What is a care plan?
A care plan is a structured record describing a person’s needs, preferences, risks and the support they require. It explains how care should be delivered and guides staff to provide consistent, safe and person-centred support. It typically includes health conditions, daily support needs, risk management, medication support and personal preferences.
Who needs a care plan?
Care plans are designed for anyone who receives care, with the intention of supporting their health and well-being.
The person receiving care should be able to access their care plan in a format they understand, and with their consent, it may also be shared with family or representatives involved in their care.
Care planning guidance
Care planning should be a collaborative process involving the person, care staff and, where appropriate, family members or advocates, where possible, so that an entirely accurate plan can be developed. Where they have capacity, the resident must understand all elements of their care plan – including the conditions they have, as well as the care and treatment they will receive – and their input must be valued.
The care plan must be written clearly so that all carers can easily understand what is required of them and what they are expected to do while caring for the resident.
A resident’s family member can also be a part of this process, allowing them to give their input/advice on how the resident should be cared for. This can be beneficial as it helps the carer to further understand the personality of the resident, especially in cases where accurate communication with a resident is difficult.
Having all of these members involved in the plan ensures the most accurate, detailed and effective care plan can be created.
Care planning processes
While providers may structure care plans differently, they should always be based on a thorough assessment and regularly reviewed to reflect changes in needs. However, there is some crucial and common information that is necessary on all plans, such as a comprehensive assessment of the person, which includes their medical and physical requirements. All of this information is stored on the care plan and, depending on the health of the service user, there may be regular and further assessments to keep up to date with all the conditions that the resident may have.
The next step is often to develop a care strategy that will meet all of the resident’s requirements, which should also include the patient-centered outcomes. This will help ensure that the holistic package of care is having a positive impact and is beneficial for the resident. However, the focus shouldn’t just be on the service user’s weaknesses, it should also identify and try to improve their strengths too.
Digital care planning systems can support this process by guiding staff through assessments and ensuring information is consistent, structured and easy to update. Our care planning process is quick and easy to grasp, and our care plans are produced as a digital document that is available for all carers of the resident to access.
We use a unique three-step system to produce our fully personalised care plans:
- Staff complete guided assessments
- A draft care plan is generated using recorded information
- The plan is reviewed and personalised before being put into use
Key features of a care plan
Care plans are generally separated into sections, to make it easy to find the information you need at the time you need it. Care plans are usually structured around Activities of Daily Living (ADLs).
When caring for someone, risks need to be identified and managed to ensure a person’s safety, while maintaining their freedom of choice. A risk assessment must be completed and, where the risk is deemed too high, appropriate steps should be taken to reduce or remove the risk. Risks and associated actions should be clearly documented within the care plan so staff can easily understand how to support the person safely.
Another common feature of a care plan is to list the outcomes that the patient wants to achieve. For example, they might state that they want to be ‘as independent as possible’. The carer could then develop some ideas to help them reach or maintain this goal, such as leaving clothes on a bed for a person to get dressed independently, but for support to always be available in case the resident requires assistance.
Perhaps the most important feature of a care plan is making it truly person-centred, and ensuring the resident’s preferences, wishes and choices are clearly documented. A well-designed care planning system should encourage recording preferences, wishes and choices and support writing in the first person where appropriate.
CareDocs and our approach to care
Effective care planning relies on accurate information, regular review and clear communication across the team. Digital care records such as CareDocs DSCR help support this by keeping assessments, care plans and daily records up to date and accessible, making it easier for providers to evidence person-centred care and regulatory compliance.
