Health carePublic Health

Creating an effective care plan: The ultimate guide

3 Mins read

The care industry has been under huge scrutiny in the media in recent months. Care providers have had to make huge adaptations to the way they run their services. Social distancing measures along with visitor bans have taken their toll on both those who use the services and those who provide them.

One thing that remains the same though is the care plan. A care plan is an essential element of organising the services and support available to the client or patient and tailoring the offering to their individual needs.

An effective care plan will outline the type of support an individual needs and how this support will be given.

In recent years, there has been a move more towards person-centred care plans which focus on providing plans with the end-user in mind, prioritising their needs rather than focusing first on what is easiest for the care providers.

So, what is it that providers need to think about when putting together a care plan?

How to get a care plan

The first thing to do is to organise a needs assessment for the individual. To do this, you will need to contact social services to apply.

This is an essential step in the process because, without the assessment, the council will not be able to recommend the services needed for the individual. This could include recommendations for specialist equipment such as walking frames or how many times a day carers should visit.

Formulating a care plan

Once the needs assessment has been carried out, social services will means test the recipient to see how much of the care the council will pay for. They will then write up the outcome of their assessment in the form of a care plan. Care providers can then use this plan to structure their own plan for their services.

What to include

Ultimately the care plan should describe:

  • the needs of the person
  • their preferences and choices
  • what resources are available
  • an outline of actions by members of the care team.

The service user should be an integral part of the process of compiling the care plan and each aspect of it should be agreed with them. The practicalities of providing care must at least cover each of these areas:

  • Nutritional needs and allergies.
  • Health problems – monitoring and medication.
  • Personal hygiene needs.
  • Times when the care is required.

The care plan should also allow for crisis and contingency planning in case of emergency.

How to gather the right information

Care providers might begin the process of care planning with their own ideas about what should be in the care plan and how it should be implemented.

It is important though, to put our own views to one side, to begin with, and treat the process more holistically. We need to ensure that we:

  • listen to the views of all concerned – this includes the service user, their family and carers, and any professionals involved in their care
  • take care to outline mutual expectations between the service providers and the user
  • carry out a meticulous and systematic review of the person’s needs
  • explore and discuss all choices in order to find out what is important and what the implications are of the different options
  • set goals and timescales for what is to be achieved
  • be aware of questions of health and safety
  • be aware of MCA-compliance, especially for cases in which individuals may lack capacity
  • offer support to the individual in terms of managing their own health as far as they possibly can.


As the needs of individuals change over time, the care plan should be a working document that is regularly reviewed.

The first review should happen soon after the care plan is first implemented and then on a regular basis – at least once a year – after that. This is a minimum though, and the service user can request a review of the care plan at any time. If there is a sudden or marked change in circumstances, adult social services should be contacted for a review.

There is a lot to consider when developing care plans for all service users. Care management systems, like those at uRoster, can help co-ordinate care efficiently, allowing providers to record notes and accurately keep track of their clients’ needs while also enabling them to evidence outstanding care. A well-written and considered care plan is central to providing the best quality of life to some of society’s most vulnerable people.

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