How to Write Person-Centred Care Plans That Satisfy CQC
A practical guide for Registered Managers and senior care staff
Care plans are not administrative paperwork. They are the living documents that describe how your service meets the individual needs of every person in your care. When CQC inspectors arrive, care plans are among the first things they examine because these documents reveal whether your service truly delivers person-centred care or simply claims to.
Under Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, providers must ensure that the care and treatment of service users is appropriate, meets their needs, and reflects their preferences. The care plan is your primary evidence of compliance with this regulation. It is the document that bridges the gap between what you say you do and what you actually do.
CQC inspectors assess care plans against the Key Lines of Enquiry under the Safe, Effective, Caring, Responsive, and Well-Led domains. They are looking for evidence that each care plan is written for a specific individual, not copied from a template. They check whether the plan reflects the person's current needs, whether it has been reviewed regularly, and whether the care being delivered on the ground matches what the plan describes.
Inspectors will cross-reference your care plans with daily records, speak to staff about the individuals they support, and ask the people themselves whether their care reflects their wishes. A care plan that sits in a folder gathering dust is worse than no care plan at all, because it demonstrates that your documentation is disconnected from your practice.
A task list tells staff what to do: give medication at 8am, assist with washing, prepare lunch. A genuine care plan explains who this person is, what matters to them, what their assessed needs are, what outcomes they want to achieve, and how your service will support them to achieve those outcomes. The task list is a schedule. The care plan is a strategy for delivering personalised care.
Many services fail inspections not because they deliver poor care, but because their care plans read like task lists. Staff may know Mrs Johnson prefers a shower over a bath, likes her tea strong with no sugar, and becomes anxious if her routine changes. But if the care plan says nothing more than "assist with personal care" and "prepare meals," the inspector has no evidence that this knowledge exists or is shared consistently across the team.
Generic care plans are the single most common reason services receive a Requires Improvement rating under the Responsive domain. If an inspector reads three care plans and they all use identical language, identical phrases, and identical structures with only the name changed at the top, that is an immediate red flag. It tells the inspector that your care planning process is a copy-and-paste exercise, not a genuine assessment of individual needs.
Generic care plans also create clinical risk. If the plan does not describe this specific person's mobility limitations, swallowing difficulties, communication preferences, or behavioural triggers, then staff who rely on the plan for guidance are working without the information they need to deliver safe care.
Care planning does not exist in a vacuum. It sits within a legal framework that defines what providers must do, what individuals are entitled to, and what happens when things go wrong. Understanding this framework is not optional. It is the foundation upon which every care plan is built.
The Care Act 2014 established the modern framework for adult social care in England. Section 9 requires local authorities to carry out a needs assessment for any adult who appears to have needs for care and support. Section 13 sets out the eligibility criteria based on whether the person has needs arising from a physical or mental impairment or illness, and whether those needs result in an inability to achieve two or more specified outcomes, leading to a significant impact on wellbeing.
For care providers, the Care Act means that every person you support has been through an assessment process that identified eligible needs. Your care plan must demonstrate how you are meeting those identified needs. It must align with the local authority care and support plan where one exists, and it must be reviewed whenever needs change.
Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 is the regulation most directly relevant to care planning. It requires that the care and treatment of service users must be appropriate, must meet their needs, and must reflect their preferences. The regulation specifically states that providers must carry out an assessment of needs and preferences, design care to meet those needs and preferences, and ensure that care is delivered in a way that enables the person to make decisions about their own care.
CQC uses Regulation 9 as its benchmark when inspecting care plans. A breach of Regulation 9 can result in a requirement notice, an enforcement action, or in serious cases a condition on your registration. The regulation does not prescribe a specific format for care plans, but it does require that whatever system you use results in person-centred, needs-led, preference-respecting care.
The Mental Capacity Act 2005 underpins every care planning decision. Its five statutory principles must be embedded in your practice: every adult is presumed to have capacity unless assessed otherwise; a person is not to be treated as unable to make a decision simply because they make an unwise decision; all practicable steps must be taken to help the person make their own decision; any decision made on behalf of someone who lacks capacity must be made in their best interests; and any intervention must be the least restrictive option.
In care planning terms, this means that the person must be involved in writing their own care plan wherever possible. If they lack capacity to make decisions about their care, you must carry out a decision-specific capacity assessment, record the assessment, and make a best interests decision involving all relevant parties. The care plan must document how capacity was assessed, what the outcome was, and how the person's wishes and feelings were considered.
The Human Rights Act 1998 incorporates the European Convention on Human Rights into domestic law. Article 8, the right to respect for private and family life, is particularly relevant to care planning. Care plans must demonstrate that the person's privacy, dignity, and autonomy are respected. This means documenting preferences about who delivers personal care, how the person wants to spend their time, and what level of risk they choose to accept in their daily life.
Article 14, the prohibition of discrimination, requires that care plans do not discriminate on grounds of age, disability, gender, race, religion, or sexual orientation. Care plans must actively consider and respect the person's cultural, religious, and spiritual needs, and must not impose a one-size-fits-all approach to care delivery.
Person-centred care is not a philosophical aspiration. It is a legal requirement with a specific meaning. Under the regulatory framework, person-centred means that care is based on an individual assessment, reflects the person's preferences and choices, enables the person to participate in decisions, treats the person with dignity and respect, and is responsive to changes in needs. When CQC assesses whether your service is person-centred, they are applying a legal standard, not a subjective opinion. Your care plans are your primary evidence of meeting that standard.
A care plan is only as good as the assessment that informs it. Before you write a single word of the care plan, you must have a thorough, holistic assessment of the person's needs. This is not a tick-box exercise. It is a skilled process of gathering information, building a picture of the whole person, and identifying what support they need to live the life they choose.
A comprehensive needs assessment examines every dimension of the person's life, not just their medical conditions or physical limitations. It must cover the following areas:
Physical needs: Mobility, personal care, continence, nutrition and hydration, skin integrity, pain management, sensory impairment, sleep patterns, and any diagnosed medical conditions that affect daily living. Be specific. "Mobility issues" is not an assessment. "Mrs Garcia uses a wheeled Zimmer frame for all indoor mobility, can stand independently for up to two minutes, requires one-person assistance for transfers, and is at high risk of falls due to postural hypotension" is an assessment.
Cognitive needs: Memory, orientation, decision-making ability, understanding of risk, any diagnosed cognitive impairment such as dementia or acquired brain injury, and the impact of cognitive changes on daily living. Include the person's good days and difficult days, what time of day they function best, and what environmental factors help or hinder their cognitive function.
Emotional and psychological needs: Mental health conditions, anxiety triggers, mood patterns, coping strategies, bereavement and loss, loneliness and isolation, self-esteem, and the emotional impact of receiving care. Many people experience a grief reaction when they begin receiving care services because it represents a loss of independence. Your assessment should recognise and address this.
Social needs: Relationships with family, friends, and community. Social activities, hobbies, interests. Roles the person holds or held that are important to their identity, such as parent, grandparent, volunteer, member of a faith community. Barriers to social participation and what support would help maintain connections.
Cultural and spiritual needs: Religious beliefs and practices, dietary requirements linked to faith or culture, festivals and observances, language preferences, cultural norms around personal care and family involvement, end-of-life wishes linked to faith. These are not optional extras. They are fundamental to person-centred care and are specifically examined by CQC under the Caring domain.
Communication needs: How the person communicates, any barriers to communication such as hearing loss, visual impairment, aphasia, or English as a second language. What aids or approaches support communication, such as hearing aids, large print, pictures, Makaton, interpreters, or communication passports. How the person expresses pain, distress, or preferences when verbal communication is limited.
The person must be at the centre of their own assessment. This means conducting the assessment at a time and place that suits them, using communication methods they can engage with, going at their pace, and checking understanding throughout. Ask open questions. Listen more than you speak. Use the person's own words when recording the assessment.
Family members, friends, and advocates can provide invaluable context, particularly about the person's history, personality, preferences, and routines. However, the person's own voice must come first. Where the person and their family disagree, record both perspectives and explain in the care plan how the conflict was resolved. Always document who was involved in the assessment and what their relationship to the person is.
If there is reason to believe the person may lack capacity to participate in the assessment or to make decisions about their care, you must carry out a decision-specific capacity assessment before proceeding. Follow the two-stage test under the Mental Capacity Act: does the person have an impairment of the mind or brain, and does that impairment mean they are unable to make the specific decision at the specific time?
If the person lacks capacity for a specific decision, you must make a best interests decision. This involves consulting the person as far as possible, considering their past and present wishes, consulting family members, carers, and any appointed representative such as an attorney under a Lasting Power of Attorney or a court-appointed deputy. Document every step. Record who was consulted, what their views were, and how the final decision was reached.
A thorough assessment draws on multiple sources: the person themselves, their family and friends, the local authority care and support plan, hospital discharge summaries, GP records and referral letters, previous care provider records, allied health professional assessments such as occupational therapy or physiotherapy reports, and the observations of staff who deliver care. Cross-reference information from different sources and resolve any discrepancies before writing the care plan.
Every care plan, regardless of format, must contain these seven elements. Miss any one of them and your care plan is incomplete. An incomplete care plan is a compliance risk, a clinical risk, and an inspection risk.
The personal profile is the first thing anyone reading the care plan should see. It tells the reader who this person is as a human being, not just as a recipient of care. It should include the person's preferred name, their background and life history, their personality, their likes and dislikes, what matters most to them, and what a good day looks like for them.
This is not a luxury. It is essential context for every member of staff who delivers care. A care worker who knows that Mr Ahmed was a civil engineer, is passionate about cricket, takes pride in his appearance, and misses his wife who died three years ago will deliver fundamentally different care from one who only knows that Mr Ahmed needs help with washing and dressing.
Example: "James prefers to be called Jim. He is 82 years old and has lived in Wolverhampton his whole life. He worked as a toolmaker at the Goodyear factory for 38 years and is proud of his working-class roots. Jim is a lifelong Wolverhampton Wanderers supporter and watches every match on television. He has two daughters, Karen and Dawn, who visit on Wednesdays and Sundays. Jim likes his routines and becomes anxious when things change without warning. He enjoys a cooked breakfast, reads the Express and Star every day, and listens to Radio 2 in the afternoons. Jim describes himself as a private man and prefers male carers for personal care."
Each identified need must be documented clearly and specifically. Vague language like "mobility problems" or "requires assistance with personal care" tells staff nothing useful. The care plan must describe the specific nature of the need, the level of support required, any equipment involved, and any factors that affect the need such as time of day, medication effects, or environmental conditions.
Example: "Jim has osteoarthritis in both knees and his left hip, which significantly affects his mobility, particularly first thing in the morning when stiffness is worst. He uses a wheeled Zimmer frame for indoor mobility and can walk approximately 15 metres before needing to rest. He requires one-person physical assistance for transfers from bed to chair and chair to standing. His mobility improves after his morning medication (Naproxen 500mg taken at 8am) takes effect, usually by approximately 9:30am. Jim is at high risk of falls, scoring 14 on the Waterlow scale. He has a call bell within reach at all times."
Outcomes are what the person wants to get from their care, not what the service wants to deliver. They should be expressed in the person's own words wherever possible, and they should be meaningful, realistic, and measurable. Each outcome should link directly to an assessed need and describe what success looks like.
Example: "Jim says: 'I want to stay living in my own home for as long as I can. I want to be able to get to the bathroom on my own without falling. I want to keep watching the Wolves and having my daughters round for tea. I don't want strangers fussing over me - I want to know who's coming and when.' These outcomes guide everything we do. Our care plan is designed to support Jim's independence, maintain his safety, protect his routines, and ensure continuity of carers wherever possible."
This is the operational heart of the care plan. For each assessed need, the plan must describe exactly what staff will do, how they will do it, when they will do it, and who is responsible. This section should be detailed enough that a new member of staff could read it and deliver safe, person-centred care without needing to ask someone else what to do.
Example: "Morning personal care (visit 1, approximately 8:00am): The care worker will knock and wait for Jim to respond before entering. Jim sleeps in the downstairs bedroom. The care worker will assist Jim to sit up on the edge of the bed and allow two minutes for his blood pressure to stabilise before standing (postural hypotension). The care worker will hand Jim his Zimmer frame and walk beside him to the bathroom. Jim washes his own face and upper body at the sink. The care worker provides standby assistance only for this. Jim requires physical assistance to wash his lower legs and feet and to dry his back. Jim chooses his own clothes. The care worker assists with socks and shoes as Jim cannot bend to reach his feet. Jim shaves himself using an electric razor. Total visit time approximately 45 minutes."
Risk assessments must not exist as separate, disconnected documents. Each risk identified in the assessment must be linked to a specific risk assessment, and the risk management strategies must be reflected in the care plan. If the falls risk assessment says the person needs a sensor mat at night, the care plan must reference the sensor mat and explain how staff should respond when it activates.
Example: "Jim's falls risk assessment (reviewed 15 January 2026, score: High) identifies the following risk factors: osteoarthritis affecting balance and mobility, postural hypotension causing dizziness on standing, night-time visits to the bathroom, and uneven threshold between kitchen and conservatory. Risk management: Zimmer frame accessible at all times, two-minute seated pause before standing from any position, night light installed on landing and in bathroom, threshold ramp fitted between kitchen and conservatory. Staff must record any near-misses or changes in mobility in the daily notes and report immediately to the senior carer."
The care plan must record how consent was obtained for the care described. If the person has capacity, the plan should state that they have read or had the plan read to them, that they agree with its contents, and that they understand they can withdraw consent at any time. If the person lacks capacity for specific decisions, the plan must reference the capacity assessment and the best interests decision, and explain how the person's wishes and feelings were taken into account.
Example: "Jim has full mental capacity and has been actively involved in writing this care plan. He has read the plan, discussed it with his daughter Karen, and agreed to its contents. Jim has signed the consent form dated 10 January 2026. Jim understands that he can change his mind about any aspect of his care at any time and that we will update the plan accordingly. Jim has expressed a preference not to have a Lasting Power of Attorney at this time. His next of kin for emergency contact purposes is Karen Williams (daughter), telephone 01902 XXXXXX."
Every care plan must state when it will next be reviewed, who is responsible for the review, who will be invited to participate, and what events would trigger an earlier review. Reviews must be genuine reassessments, not rubber-stamping exercises. The review record should note what has changed, what is working well, what needs to change, and whether the person's outcomes are being met.
Example: "This care plan will be formally reviewed on 10 April 2026 (three months from the date of writing). The review will be led by Sarah Thompson, Senior Care Coordinator. Jim and his daughter Karen will be invited to participate. An earlier review will be triggered by any of the following: a fall or near-miss, hospital admission or discharge, a significant change in Jim's health or mobility, a change in medication, a safeguarding concern, or a request from Jim or his family. All reviews will be documented and the updated care plan signed by Jim and the reviewing officer."
The language you use in a care plan matters more than most managers realise. Institutional, clinical language dehumanises the person and distances staff from the individual they are supporting. Person-centred language keeps the person at the centre of their own story and reminds staff that they are supporting a human being with preferences, opinions, and a life beyond their care needs.
The simplest test is this: would the person recognise themselves in this care plan? Would they feel respected by how they are described? If the answer is no, the language needs to change.
The following examples show the difference between institutional task-focused language and person-centred language that captures the individual.
Risk assessment is inseparable from care planning. Every identified need carries some degree of risk, and every risk must be managed through the care plan. The goal is not to eliminate risk, which would mean eliminating choice and independence, but to identify risk, assess it proportionately, and manage it in a way that respects the person's autonomy while keeping them safe.
Risk assessments must be living documents that feed directly into the care plan. The risk assessment identifies the hazard, evaluates the likelihood and severity of harm, and specifies the control measures. The care plan then incorporates those control measures into the practical delivery of care. If there is a disconnect between the risk assessment and the care plan, neither document is doing its job. For example, if the falls risk assessment recommends that the person should use a walking frame for all indoor mobility, but the care plan does not mention the walking frame, there is a gap that could lead to harm.
Falls: Falls are the most common serious incident in adult social care. Your risk assessment should consider intrinsic factors such as balance, gait, vision, medication side effects, and cognitive impairment, as well as extrinsic factors such as footwear, flooring, lighting, clutter, and equipment. The care plan should specify what equipment is used, how transfers are carried out, what environmental modifications are in place, and what staff should do if a fall occurs. Post-fall protocols should include neurological observations where appropriate, notification of GP or paramedics, documentation, and incident reporting.
Pressure ulcers: Pressure ulcers are preventable with good care planning. Use a validated tool such as the Waterlow or Braden scale to assess risk. The care plan should specify repositioning schedules, skin inspection frequency, the use of pressure-relieving equipment such as mattresses and cushions, nutritional support to promote skin integrity, and what to do if skin changes are observed. Record the current condition of the skin at each assessment and review.
Medication errors: Medication risk includes wrong dose, wrong time, missed dose, wrong person, wrong route, and adverse reactions. The care plan should describe the person's medication regime, any specific administration requirements such as crushing tablets or taking medication with food, what PRN medication is prescribed and when it should be given, and how medication competency is maintained among staff. Controlled drugs require additional safeguards including double-signing, locked storage, and register reconciliation.
Nutrition and hydration: Malnutrition and dehydration are significant risks, particularly for older people and those with swallowing difficulties. The care plan should describe the person's dietary needs and preferences, any modified diet such as soft, pureed, or thickened fluids, the level of assistance required at mealtimes, food and fluid intake monitoring where required, and referral triggers for dietetic or speech and language therapy input. Use a validated screening tool such as MUST to assess nutritional risk.
Moving and handling: Every person who requires physical assistance with mobility, transfers, or repositioning must have a moving and handling risk assessment. The care plan should specify the level of assistance required for each type of movement, the equipment to be used, the number of staff required, the technique to be used, and any contraindications or precautions. This section must be consistent with the person's moving and handling assessment carried out by a qualified assessor.
Person-centred care requires a positive approach to risk. This means supporting people to take risks that are important to them, rather than restricting their lives in the name of safety. If a person wants to walk to the local shop despite being at risk of falls, the care plan should document the risk, describe the control measures, record the person's informed decision, and explain how staff should support the activity rather than prevent it. CQC specifically looks for evidence that services balance safety with autonomy and do not adopt an overly risk-averse culture.
When a person makes a decision that involves risk, the care plan should document the risk assessment that was carried out, the information provided to the person about the risk, the person's understanding of the risk and their informed decision, the control measures in place to reduce the risk as far as reasonably practicable, and the review date. This is not about creating a paper trail to protect the service. It is about demonstrating that you support people to live the life they choose while managing risk responsibly. Positive risk-taking must be an active, documented process, not an absence of risk assessment.
Mental capacity is one of the most frequently misunderstood areas in social care and one of the areas where CQC most commonly identifies failings. Getting it right is essential for lawful, ethical care planning.
A capacity assessment must be carried out whenever there is reason to believe that a person may lack the capacity to make a specific decision. This might be triggered by a diagnosis of dementia, a learning disability, a brain injury, a mental health condition, or any other impairment of the mind or brain. The trigger is not the diagnosis itself but rather an observed difficulty in making a specific decision at a specific time.
Common triggers in care planning include decisions about whether to accept care services, whether to take prescribed medication, whether to move to a different type of accommodation, whether to accept restrictions on their freedom for safety reasons, and whether to agree to specific interventions such as PEG feeding or catheterisation. Do not assess capacity routinely or as a blanket exercise. Assess only when there is a specific decision to be made and a reason to question the person's ability to make it.
The capacity assessment must be recorded in writing and should include the specific decision that needs to be made, the reason for questioning the person's capacity, the steps taken to support the person to make the decision themselves including the use of communication aids, simple language, familiar settings, and optimal timing, the two-stage test findings including whether the person can understand the relevant information, retain it, use or weigh it, and communicate their decision, the conclusion as to whether the person has or lacks capacity for this specific decision, and the name and role of the person carrying out the assessment.
If the person lacks capacity for a specific decision, a best interests decision must be made. This is not a decision made by the service alone. It must involve the person as far as possible, their family or friends, any attorney appointed under a Lasting Power of Attorney, any court-appointed deputy, and an Independent Mental Capacity Advocate where required. The best interests decision must consider the person's past and present wishes and feelings, their beliefs and values, and any other factors they would consider if they had capacity. The decision must be the least restrictive option that achieves the desired outcome.
An advance decision to refuse treatment is legally binding if it is valid and applicable to the circumstances. If a person has made an advance decision, the care plan must reference it and explain how it affects the delivery of care. A Lasting Power of Attorney for Health and Welfare gives the attorney the power to make decisions about the person's care when they lack capacity. The care plan must identify any attorneys, state what powers they hold, and describe how they are consulted when decisions need to be made. Obtain and file a copy of the LPA document and check that it has been registered with the Office of the Public Guardian.
A person with capacity has the absolute right to refuse care, even if the refusal seems unwise or puts them at risk. The care plan must document the refusal, the information provided to the person about the consequences of refusal, the person's understanding of those consequences, any alternative support offered, and the ongoing plan for review. If the person lacks capacity and is refusing care, this is a more complex situation requiring a best interests assessment. Staff should never force care on anyone. If a person is consistently refusing care, this should trigger a care plan review involving the person, their family, and relevant professionals.
A care plan that is not reviewed is a care plan that is out of date. People's needs change, sometimes gradually and sometimes suddenly. The care plan must be a living document that evolves with the person, not a static record that becomes increasingly disconnected from reality.
As a minimum, every care plan should be formally reviewed at least every three months for complex or changing needs, and at least every six months for stable needs. However, these are minimum frequencies, not targets. Many individuals will need more frequent reviews, and the care plan should specify the review frequency based on the individual's circumstances. CQC expects to see a review schedule that is proportionate to the person's needs and that reviews actually happen when they are due.
In addition to scheduled reviews, certain events must trigger an immediate review of the care plan. These include:
Hospital discharge: The person may return with changed needs, new medication, new equipment, or new restrictions. The care plan must be updated before care resumes to reflect the current situation. Request and review the hospital discharge summary before the first visit.
A fall or serious incident: Any fall, whether or not it results in injury, should trigger a review of the care plan and associated risk assessments. Look at what happened, whether the existing control measures were followed and whether they were adequate, and what needs to change.
Change in condition: Any noticeable change in the person's physical health, cognitive function, emotional wellbeing, or behaviour should trigger a review. This includes gradual changes such as increasing confusion or weight loss, not just sudden events.
Medication change: New medication or a change in dose can affect the person's needs, their risk profile, and the care they require. Review the care plan whenever medication changes, paying particular attention to side effects that may affect mobility, cognition, continence, or mood.
Safeguarding concern: Any safeguarding concern relating to the person must trigger a review of the care plan to assess whether the current plan adequately protects them and whether any changes are needed.
Family request: If the person or their family request a review, it should be arranged promptly. Families often notice changes that staff may not, particularly if care workers rotate frequently.
When a care plan is reviewed and changes are made, the review record should document what was reviewed, who was involved in the review, what has changed since the last review, what is working well and should continue, what is not working and needs to change, the specific changes made to the care plan, and the date of the next scheduled review. Do not simply overwrite the old care plan. Keep a record of previous versions so that there is a clear audit trail showing how the plan has evolved over time.
Every care plan should have a version number or date, and all previous versions should be retained on file. This is important for two reasons. First, it provides an audit trail that demonstrates the care plan is regularly reviewed and updated. Second, it allows anyone investigating an incident to see what the care plan said at the time the incident occurred, not what it says now. CQC inspectors will check for version control and will note its absence.
The reviewed care plan should be signed by the person responsible for the review, the service user if they have capacity and are willing, and a senior member of staff or the Registered Manager. If the service user lacks capacity to sign, the plan should be signed by their representative such as an attorney or family member, and this should be recorded with a note explaining why the service user did not sign. All signatures should be dated.
These are the ten mistakes that most frequently lead to CQC findings of non-compliance with Regulation 9. For each mistake, we show what the wrong version looks like and what the correct version looks like. Use these examples to audit your own care plans.
Use this audit checklist to review each care plan in your service. Complete one checklist per service user. Score each item as Yes, No, or Partially. Total your score using the guide below and take action on any gaps identified.
| # | Audit Question | Yes | No | Partial |
|---|---|---|---|---|
| 1 | Does the care plan include a personal profile that describes who the person is, their background, personality, and preferences? | |||
| 2 | Is the care plan written in person-centred language using the person's preferred name and reflecting their own words? | |||
| 3 | Does the care plan describe specific, assessed needs rather than vague or generic statements? | |||
| 4 | Are desired outcomes recorded in the person's own words, describing what they want to achieve? | |||
| 5 | Does the care plan describe exactly how each need will be met, including specific tasks, timings, and responsibilities? | |||
| 6 | Are risk assessments in place for all identified risks, and are they linked directly to the care plan? | |||
| 7 | Is there documented evidence that the person (or their representative) consented to the care plan? | |||
| 8 | If the person may lack capacity, has a decision-specific capacity assessment been completed and recorded? | |||
| 9 | Does the care plan include cultural, religious, and spiritual needs and preferences? | |||
| 10 | Are communication needs assessed and documented, including how the person expresses pain or distress? | |||
| 11 | Is there evidence that the person and their family were involved in writing the care plan? | |||
| 12 | Does the care plan include a review date that is proportionate to the person's needs? | |||
| 13 | Has the care plan been reviewed on or before the scheduled review date? | |||
| 14 | Is there documented evidence of what was discussed and decided at the most recent review? | |||
| 15 | Are daily care records consistent with what the care plan says should be happening? | |||
| 16 | Does the care plan reflect any recent changes in the person's condition, medication, or circumstances? | |||
| 17 | Is there version control showing the history of changes to the care plan over time? | |||
| 18 | Are the care plan and associated risk assessments signed and dated by the appropriate people? | |||
| 19 | Would a new member of staff be able to deliver safe, person-centred care using only this care plan as a guide? | |||
| 20 | Does the care plan reflect this specific person, or could it belong to anyone? |
Score each "Yes" as 1 point, each "Partially" as 0.5 points, and each "No" as 0 points. Total your score out of 20.