A care plan is the only thing a new carer has to go on when they let themselves into someone's home for the first time. If it says "assist with personal care", they will guess. If it says Edna likes the bathroom warmed up first, washes her own face and wants her cardigan on before her tea, they will get it right on day one.
That is the whole point of a person-centred plan. It is not a longer plan, or a nicer-sounding one. It is a plan that tells a carer how to support this particular person in the way they want, and that the person recognises as being about them.
This guide covers home care (domiciliary care) in England, and links the rules that apply there. The approach works just as well in Wales, Scotland and Northern Ireland, but check your own regulator's standards. Everyone in the examples is made up. Any resemblance to a real person is a coincidence.
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What the rules ask a care plan to do
You do not need to quote legislation in a care plan, but it helps to know what the plan is there to prove.
Regulation 9 (person-centred care). Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 says care must be appropriate, meet the person's needs and reflect their preferences. It requires providers to assess needs and preferences collaboratively with the person, design care to achieve their preferences, and make reasonable adjustments. CQC's guidance on Regulation 9 adds that a clear plan with agreed goals must be developed and made available to all staff and others involved, that it should include ways the person can keep their independence, and that plans should include an agreed review date.
The Care Act 2014 wellbeing principle. Section 1 of the Care Act 2014 puts a duty on local authorities to promote a person's wellbeing, and lists what that covers: dignity, physical and mental health, protection from abuse, control over day-to-day life, work and recreation, relationships, suitable accommodation and the person's contribution to society. It also starts from the assumption that the person is best placed to judge their own wellbeing. Your agency is usually delivering a package a council has assessed against that list, so your plan should pick up where their assessment leaves off.
The Mental Capacity Act 2005. The principles in section 1 say a person must be assumed to have capacity unless it is shown otherwise, must be helped to decide before anyone concludes they cannot, and is not to be treated as lacking capacity just because they make an unwise decision. Where someone does lack capacity for a particular decision, anything done for them must be in their best interests and as least restrictive as possible. A plan should show which decisions the person makes, and who decides anything they cannot.
NICE guidance for home care. NICE's guideline NG21 on home care is the most practical of the lot. Recommendation 1.3.13 says the home care plan should recognise what the person can and wants to do, address safety, wellbeing and independence, cover practical support such as shopping, cooking and socialising as well as personal care, make the role of family carers explicit, describe how success will be measured, be clear and easy to navigate, and have a summary at the start. Recommendation 1.3.14 covers risk, 1.3.16 covers medicines, and 1.3.25 says to review the plan within 6 weeks and then at least annually. The matching quality standard QS123 says older people using home care should have a plan that identifies how their personal priorities and outcomes will be met.
CQC's quality statements. Under the single assessment framework, the person-centred care statement says care plans should fully reflect people's physical, mental, emotional and social needs, and that people and those close to them are regularly involved in planning. The independence, choice and control statement covers keeping relationships, getting out into the community and having the equipment to stay independent. Both are good tests to hold a plan up against.
Task-led and person-centred, side by side
A task-led plan lists what the carer does. A person-centred plan says how the person wants it done, what they will do themselves, and why it matters. Here is the same morning call written both ways.
| Task-led | Person-centred |
|---|---|
| Assist with personal care. | Edna washes her own face and hands at the sink. Warm the bathroom with the fan heater first. Help her with her back and feet, and pass her the towel rather than drying her. |
| Prompt medication. | Edna's morning tablets are in the pharmacy blister pack in the kitchen drawer. Remind her, pass her the pack and a glass of water, watch her take them, and record it. |
| Prepare breakfast. | Ask what she fancies. It is usually porridge made with milk, a spoon of golden syrup, and tea in the blue mug, milky, no sugar. |
| Check client is OK. | Ask about the crossword and whether she slept. If she seems more confused than usual, or has not eaten since yesterday, ring the office before you leave. |
| Assist with mobility. | Edna walks with her frame indoors. Walk beside her on the left, as her right knee is the stronger one. |
The person-centred version is longer, but every extra word is something a carer would otherwise have to guess or ask.
The sections every example uses
Each example below follows the same shape, so a carer always knows where to look. You can use the same shape in your own plans, and it is the shape of the printable template at the end.
- One-page summary. The five or six things a carer must know before they start. NICE asks for a summary at the start, and on a busy day it is all some carers will read.
- About me. Who the person is, in their words where possible: their history, family, what they did for work, what makes them laugh.
- What matters to me. Their priorities, not the agency's.
- What I can do for myself. So carers do not take over.
- My outcomes. What the person wants to achieve or keep, written so you can tell whether it is happening.
- My visits. What happens at each call and how the person likes it done.
- Risks, and the risks I choose to take. Each risk, what has been agreed to reduce it, and who agreed it.
- My medicines. The exact level of support at each call, and who to contact with concerns.
- How I communicate. How to talk with the person, and how they let you know things.
- Who is involved. Family, friends and professionals, and what each one does.
- If things change. What to look out for and who to call.
- Review. When it will next be reviewed, and what would bring the review forward.
Example 1: Edna, 84, living alone with dementia
One-page summary
- Edna has Alzheimer's disease and lives alone in the terraced house she has lived in for 52 years.
- Call her Edna, never "love" or "darling". She was a primary school head teacher and notices.
- Four calls a day: breakfast (45 minutes), lunch (30), tea (30) and bed (30).
- She walks to the corner shop for her newspaper most mornings. This is her choice and it has been agreed (see risks).
- Late afternoon is her hardest time. Keep the tea call calm and unhurried.
- Her daughter Carol is her lasting power of attorney for health and welfare, and lives about an hour away.
About me
I taught at the same school for 30 years and was head for the last twelve. My husband Ted died six years ago. I have a daughter, Carol, and two grandsons who are both taller than me. I like things done properly, I like a tidy kitchen, and I am still better at the crossword than anyone who comes in here.
What matters to me
- Staying in my own house.
- Getting my paper and doing the crossword.
- Being treated as a grown woman who knows her own mind.
- Seeing Carol and the boys on Sundays.
- Ted's photographs staying where they are.
What I can do for myself
Edna can wash her face, hands and top half with a prompt, dress herself if clothes are laid out in order, make a cup of tea, and walk indoors with her frame. She can choose what to eat if offered two options rather than an open question.
My outcomes
| Outcome | How we will know |
|---|---|
| Edna stays living at home. | She is still at home at each review, with no unplanned moves. |
| Edna keeps her morning walk to the shop. | Carers record whether she went, and whether she came back without help. |
| Edna eats three meals a day. | Food and drink are recorded at every call. Carol and the GP are told if she loses weight. |
| Edna feels less anxious in the late afternoon. | Carers note her mood at the tea call. Fewer calls to Carol or the office about distress. |
My visits
| Call | What happens and how Edna likes it |
|---|---|
| Breakfast, 8am | Knock and call out "It's [your name] from the agency" as you come in. Warm the bathroom first. Lay her clothes on the bed in the order she puts them on. Porridge, blue mug. Prompt her morning tablets (see medicines). Check she has her purse and her card before she goes for the paper. |
| Lunch, 12.30pm | Offer two choices for lunch. She likes a sandwich and soup more than a hot meal at lunchtime. Ask about the crossword and help if she wants you to. Check the fridge for food past its date and tell the office if she is running low. |
| Tea, 4.30pm | This is when she is most unsettled. Sit down with her before you start anything. Radio 3 or her Glenn Miller CD usually helps. Hot meal, and a pudding if she wants one. Close the front curtains, as dark windows worry her. |
| Bed, 8pm | Lay out tomorrow's clothes. Help her with her nightdress if she asks. Check the back door is locked, the hob is off and her pendant alarm is on. Leave the landing light on. |
Risks, and the risks Edna chooses to take
| Risk | What has been agreed |
|---|---|
| Getting lost on the walk to the shop. | Edna has capacity to decide to go and wants to keep going. Carol agrees. She carries a card in her purse with her address and Carol's number. The shop owner knows her. If she is not home 45 minutes after leaving, the carer rings the office, who will ring Carol. Reviewed at every plan review. |
| Falls at home. | Frame in every room she uses. Rugs removed with her agreement, apart from the hall runner she wanted to keep, which is now taped down. Pendant alarm worn day and night. |
| Leaving the hob on. | Carers cook the hot meal. Edna makes her own tea and toast. A gas safety cut-off was discussed and fitted with Edna's and Carol's agreement. |
| Not eating enough. | Recorded at every call. Easy snacks left out where she can see them. |
NICE NG21 says to talk through whether telecare could help. A location tracker was discussed. Edna said she did not want one, and that is recorded. A pendant alarm was accepted.
My medicines
The pharmacy supplies her tablets in a monitored dosage blister pack. At breakfast and tea, carers remind Edna, pass her the pack and a glass of water, watch her take the tablets and record each one. Carers do not pop tablets out for her unless the plan is changed. If she refuses, do not insist. Record it, and ring the office, who will speak to the pharmacist or GP. Any concerns go to the GP surgery or the community pharmacist, whose numbers are on the front of the folder.
How I communicate
Short sentences, one question at a time. Give her time to answer. If she is repeating herself, answer kindly each time. Do not argue about what day it is. If she asks for Ted, ask her about him rather than telling her again that he has died.
Who is involved
- Carol (daughter, LPA for health and welfare): visits on Sundays, does the big shop online, and wants a call if anything changes.
- GP and memory clinic: reviews her dementia medicines.
- Community pharmacist: supplies the blister packs.
- Corner shop: knows Edna and will ring Carol if worried.
If things change
Signs to report the same day: sudden worse confusion (which can mean an infection), not eating or drinking, a fall, bruises, or Edna saying someone has been in the house. Safeguarding concerns follow your safeguarding procedure.
Review
Next review in six months with Edna and Carol, or sooner after a fall, an infection, a hospital stay, or if she stops going to the shop.
What makes this person-centred
The task-led version of Edna's plan would say "high risk of wandering, do not allow to leave the house alone". That would take away the one thing she does every day that is entirely hers. This plan keeps the walk, records that she has capacity to choose it, and makes it safer with a card, a shopkeeper and a 45-minute rule.
Example 2: Raymond, 79, home from hospital with reablement
One-page summary
- Raymond has just come home after two weeks in hospital with pneumonia. He has lost strength and confidence.
- This is a six-week reablement package. The aim is to need less help each week, and possibly none at the end.
- Carers do things with Raymond, not for him. Stand by and encourage before you step in.
- He walks with a stick. The hospital occupational therapist has fitted a perching stool and a second banister.
- He lives with his wife June, who has arthritis and cannot help him physically.
About me
I was a bus driver for 40 years. I play darts for the British Legion team on Thursdays and I want to get back to it. I have never been ill in my life and I do not like being fussed over. June and I have been married 55 years.
What matters to me
- Getting back to darts on Thursday nights.
- Not being a burden on June.
- Showering on my own again.
What I can do for myself
At the start: wash his top half sitting at the sink, dress his top half, eat and drink independently, and walk short distances indoors with his stick.
My outcomes
| Outcome | Starting point | Goal by week 6 |
|---|---|---|
| Shower on his own. | Needs a carer to help him in and out, and to wash his legs and feet. | Showers using the perching stool and grab rail, with nobody in the room. |
| Make his own breakfast. | Sits while a carer makes it. | Makes tea and cereal, using the trolley to carry them. |
| Walk to the end of the road and back. | Walks about 20 steps indoors. | Walks to the bus stop at the end of the road, which is the route to the Legion. |
My visits
| Weeks | Calls | What happens |
|---|---|---|
| 1 and 2 | Morning (45 minutes) and evening (30). | Morning: support with a strip wash, then the OT's exercise sheet. Raymond makes his own tea with a carer beside him. Evening: help with lower body undressing. |
| 3 and 4 | Morning (45) and evening (30), if goals are on track. | Morning: first showers with a carer just outside the door. Walk to the front gate and back together. Evening: stand by while he undresses. |
| 5 and 6 | Morning only (30), then reducing. | Carer checks the shower went well and walks with him towards the bus stop. Agree a date to stop the calls. |
Each move to the next stage is agreed with Raymond and the reablement OT, not decided by the rota.
Risks, and the risks Raymond chooses to take
| Risk | What has been agreed |
|---|---|
| Falling in the shower. | Perching stool, grab rail and non-slip mat fitted by the OT. Carer stays outside the door for the first showers. Raymond wears his pendant alarm in the bathroom, which he agreed to for the six weeks only. |
| Overdoing it. | He tends to push too hard. Follow the exercise sheet. If he is breathless, sit him down and let him rest before going on. |
| Walking outside. | He wants to walk further than the OT suggests. Agreed: he goes with a carer until week 5, takes his phone, and walks the route on a dry day. |
My medicines
Raymond and June manage his medicines themselves. Carers do not give, prompt or record his medicines, but should tell the office if he says he has stopped taking anything, or if there are signs he is unwell.
How I communicate
He is hard of hearing in his left ear. Sit on his right. He will say he is "fine" when he is not, so ask specific questions, such as "how far did you get yesterday?".
Who is involved
- June (wife): company and encouragement. She should not be expected to help him move.
- Reablement OT: sets the exercises and decides on equipment and goals.
- GP: follow-up appointment after discharge.
- British Legion darts captain: has offered him a lift once he is ready.
If things change
Report the same day: a new or worse cough, a temperature, more breathlessness, confusion or a fall. These can be signs of the pneumonia coming back.
Review
Weekly progress check with Raymond and the OT, and a full review at week 6 to agree whether calls stop, continue or change.
What makes this person-centred
The outcomes are his, measured against where he started, and they all lead back to Thursday nights. NICE's guideline NG74 on intermediate care including reablement is the one to read for this kind of package. The plan also changes shape over the six weeks, which is how a reablement plan should look on paper.
Example 3: Sunil, 38, learning disability and autism, in his own flat
One-page summary
- Sunil has a learning disability and is autistic. He lives on his own in a housing association flat.
- He has support every morning and evening, and four hours on Saturdays for going out.
- The same small team of carers supports him. A new carer is always introduced first, with a photo shown the week before.
- He does not like surprises. Tell him about any change as early as possible, and update his picture timetable on the fridge.
- He loves trains and knows the timetable for the local line by heart.
About me
Sunil chose to write this part with his support worker using photos and short sentences.
I am Sunil. I live in my flat. I like trains, curry, and the radio. I like my mum and my sister Priya. I work at the café at the garden centre on Tuesdays and Fridays. I do not like loud noises or people talking all at once.
What matters to me
- Living in my own flat.
- My job at the café.
- Going to the railway museum.
- Knowing who is coming, and when.
What I can do for myself
Sunil washes and dresses himself, makes breakfast, uses his bus pass on routes he knows, and buys things in shops he knows. He needs support to plan meals, cook anything that uses the oven, manage his money, open post, and go somewhere new.
My outcomes
| Outcome | How we will know |
|---|---|
| Cook two meals a week himself. | Recorded at the evening call. Started with one simple recipe in pictures. |
| Travel to the café on his own on a new route after his bus changed. | Carer travels with him, then follows on the next bus, then he goes alone. Agreed stages recorded. |
| Keep on top of his bills. | Weekly money check with a carer, using his picture budget sheet. Bills paid on time. |
My visits
| Call | What happens and how Sunil likes it |
|---|---|
| Morning, 7.30am (30 minutes) | Knock twice, wait for him to answer. Check the day on his picture timetable together. On café days, check he has his bus pass, phone and lunch money. |
| Evening, 6pm (45 minutes) | Cooking support, hands off where possible: he does the steps, you read the picture recipe. Open post with him on Mondays. Weekly money check on Thursdays. |
| Saturday, 11am to 3pm | His choice of outing, agreed on Thursday. Usually the railway museum, the market, or watching trains at the station. |
Risks, and the risks Sunil chooses to take
| Risk | What has been agreed |
|---|---|
| Using the oven. | He uses it only with a carer present for now. Goal reviewed at each review. Microwave and kettle he uses alone. |
| Being taken advantage of with money. | Large amounts kept in the bank. He carries a set amount for the week. Anyone asking him for money is reported to the office. |
| Travelling alone on a new route. | Staged plan above. He carries a card in his phone case saying he is autistic and giving his sister's number. |
My medicines
Sunil has one tablet each morning, which he takes himself from the box on the kitchen shelf. The morning carer asks if he has taken it and records his answer. If he has missed it twice in a week, tell the office, who will talk to him and his GP.
How I communicate
Speak clearly in short sentences and give him time to answer. He may not look at you, and that does not mean he is not listening. Use his picture timetable and recipes. Do not say "in a minute" unless you mean it. If he is anxious, he will rock or hum. Turn the radio down, stop talking, and give him space. Do not touch him without asking.
Who is involved
- Sunil's mum and sister Priya: Sunday lunch, help with big decisions if Sunil wants them involved.
- Garden centre café manager: his employer.
- Community learning disability team: annual health check and support with any changes.
- GP: his health action plan and hospital passport are on file.
If things change
A change in routine, sleep, eating or how he copes with noise can mean he is unwell or something is wrong. Tell the office the same day. Reasonable adjustments for any health appointment are in his hospital passport.
Review
Every six months with Sunil, and anyone he wants there, using his picture version of the plan.
What makes this person-centred
Sunil's plan is about the life he wants, not his diagnosis. It supports a job, a hobby and his independence, and builds in the reasonable adjustments Regulation 9(3)(h) requires. Every carer supporting Sunil should have the training covered in our guide to Oliver McGowan training for home care.
Example 4: Iris, 81, end of life care at home
One-page summary
- Iris has advanced heart failure. She has chosen to die at home, and her husband Frank and her GP know this.
- A ReSPECT form is in the red folder on the hall table. Read it before your first visit.
- District nurses manage her symptoms and any "just in case" medicines. Carers do not give these.
- Four calls a day, with two carers at each call as she is now cared for in bed.
- Frank, 85, is with her all the time. Look after him too.
About me
I ran a flower shop for 25 years. I have been married to Frank for 60 years this spring. I am a Catholic and my faith matters to me. I am not frightened. I want to be in my own bed, with the window open, and with my family around me.
What matters to me
- Dying at home, not in hospital.
- Being comfortable and free from pain.
- Frank being looked after, and not being worn out.
- Father Michael visiting.
- Fresh flowers in the room.
What I can do for myself
Iris can still tell you what she wants, choose what to wear, and take sips of drink. She tires very quickly. Let her decide how much she wants to do on each visit.
My outcomes
| Outcome | How we will know |
|---|---|
| Iris is comfortable. | Carers record comfort at each visit and tell the district nurse straight away about pain, breathlessness or agitation. |
| Iris dies where she has chosen. | The plan and ReSPECT form are followed, and everyone knows who to call. |
| Frank gets rest. | He is asked at every visit how he is. Sitting service offered twice a week so he can sleep. |
My visits
| Call | What happens and how Iris likes it |
|---|---|
| Morning (45 minutes, two carers) | Gentle wash in bed, her choice of nightdress. Change her position as shown by the district nurse. Mouth care. Open the window a little. Ask Frank how the night was. |
| Lunch (30 minutes, two carers) | Change position, mouth care, offer sips. Check pressure areas and record what you see. |
| Tea (30 minutes, two carers) | As lunch. Play her music if she wants it. Change the flowers' water. |
| Bed (45 minutes, two carers) | Wash and change for the night, position for sleep. Check Frank has the district nurse number by the phone. |
Risks, and the risks Iris chooses to take
| Risk | What has been agreed |
|---|---|
| Pressure damage. | Pressure-relieving mattress supplied by the district nurses. Position changes at every call. Report any red or broken skin the same day. |
| Choking on food or drink. | Iris wants to keep having sips of tea and small tastes of ice cream. This has been discussed with her and the district nurse. She is sat up, given small amounts, and nobody pushes her to have more. |
| Frank becoming exhausted. | Carers ask at every visit. Office has the number for the carers' support service and the hospice at home team. |
My medicines
Iris's regular medicines are managed by Frank and the district nurses. Anticipatory "just in case" medicines are kept in the house for the district nurses to give if needed. Carers do not give them. If Iris seems to be in pain, breathless or distressed, ring the district nurse straight away. The number is on the front of the red folder.
How I communicate
Iris may sleep more and talk less as time goes on. Keep talking to her as you work, tell her what you are doing, and assume she can hear you. Frank knows her best. Ask him what she would want.
Who is involved
- Frank (husband): main carer, with her day and night.
- Their son and daughter: visiting from out of the area.
- GP and district nurses: medical care, symptoms and anticipatory medicines.
- Hospice at home team: support and advice.
- Father Michael: parish priest.
If things change
If her breathing changes, she cannot be woken, or she seems distressed, ring the district nurse. When Iris dies, follow the instructions in her plan and the ReSPECT form, which say who to ring. Her death is expected. Stay with Frank until someone arrives if he wants you to.
Review
At least weekly with Iris, Frank and the district nurse, and whenever her needs change. At this stage plans can change from day to day.
What makes this person-centred
It is built around where and how Iris wants to die, and it treats Frank as part of the plan rather than a visitor. It also keeps her small pleasures, like the tea and the open window, even where a task-led plan might have removed them. NICE's guideline NG142 on end of life care for adults covers how services should work together at this stage, and the ReSPECT process explains the form many areas use to record emergency care wishes.
Example 5: Winston, 76, diabetes and support with medicines
One-page summary
- Winston has type 2 diabetes and macular degeneration, so his eyesight is poor.
- Two calls a day: breakfast and tea. Carers assist with his tablets at both.
- His diabetes plan from the practice nurse is in the folder. It says what a low blood sugar looks like for him and what to do.
- He loves to cook. Carers help him cook, not cook for him.
- Read everything to him. Do not hand him anything to read.
About me
I came to England from Jamaica in 1968 and worked for the railways. My wife Gloria died three years ago and I miss her cooking, so now I do it myself. I go to church on Sundays and play dominoes on Wednesdays at the community centre. I have two daughters and five grandchildren.
What matters to me
- Cooking my own food the way Gloria taught me.
- Church on Sunday and dominoes on Wednesday.
- Not losing my sight any faster.
- Managing my diabetes so I do not end up in hospital.
What I can do for myself
Winston washes and dresses himself and moves around his house without help. He knows where everything is in his kitchen, so do not move things. He needs help to read labels, packaging and post, to manage his tablets safely, and to check his feet.
My outcomes
| Outcome | How we will know |
|---|---|
| Takes his diabetes tablets as prescribed. | Each dose recorded on the medicines record. Missed or refused doses reported. |
| Keeps cooking his own meals. | Carers record what he cooked and how much help he needed. |
| Spots foot problems early. | Carers look at his feet with him once a week and report anything new to the podiatrist via the office. |
My visits
| Call | What happens and how Winston likes it |
|---|---|
| Breakfast, 8am (30 minutes) | Help with his tablets (see medicines). He makes his own porridge. Read his post to him if he asks. Make sure the kitchen is as he left it. |
| Tea, 5pm (45 minutes) | Help him cook. He does the chopping and seasoning by feel and taste, you read the cooker dial and check things are cooked through. Help with his evening tablets. Sunday: check his best shirt is ironed for church. |
Risks, and the risks Winston chooses to take
| Risk | What has been agreed |
|---|---|
| Low blood sugar. | His practice nurse's diabetes plan says what the signs are for Winston and what to do. Carers have read it. Glucose tablets are kept on the kitchen windowsill. |
| Cuts and burns while cooking. | He has been cooking with poor sight for some years and wants to carry on. A sight loss charity has put tactile bumps on his cooker dials. Carers stay with him while the hob is on at the tea call. |
| Food that affects his diabetes. | Winston wants to keep cooking traditional food and enjoys a rum punch after church. This has been talked through with him and his practice nurse. It is his choice and it is recorded. |
My medicines
Winston's tablets come in their original boxes. He cannot read the labels. At breakfast and tea, the carer reads the label and the medicines record aloud, takes the right tablets out with him, watches him take them and records each one on the medicines record. This is assisting, which is more than a reminder, and every carer on his calls must be trained and assessed as competent to do it. If anything on the box does not match the record, do not give it. Ring the office, who will check with the pharmacist. The medicines management guide explains how this links to NICE NG67.
How I communicate
Say your name as you come in, every time. Describe where things are using the clock face ("your tea is at two o'clock"). Read everything out. He has a dry sense of humour. If he says something outrageous, he is probably joking.
Who is involved
- Daughters Marcia and Joy: one visits most weekends, the other manages online shopping.
- Practice nurse: diabetes reviews and his diabetes plan.
- GP and community pharmacist: his medicines.
- Podiatrist: regular foot checks.
- Sight loss charity: equipment and advice.
If things change
Report the same day: sweating, shakiness, confusion or drowsiness (follow his diabetes plan first), a sore or cut on his feet, more trouble seeing, or not eating.
Review
Six months, or sooner if his medicines change, his sight gets worse, or he has a hospital admission.
What makes this person-centred
It treats Winston as the cook in his own kitchen, sets out exactly what carers do with his tablets because he cannot read the box, and records a food choice that matters to him rather than pretending it is not happening. NICE's guideline NG28 on type 2 diabetes is the clinical background, but the detail of what to do for Winston comes from his own practice nurse.
Example 6: Hannah, 46, multiple sclerosis and double-up visits
One-page summary
- Hannah has secondary progressive MS and uses a powered wheelchair.
- Transfers are by ceiling track hoist, with two carers, as set out in her moving and handling plan from the OT.
- Morning and bed calls are double-ups (two carers). The lunch call is one carer.
- Hannah directs her own care. Ask her, not her husband.
- She works from home as a bookkeeper on Mondays, Wednesdays and Thursdays. Her morning call must finish by 9am on those days.
About me
I am a mum of two, a bookkeeper and a terrible singer. I was diagnosed with MS at 31. I know my body and my condition better than anyone, so please listen to me. I want my kids to see me as their mum, not as someone who is looked after.
What matters to me
- Being ready for work on time.
- Doing the school run conversations at breakfast, even if I am not driving.
- Showering, not a bed bath.
- Keeping my energy for the things I care about.
What I can do for myself
Hannah can use her hands for light tasks, though they tire, and can feed herself, use her phone and laptop, and drive her wheelchair. Fatigue gets worse through the day and in warm weather, so what she can do at 8am may not be the same at 4pm.
My outcomes
| Outcome | How we will know |
|---|---|
| Ready for work by 9am on work days. | Call start and finish times. Hannah's own feedback at review. |
| Keeps showering. | Showers recorded. Any shower swapped for a wash, and the reason, recorded. |
| Manages her fatigue. | Hannah tells carers how she is at the start of each call, and the call adapts. |
My visits
| Call | What happens and how Hannah likes it |
|---|---|
| Morning, 7.30am (60 minutes, two carers) | Ask how her night was and how tired she is. Hoist to shower chair, shower on the days she chooses, dress in her work clothes. Breakfast at the table with the children. Finish by 9am on work days. |
| Lunch, 1pm (30 minutes, one carer) | Lunch she has chosen, leg bag check as shown by the continence nurse, drinks within reach. No hoist transfers at this call. |
| Bed, 9.30pm (45 minutes, two carers) | Hoist to bed, wash, night bag, position for sleep with pillows as she directs. Fan on in warm weather. |
Risks, and the risks Hannah chooses to take
| Risk | What has been agreed |
|---|---|
| Injury during transfers. | Two carers for every hoist transfer, using her own slings, as set out in the OT's moving and handling plan. Carers must be trained in using the hoist, and the hoist and slings are checked as the plan says. If only one carer arrives, no hoist transfer happens. Ring the office. |
| Fatigue from showering. | Hannah wants to shower rather than have a bed wash. Agreed: showers on her choice of days, using a tilting shower chair, with a bed wash on days she is too tired. Her choice, recorded each time. |
| Overheating. | Heat makes her symptoms worse. Fan, cool drinks, and shorter showers in hot weather. |
My medicines
Hannah manages her own medicines. Carers pass her the boxes from the shelf if she asks, but do not prompt, give or record them. Any concern about her medicines goes to her MS nurse.
How I communicate
Hannah communicates clearly, though her speech slows when she is tired. Give her time to finish. Talk to her, not over her, and do not discuss her with the other carer as if she were not there.
Who is involved
- Owen (husband): works shifts. Not a substitute for a second carer for hoisting.
- Children, 12 and 15.
- MS nurse: medicines, symptoms and relapses.
- OT: moving and handling plan and equipment.
- Continence nurse: catheter care training for carers.
- Wheelchair service: maintenance of her chair.
If things change
Report the same day: new weakness, a sudden change in her symptoms (which can be a relapse), signs of a urine infection, red skin from her chair or sling, or Hannah saying a carer is not following her moving and handling plan.
Review
Every six months, with the OT reviewing the moving and handling plan at least yearly, and sooner after a relapse or a change in equipment.
What makes this person-centred
Hannah is in charge of her own care, and the plan is built around her job and her children rather than around the rota. The double-up is there for safety, not convenience, and the plan says what happens if only one carer turns up. NICE's guideline NG220 on multiple sclerosis covers the wider clinical picture.
Six things that let a plan down
These come up again and again when a plan is read by a new carer, a family member or an inspector.
- Vague verbs. "Assist", "support" and "encourage" mean nothing on their own. Say what the carer actually does.
- No voice. If the plan could be about anyone with the same diagnosis, it is not person-centred.
- Risk as a reason to say no. Record risks the person has chosen to take and what has been agreed, rather than quietly banning things.
- Medicines support that is not clear. Prompting, assisting and administering are different, and need different training. Say which one, at which call.
- Family roles left unsaid. NICE asks the plan to make the role of family and other carers explicit. If you rely on a daughter to do the shopping, write it down.
- A review date nobody keeps. A plan written two years ago for someone who has had three hospital stays since is not their plan any more.
Reviewing a plan
NICE NG21 recommends an initial review within 6 weeks of care starting, then at least annually. CQC's Regulation 9 guidance says plans should include an agreed review date, and that assessments should be reviewed whenever needed, including when people move between services or are discharged.
In practice, most agencies review more often than once a year. Bring a review forward after a fall, an infection, a hospital stay, new medicines, a safeguarding concern, a change in who lives with the person, or whenever the person or their family says something is not working. Reviews are also the natural time to look at whether outcomes are being met, and to stop anything that is no longer needed.
Free printable person-centred care plan template
We have turned the twelve sections above into a plain, printable template you can use for free. No sign-up, no email address needed.
Download the template (PDF, 5 pages)
It includes a one-page summary, prompts for each section, tables for outcomes, visits and risks, and a review and sign-off page. Print it, adapt it to your service, and make sure it fits your own policies and your regulator's requirements.
How care plans work in HomecareOS
In HomecareOS, each person's care plan is written in sections that follow your regulator, including about me, personal care, mobility, nutrition, medication and communication, and each section has its own review date. Tasks show which calls they belong to, so the morning call gets the morning tasks. Risks, medicines and outcome goals link back to the section they belong to, and carers update goals at each visit.
Carers read the relevant parts of the plan on their phone during the visit, and you can preview exactly what a carer will see before you publish a change. With the person's agreement, you can also let a relative read the care plan in the family portal, choosing what they can see.
On the Pro plan, Care Conversations lets you record the assessment conversation and drafts plan sections from it. Nothing goes on the plan until someone on your team has read it, edited it and saved it, so the person's own words can stay in the plan without anyone typing them up from scratch.
If you would like to see how one of these examples would look, book a 15-minute demo or call Phil on 01905 674704.
Sources
- Regulation 9 on legislation.gov.uk, for the wording of the person-centred care regulation.
- CQC guidance on Regulation 9: Person-centred care, for what a plan must include, agreed goals and review dates.
- Care Act 2014, section 1, for the wellbeing principle.
- Mental Capacity Act 2005, section 1, for the five principles.
- NICE NG21, Home care: recommendations, for what a home care plan should contain (1.3.13), risk (1.3.14), medicines (1.3.16), sharing the plan (1.3.21) and review (1.3.25).
- NICE QS123, Quality statement 1: Person-centred planning, for the quality standard on personal priorities and outcomes.
- CQC quality statement: person-centred care and independence, choice and control, for what CQC looks for in assessment.
- NICE NG74, Intermediate care including reablement, NG142, End of life care for adults: service delivery, NG28, Type 2 diabetes in adults, NG220, Multiple sclerosis in adults and NG67, Managing medicines for adults receiving social care in the community, as background for the examples.
- Resuscitation Council UK, ReSPECT, for the ReSPECT process.
- Skills for Care, person-centred approaches in health and care, for training resources, including Care Certificate standard 5 on working in a person-centred way.