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Creating a person-centred care plan isn't just a CQC requirement. It's the foundation of good homecare. When done well, it gives people real control over their support, helps your team deliver consistent care, and provides clear evidence of quality when inspectors come knocking.
But "person-centred" has become one of those phrases everyone uses and nobody defines. This guide cuts through the noise. You'll learn what a person-centred care plan actually looks like, how to structure one properly, and how to maintain quality as your agency grows.
What the CQC expects from your care plans
CQC Regulation 9 (Person-centred care) is clear:
"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."
This means three things in practice:
- The person directs their care – not just consents to it
- They understand what support they're receiving – and why
- The plan reflects their goals – not just your tasks
You might see terms like patient-centred, family-centred, individualised, or personalised. They all point to the same principle: the person receiving care should be at the centre of decisions about that care.
What is a person-centred care plan?
A person-centred care plan documents the outcomes of a planning conversation between an individual and their care professional.
It should include:
- Personal details – including preferences that affect daily life
- Health and wellbeing goals – what the person wants to achieve
- Support strategies – how your team will help them get there
- Medical information – diagnoses, medications, test results, clinical notes
- Agreed actions – specific, practical steps
- Review dates – when you'll check progress together
Templates can help ensure you don't miss anything critical. But a template is a starting point, not a finished document. The plan only becomes person-centred when it reflects that individual's priorities, goals, and voice.
The four principles of person-centred care
The Health Foundation identifies four principles that underpin genuinely 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 live independently
These aren't aspirational. They're practical tests for whether your care planning process is working.
How to write a person-centred care plan
Start with the person's own goals
Person-centred planning means asking the individual what they want to achieve – not assuming you know.
Some people will articulate their goals clearly. Others may need prompting. You can offer examples or suggestions, particularly if someone finds it difficult to express themselves. But their wishes take priority, even if they seem different from your expectations.
A useful starting point: ask about activities or interests they enjoyed in the past but do less now. This often helps restore independence and quality of life.
If a larger goal doesn't seem immediately achievable, work together to set smaller steps. Breaking down a bigger aim into manageable milestones builds confidence and demonstrates progress.
Use the person's own words when recording their goals. This isn't just about politeness. When you swap someone's language for clinical jargon or standard abbreviations, you strip away their sense of ownership. The plan starts to feel distant and impersonal.
Using their own words ensures their wishes and preferences are accurately reflected. It helps them feel heard and understood, which is essential for building trust and encouraging active involvement.
Structure each area of the care plan properly
For each section of your care plan:
Current situation – Describe the person's present circumstances and, importantly, how they feel about this aspect of their life
Goals and outcomes – Outline the individual's own ambitions, whether related to health, independence, social engagement, or day-to-day wellbeing. Be as specific as possible. Let them set the direction.
Support strategies – Detail how your team and wider support networks will help the person achieve their goals, in line with their preferences
Connections to other areas – Recognise that each part of the care plan may influence another. Mobility needs might connect to both personal care and social activities. Make note of linked areas and ensure support is joined up.
This approach helps create a plan that feels authentic to the individual and adapts as their needs evolve.
Focus on what the person can do
You'll need to specify whether someone can physically do something so your team can assist appropriately. But to make a care plan person-centred, you need to understand what they can do and what they want to do.
Someone may not be able to walk unaided, but they might get great satisfaction from choosing how they dress or the activities they enjoy. By focusing on strengths, you build a plan that supports their goals rather than just managing risk.
As NICE guidance notes:
"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."
This is particularly important when supporting people with dementia or cognitive impairment. These individuals may face additional barriers to expressing their preferences, or may be at greater risk of social isolation. Careful, thoughtful planning ensures that everyone, regardless of cognitive ability, continues to have their voice heard and their potential recognised.
Involve everyone who matters
Person-centred planning means treating everyone involved in someone's care as part of an extended team – including the person receiving care.
Treat people with empathy and respect. Ask about their wishes, likes, dislikes, and factors that influence the care you provide. Agree on mutual expectations and review these frequently, involving all parties in decisions.
Tracey, Registered Manager at Harino Care, explains:
"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.'"
This level of detail matters. It turns a generic task into something that respects the individual's routine and preferences.
Where appropriate, involve family members or advocates in shaping the plan. Their perspective can add valuable context, particularly when someone finds it difficult to express their own preferences.
When preferences can't be fully met
Even when you work hard to honour every preference, there will be occasions when a person's choices can't be completely fulfilled.
When this happens, transparency is essential.
Have an open, honest conversation. Explain clearly why a specific preference isn't possible at this time. Invite the person (and their loved ones, if appropriate) to discuss alternatives. The aim is to find the next best option together, so the person's voice remains central.
This approach upholds dignity and ensures people remain active partners in their care, even when compromises are needed.
Create a sense of ownership
A truly person-centred care plan isn't something done to someone. It's a living, collaborative agreement that gives ownership to the person receiving care.
When someone feels genuine ownership over their care plan, they're more likely to speak up when something isn't right, request changes, or highlight concerns. This sense of control leads to better satisfaction, empowerment, and outcomes.
Make sure the person understands that care is being done with them, not to them. They should always be involved in reviews and updates. If a preference isn't possible, explain why – helping them make informed decisions while maintaining control.
Reviewing and updating care plans
A person-centred care plan is not a tick-box exercise. It's an ongoing partnership.
Make it standard practice to revisit the care plan regularly, asking:
- Has the care plan been reviewed and adapted to reflect changing needs or preferences?
- Are individuals and their families actively involved in discussions about updates?
- Is feedback from all parties not only welcomed, but visibly acted upon?
Gather feedback systematically. With so many people involved in a single person's care, opinions will vary. But if you've built a person-centred approach from the start, this becomes easier.
When you receive feedback that highlights improvements, communicate what you'll do to action it. Regular contact with the people you care for allows them to direct and discuss their care. Find out what's working, what they'd like more of, and how you can support it.
This ensures the care plan remains a living document that evolves as needs, wishes, and circumstances change.
How digital care planning supports person-centred care
Paper-based care plans are being replaced by digital systems, with both CQC and NHS driving this change.
Digital care planning makes person-centred care easier to implement and maintain. It's more efficient, easier to evidence, simpler to link to relevant processes (like medication tracking or visit scheduling), and more secure.
When you use digital care planning software like Birdie, you can:
- Create flexible, detailed care plans using templates as starting points, then customise them fully to reflect each person's needs and goals
- Add personalised notes to each task, capturing the specific preferences that make care truly person-centred
- Track progress in real-time so your team always works with the most current information
- Record observations and concerns as they happen, with alerts triggering workflows across your team
- Generate evidence quickly for inspections or reviews, with a complete audit trail from assessment through to delivery
Digital systems also make collaboration smoother. Updates can be shared instantly with families through the Family App. Care professionals access information on the go through the Carer App. Everyone stays informed, reducing miscommunication and ensuring the plan evolves as needs change.
Birdie's care planning features include:
- Care plan recommendations based on assessments and actions you take (for example, entering medication triggers a recommendation to complete the medication care plan)
- Digital body maps for recording everything from cuts to pressure sores
- Clinical observations to track vital signs and test results
- Assessment review tools that make it easy to deliver responsive care
- eMAR medication management with PRN protocols that give carers comprehensive information for confident administration
(Learn more about person-centred care planning software)
Maintaining care continuity
Wherever possible, ensure the person is supported by the same care worker(s) so they can become familiar with them.
When you know someone well, you notice subtle changes in their wellbeing. Trust develops. Care becomes more responsive.
Consider the person's care needs, the care workers' skills, and, where appropriate, both parties' interests and preferences. This "matching" process enhances quality and supports the development of trust.
Birdie's Pulse Dashboard provides visibility over care continuity, showing you the percentage of visits to each client by care professional. You can also track:
- Client outcomes and progress towards goals
- Concerns raised and follow-up actions taken
- Assessment completion and review dates
- Scheduled hours versus reported hours
- Compliments and complaints
This data helps you demonstrate quality and make informed decisions about staffing and care delivery.
Auditing for person-centred care planning
When auditing your care plans, look for evidence that they are genuinely person-centred:
Understanding and engagement – Can the person clearly explain their care plan? There should be documented conversations that evidence this, not just assumed understanding.
Active involvement – Has the individual shaped and continues to shape their care plan? Ownership isn't a one-off event; it's an ongoing partnership.
Personal language – Is the care plan written in words that feel familiar and relevant to the person? Avoid generic, copy-paste sections.
Uniqueness – Each plan should be as unique as the person it supports. Watch for signs of duplication that suggest a one-size-fits-all approach.
Accessibility – Can the care plan be easily accessed and understood, with language and presentation tailored to the person's needs?
Adaptability – Does the plan evolve as needs and preferences change, rather than gathering dust between reviews?
Support network participation – Where appropriate, have loved ones or advocates contributed in ways that matter to the person?
Promotion of independence – Does the plan encourage independence and goal achievement, not just risk management?
Personalised goals – Are there individualised objectives, with concrete steps for how you'll work towards them together?
Clear ownership – Is there proof of the person's input, control, and sense of ownership throughout?
Birdie's Q-Score provides quality evidence based on CQC criteria, helping you demonstrate care quality ratings across Safe, Person-centred, Responsive, and Caring domains.
What good looks like
Person-centred care planning must be embedded in everything you do, not just in the documents you create.
The philosophy underpinning person-centred care is about doing things with people, rather than to them. You need to be flexible to meet people's needs and work with individuals and their families to find the best way to provide care.
When you get this right, you can expect to score highly when inspected by CQC. (Review CQC's key lines of enquiry here)
Further reading:
- The SMART approach to care planning: a checklist
- Person-centred care: the complete guide
- How to meet and exceed CQC standards
- Advanced care planning: what you need to know
- eMAR systems explained
See how Birdie supports person-centred care planning
Birdie helps homecare providers create, maintain, and evidence truly person-centred care plans – from initial assessment through to ongoing review.
Explore our care planning features or book a demo to see how it works in practice.
Published date:
April 17, 2024
Author:
Emma-Lee Curtis
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