC KLOEs here, to review how your person centred planning will assist with hitting their requirements.
If you're thinking about going digital, read up on the benefits of digital care plans vs paper care plans, here. Find out more about person centred care planning, here or get a free SMART care plan template, here.