A care plan is a personalised document that sets out the care and support a person needs, how that support should be provided and what matters to them.
If you receive care at home, your care plan should reflect your individual needs, preferences, routines and goals. It gives the people involved in your care clear information about the support you need and helps ensure care is delivered consistently.
The exact content and purpose of a care plan can vary depending on who created it. A local authority may create a care and support plan following an assessment, while a homecare provider will create its own care plan to explain how it will deliver care.
What is the purpose of a care plan?
The main purpose of a care plan is to make sure care is person-centred, consistent and appropriate to the individual’s needs.
A care plan should help everyone involved understand:
- What support the person needs
- What they can do independently
- What matters to them
- How they prefer to receive care
- When support is required
- Who is responsible for providing it
- Any risks that need to be managed
- What to do if their needs change
A care plan shouldn’t simply list tasks for a carer to complete. It should explain how support can help the person maintain their independence, dignity and quality of life.
What does a home care care plan include?
The contents of a care plan will depend on the individual and the type of care being provided.
A homecare plan may include information about:
- Personal care – This can explain what help someone needs with activities such as washing, dressing, using the toilet or maintaining personal hygiene. The plan should also record the person’s preferences, helping carers provide personal care in a respectful and dignified way.
- Medication – Where medication support forms part of the care arrangement, the plan should clearly record the relevant information and what the carer is expected to do. The level of medication support will depend on the person’s needs and the provider’s responsibilities.
- Mobility – The care plan can explain how someone moves around their home, whether they use mobility equipment and what support they need to move safely. It may also identify potential risks, such as falls, and set out appropriate measures to reduce those risks.
- Meals and nutrition – The plan may include information about meals, dietary requirements, allergies, preferences and the level of support someone needs with eating and drinking. For example, a carer may need to prepare meals, encourage regular fluids or provide support during mealtimes.
- Communication – A care plan should explain how the person prefers to communicate and whether they have any difficulties communicating their needs. This is particularly important for people living with conditions that can affect speech, hearing, memory or understanding.
- Hobbies, interests and social activities – Good care planning looks beyond essential tasks. If someone enjoys gardening, going for walks, meeting friends or attending a regular activity, their care plan can include ways for their carer to support them to continue doing the things they enjoy.
- Personal preferences and routines – Small details can make a significant difference to how comfortable someone feels receiving care. A care plan may include preferred meal times, morning routines, how someone likes their home arranged or other personal preferences.
Who creates a care plan?
This depends on the type of care plan.
Local authority care and support plans
- If someone has eligible care and support needs, their local authority may carry out a care needs assessment and create a care and support plan.
- The plan should explain the person’s assessed needs, the outcomes they want to achieve and how those needs will be met.
- The local authority may also assess the person’s finances to establish whether they are eligible for financial support towards their care.
Care provider care plans
- A home care provider will normally carry out its own assessment before starting care.
- This allows the provider to understand the person’s needs, preferences, routines and risks before creating a care plan for the care team to follow.
- A provider’s care plan should be reviewed regularly and updated when the person’s needs or circumstances change.
What is a care needs assessment?
A care needs assessment is used to understand what help a person may need with everyday life.
The assessment may consider areas such as:
- Personal care
- Preparing and eating meals
- Managing medication
- Mobility
- Maintaining relationships
- Accessing the community
- Managing the home
- Emotional wellbeing
- Safety and risks
The assessment should involve the person receiving care wherever possible. Their wishes and preferences should form an important part of the planning process.
A care needs assessment is different from a medical assessment. If you have concerns about a health condition, you should speak to an appropriate healthcare professional.
How often should a care plan be reviewed?
There is no single review schedule that applies to every care plan.
A care plan should be reviewed when a person’s needs or circumstances change and at appropriate intervals set by the care provider or relevant authority.
For example, a review may be needed if someone:
- Becomes less mobile
- Has a change in their health
- Needs additional personal care
- Starts or stops taking certain medication
- Has a change in their living arrangements
- Needs more or less support
- Wants to change their routines or goals
Regular reviews help make sure the care being provided continues to reflect the person’s needs.
Why is a person-centred care plan important?
A person-centred care plan puts the individual at the heart of their care.
Two people with the same health condition may need very different types of support. Their abilities, routines, personalities, preferences and goals can all be different.
For example, one person may need help with preparing meals but want to continue cooking independently where possible. Another may need more extensive support but place particular importance on getting out into their local community.
A good care plan recognises these differences rather than taking a one-size-fits-all approach.
What makes a good care plan?
A good care plan should be:
- Personalised – based on the individual’s needs, preferences and goals
- Clear – written in a way that the person and their care team can understand
- Practical – gives carers clear information about the support required
- Current – reviewed and updated as needs change
- Person-centred – supports independence, dignity and choice
- Accessible – available to the people who need the information to provide safe care
- Responsive – able to adapt when circumstances change
It should also contain only the information that is necessary and appropriate, with personal information handled securely.
Can a family member be involved in creating a care plan?
Yes. With the person’s consent, family members can often play an important role in care planning.
A family member may have useful knowledge about the person’s routines, preferences, communication style and usual behaviour.
However, the person’s own views should remain central wherever they are able to express them. Family involvement should support their choices rather than replace them.
If someone is unable to make a particular decision themselves, the appropriate legal and professional processes should be followed.
What happens if care needs change?
A care plan should not be treated as a permanent document.
If someone’s needs change, the care provider should review the plan and establish whether additional or different support is required.
For example, someone who initially needs help with shopping and household tasks may later need support with personal care or mobility.
If there is a significant change in someone’s health or care needs, they may also need a further assessment by the relevant health or social care professional.
What should you do if you disagree with a care plan?
If you or your loved one is unhappy with a care plan, raise the issue with the person or organisation responsible for creating it.
If the concern relates to a local authority’s assessment or care and support plan, the council should have a complaints process you can follow.
If you are unhappy with how a council has dealt with your complaint, you may be able to contact the Local Government and Social Care Ombudsman.
If the concern relates to a care provider, you should normally raise it directly with the provider first and follow its complaints procedure.
How do you arrange a care plan with Trinity Homecare?
If you are considering homecare, Trinity Homecare can carry out an assessment to understand your loved one’s individual needs and develop a personalised care plan for the care we provide.
The assessment considers more than the practical tasks someone needs help with. We also look at their routines, preferences, interests, abilities and the things that matter to them.
This information helps our care team provide support that fits around the individual’s life rather than asking them to fit around their care.
Trinity provides a range of homecare services, including visiting care and live-in care.
Frequently asked questions about care plans
- What is the difference between a care plan and a care needs assessment? – A care needs assessment looks at what support a person requires, while a care plan explains how those needs will be met. A local authority may use an assessment to create a care and support plan, while a homecare provider will carry out its own assessment when planning the care it provides.
- Who writes a care plan? – The organisation responsible for providing or arranging care will usually create the relevant care plan. This could be a local authority, NHS service or a private care provider, depending on the type of care and the person’s circumstances.
- Can I write my own care plan? – You can record information about the support you or your loved one needs, but a formal care plan may need to be created or reviewed by the relevant health or social care professionals. If you are arranging homecare privately, the care provider should explain its assessment and care planning process.
- How often should a care plan be updated? – A care plan should be reviewed when care needs, health or circumstances change and at appropriate intervals. Your care provider should explain how it reviews and updates care plans.
- Does everyone receiving homecare need a care plan? – A regulated homecare provider should have appropriate care planning arrangements in place for the people it supports. The exact format and content of the plan will depend on the provider and the individual’s needs.
Talk to Trinity Homecare about care planning
If you are unsure what type of care your loved one needs, a care assessment can be a useful starting point.
Trinity Homecare can discuss your circumstances, assess your loved one’s needs and explain what support could be appropriate at home.
Our friendly care team are available Monday to Friday, 8am to 6pm & Saturday, 10am to 4pm. You can call us on 0207 183 4884 or complete our online enquiry form and we will contact you very shortly.
