Personalised Care Plans - what are they and why are they important?

Personalised care plans are one of the most important resources for providing good care.

At Cera, we believe that remaining at home is important. Most people want to avoid hospital visits or moves to care homes. Personalised care plans can enable someone to be as independent and healthy as possible.

They’re a way of taking note of decisions, desired outcomes and conversations about a person’s health and support needs.

And it’s not just about physical health! Personal care plans will take other needs into account too, allowing the care team to support people in social and community settings as well as their own home.

What’s included in a care plan?

The aim of a personal care plan is to help the person live a better life. Being able to meet their needs and wishes is key – so a care plan is as individual as each person is.

We know that life doesn’t stop just because someone has a medical condition or needs a little extra support. So when writing the care plan, the discussion will include what’s important to the person, as well as any support that’s needed to manage their health. What’s involved in making sure that their life is good for them?

Personal care and social needs can both be included in a personalised care plan.

A care plan will be outcome-focused. So to write this plan, the team will talk with the person about their hopes and wishes. What are their desired outcomes, and how can the care team support them to achieve these?

Depending on the person’s needs and situation, a care plan might include:

• Health conditions and diagnoses
• Medication information
• Information about any treatment the client receives
• Care and support needs, such as information about mobility, continence and feeding
• Dietary requirements
• Any issues faced with communication
• Support needed with social activities, such as going to clubs or day centres
• Information about things that might matter to them, such as hobbies or interests
• Personal information such as who lives with them, religious preferences and daily routine
• End of life wishes
  
  

Who is involved in personalised care plans?

Putting together a personalised care plan should be an inclusive process. So the client should always be involved. They should be able to agree what is included, and discuss what matters to them.

They may also choose for someone else to be included – maybe that’s their son or daughter, a friend, a neighbour or someone else. Sometimes people feel comfortable having someone else involved to help them talk about difficult topics, or they may have memory or speech difficulties which mean they want a little extra help.

Depending on the person’s needs, healthcare professionals like GPs and district nurses might be involved. For some people with complex needs, multidisciplinary teams might be part of the conversation. These are groups of professionals with expertise in different areas, such as physiotherapists, social workers and pharmacists, who work together to ensure a client gets the support and care they need.

If the person’s care is funded by the local authority, they will be involved from the start. They pass on a basic care plan to Cera, and our team will visit for a more thorough care assessment. We’ll put together a comprehensive personal care plan, and agree it with the client.

Personalised care and support plans should be reviewed regularly. If the client’s situation changes, different people may need to be involved at different times.

Why is personalised care important?

Having the right care for you plays a huge part in avoiding the need to leave home, whether that's to go to hospital unnecessarily, or to move to residential care. We want to ensure that people are supported to live longer and healthier lives in their own homes.

Carers are your peace of mind. Whether you’re a client or a loved one, it can feel daunting having a new person coming into your home and providing support.

A personal care plan will help establish consistency and continuity. The client will know what to expect and when, and will be able to get to know their regular carer. Establishing a rapport between client and carer makes a huge difference, especially for people who live alone or are isolated.

Care plans are about outcomes, but they’re also about the process. The plan tells the care team how to deliver care, and can act as a reminder of the person’s own wishes.

Care plans ensure that care teams are meeting their clients’ needs and wishes. For people who might have difficulties with speech or memory, a written record can provide huge peace of mind, as well as being helpful for any new carers. It’s an introduction to the whole person, not just their health or support needs.