How to Write a Care Plan
Creating a well-structured care plan is essential for delivering person-centred care that meets the unique needs of each individual. Whether you’re a care provider or support worker, understanding how to write an effective care plan is crucial for ensuring holistic, coordinated care.
What is a Care Plan?
A care plan is a detailed document that outlines an individual's care needs, goals, and preferences, ensuring that everyone involved in their care is on the same page. It promotes collaboration among healthcare providers, carers, and the individual themselves.
How to Write a Care Plan
Step 1: Initial Assessment
Start by gathering essential details during the initial assessment. This forms the foundation of the care plan. Essential details include:
Personal Details – Basic information about the individual.
Health and Well-being Goals – Include aspirations and desired outcomes.
Self-Care and Support – Address the level of self-care the person can manage and any additional support needed.
Medical Information – Include test results, diagnoses, medication details, and clinical notes. Collaborate with GPs or request discharge notes for accurate details.
Care Preferences – Document the individual’s preferences to ensure person-centred care.
Step 2: Use a Template
Take all the information from your initial assessment and start writing that up into a simple care plan template. You can find a number of free care plan templates online, or you may choose to create your own custom care plan templates that are tailored to the type of care your business provides.
Tip: The format of your care plan depends on the type of care you provide. For example, domiciliary care may require different versions for morning and evening care.
Step 3: Consult with Others
To gain a comprehensive understanding, consult with the client, their family, previous carers, GPs, and support workers. This helps you to paint a fuller picture of who you are caring for and how they liked to be cared for.
Step 4: Finalise and Store Securely
Once completed, store the care plan in a safe and secure location for staff to access. Digital care plans are preferred by the CQC as they are easier to update and securely store.
Making Your Care Plan Person-Centred
Writing a person-centered care plan is essential to delivering person-centred care, which puts the individual at the heart of their care.
“The most important thing to remember is that the care plan is unique to the person. It is so important to ensuring you deliver person-centred care. At the end of the day, person-centred care starts with a person-centred care plan.”
The Health Foundation outlines four principles of person-centred care:
Dignity, Compassion, and Respect – Treat the person with kindness and consideration.
Coordinated Care and Support – Ensure seamless communication between all parties involved in the care.
Personalised Care and Support – Tailor care to the individual’s unique needs and preferences.
Empowering Independence – Help individuals recognise and develop their own strengths to live an independent, fulfilling life.
Good vs. Poor Examples of Care Plans
To ensure your care plan is truly person-centred, it’s important to be specific and detailed.
Here’s an example:
Poor Example:
“John has limited mobility.”
Good Example:
“John has limited mobility following his hip operation. He should always have access to his walker, which he prefers to use over his walking stick.”
The good example provides context, specific needs, and personal preferences, ensuring that care is tailored to John’s situation.
Tips for Writing Effective Care Plans
Include Everyone’s Input: Ensure that everyone involved in the person’s care has a say, including the individual themselves.
Secure Storage: Store care plans securely to maintain confidentiality. Digital care plans are recommended for easier updates and safe storage.
Avoid Using AI: Do not use AI writing tools like ChatGPT to write your care plans, as this may result in a GDPR breach by exposing personal data.
Need Help Writing a Care Plan?
At Affinity Care Advisory, we understand the importance of creating person-centred care plans that comply with CQC guidelines.
Book a free 15-minute consultation today and discover how we can help you write effective and compliant care plans for your service.
