Care Planning

A care plan is the instruction manual the person themselves would write for their own support, if writing manuals were how anyone wanted to spend an afternoon. Done well, it means the tenth carer to visit does things the way the first, best one did. Done badly, it is a fat folder of photocopied phrases — "encourage fluids", "maintain dignity at all times" — that nobody could act on and nobody reads.

Planning starts with assessment: needs, strengths, risks, health conditions, and above all what a good life looks like to this person. From there the plan turns each need into specifics: what support, by whom, when, how, and what the person will do for themselves. The gold standard test is a night agency worker who has never met the person — could they deliver a decent, safe, personal visit from the plan alone?

Then the plan has to live. People change — after falls, infections, bereavements, good spells as well as bad. A plan reviewed annually out of habit while the person changed in March is fiction, and fiction in care records is dangerous.

• Care Act 2014 (ss.24–27): councils must prepare care and support plans with the person, focused on outcomes and wellbeing, and keep them under review.
• Regulation 9: providers must design care with the person, reflecting needs and preferences — and enable them to understand and participate.
• Regulation 12: risks to people's safety must be assessed and mitigated — the risk assessment is part of planning care.
• Regulation 17: records must be accurate, complete and contemporaneous — including the plan itself.
• MCA 2005: where a person lacks capacity to contribute to planning decisions, best-interests processes and consultation apply.
• NICE NG21 and NG27 set expectations for home care planning and transitions between settings.

Assessors read plans alongside daily notes, MARs and incident logs, looking for one coherent story. They expect: the person's involvement evidenced; enough detail to deliver care safely (dysphagia levels, transfer methods, early warning signs of deterioration); reviews that respond to events, with changes actually made; and no contradictions between documents. A plan that still says "independently mobile" three falls after it stopped being true is a Regulation 12 and 17 problem at once.

• Structure each area of need the same way: the outcome the person wants → their strengths → the support needed → exactly how (their words where possible) → risks and mitigations → review date.
• Be specific or be useless: "Prefers shower, water warm not hot, wash hair Tuesdays and Fridays, needs verbal prompts only" — not "assist with personal care".
• Include the person's baseline so change is spottable: usual mobility, appetite, communication, mood, continence. "Not himself today" becomes measurable.
• Set review triggers, not just dates: any fall, hospital admission, new medication, weight change beyond a set amount, safeguarding concern.
• Make reviews real: with the person, checking outcomes ("did you get back to church?"), pruning what no longer applies. Version-control the plan so staff know they're reading the current one.
• Close the loop with daily notes: notes should reference plan goals ("walked to the dining room with frame — plan target"), and repeated deviations should force a review.

Example 1. After a chest infection and a week in hospital, a man returns to his care home visibly weaker. The senior doesn't wait for the annual review: within 48 hours the plan is updated — transfers now two staff with a stand aid, fluids thickened per the new SALT advice, pressure-relieving mattress ordered, review in two weeks. The hospital discharge summary is filed and its actions written into the plan, not just filed.

Example 2. A woman receiving home care wants one outcome above all: to keep cooking Sunday lunch for her grandson. The plan is built around it — occupational therapy referral for a perching stool and kettle tipper, the Saturday visit used to prep vegetables together, a risk plan for the oven agreed with her rather than about her. Task lists would have given her microwave meals "for safety"; outcome planning gave her Sundays.