How to write a person-centred care plan, section by section

To write a person-centred care plan, start with the person rather than the paperwork: who they are, what matters to them and how they want to be supported. Then work through each area of their life, and for each one write down what it looks like for this person, what they want, and exactly what staff do. Use their words, keep it in plain English, record capacity decision by decision, set goals the person chose, and review it against what actually happens. This guide takes that process section by section.

The short answer

A care plan is the written agreement between a person and the service about how they will be supported. A person-centred one is written with the person, describes them as an individual, and tells staff what to do in enough detail that someone on their first shift could follow it. The care planning cycle is assess, plan, implement, review, and it never stops. What should be included in a care plan is every area of the person's life where support is given or a risk exists, with the person's preferences, the staff actions, the capacity position and the goal for each. What makes a good care plan is not the template but the wording: specific, present tense, in the person's voice, and true. The rest of this article shows how to get there.

What is a care plan and what is it for?

A care plan does three jobs. It tells staff how to support the person. It records what the person and the service agreed. And it is the evidence, for inspectors, commissioners and families, that support is planned and delivered around the person rather than around the building.

In England the Care Act 2014 requires the local authority to produce a care and support plan for anyone whose needs it meets. The care home's plan is a different document: it is the provider's own record of how it delivers the care it has been commissioned to deliver. Regulation 9 of the Health and Social Care Act 2008 regulations, person-centred care, requires providers to assess needs and preferences, design care to meet them, and involve the person. The CQC single assessment framework tests that under the responsive and caring key questions.

What the care plan is not is a list of tasks, a risk register, or a form to be completed at admission and filed. Where it becomes one of those, the care becomes generic and the evidence becomes hollow.

At a glance: what makes a good care plan

The care planning cycle

The cycle is assess, plan, implement, review. It sounds academic but it describes what actually happens when care planning works. You find out about the person. You agree with them what support looks like. Staff deliver it and record what happened. You compare what happened with what was planned, and change the plan.

Where it breaks is usually between implement and review. The plan is written, the daily log is written, and nobody puts them side by side. The plan says two baths a week and the log shows one in the last month. The plan says the person enjoys the garden and the log shows they have not been out since March. A review that looks only at the plan will miss both. A review that reads the log first will find them in minutes.

The other break is at assess. A plan written from the pre-admission assessment alone, before the person has lived in the home for a week, will be wrong in a dozen small ways. Treat the first plan as a draft and rewrite it properly at four weeks.

Before you write: the pre-admission assessment

The assessment is where the plan comes from. Do it with the person, in the place they are living now, with the people who know them. Read the local authority assessment and the care and support plan, the hospital discharge summary, the GP summary, and any existing plans from the previous service. Ask the person what a good day looks like and what a bad day looks like. Ask what they are worried about in moving. Ask what they want to keep doing.

Record what you find under the same headings the care plan will use, so the assessment and the plan line up. Note where information is missing rather than guessing. Record the capacity position for the decision to move, and if the person lacks capacity for that decision, who made it and on what basis.

The assessment also tells you whether you can meet the person's needs. That is a decision the manager makes before admission, not after, and it should be recorded.

Who writes the plan and who is involved

The keyworker or named nurse usually writes the plan, with the manager or deputy signing it off. The person is involved throughout, in whatever way works for them: sitting with the writer, reviewing an easy-read version, or through an advocate. Family are involved with the person's agreement, and for someone who lacks capacity, family and others who know the person are consulted as part of best interests decisions.

Professionals contribute their pieces: the GP on health, the pharmacist on medicines, the speech and language therapist on communication and swallowing, the physiotherapist on mobility, the community learning disability or mental health team on behaviour and risk. Their reports are referenced, not copied. The plan says what the physio recommended and where the report is.

Every plan records who was involved and when. An inspector will ask the person whether they were involved in their plan, and the answer needs to match the record.

Section 1: about me and what matters

Write this first and write it in the person's voice. It covers who they are, what they want to be called, their history in a few lines, what they enjoy, what they dislike, who is important to them, what they are good at, what they want for the future, and the one thing they most want staff to know. Keep it to a page. Nothing clinical goes here.

This section is what stops the rest of the plan being a list of needs. When a worker reads that Joan was a school cook for thirty years and cannot stand to see food wasted, they understand why she gets upset when plates are cleared before she has finished. The section does more work than any other, and it is the one most often left blank or filled with a diagnosis.

Section 2: communication

How does the person communicate, understand, and make choices? Speech, hearing, sight, language, signs, symbols, objects of reference, behaviour. What helps: short sentences, time to answer, a hearing aid that is checked daily, glasses, a particular position, a quiet room. What gets in the way. How the person says yes and no, and how they show pain, distress and pleasure when they cannot say. If a speech and language therapist has assessed, what they recommended.

This section is the foundation for consent and capacity. If the plan does not say how the person communicates a decision, no assessment of capacity is credible.

Section 3: health and conditions

List the diagnoses and, for each, what it means for this person day to day, what to watch for, and what to do. Epilepsy: seizure type, frequency, triggers, emergency protocol, rescue medicine. Diabetes: type, monitoring, targets, hypo signs and treatment. Dementia: type, stage, what the person can still do, what has changed recently. Include allergies, the GP and other professionals involved, the date of the last annual health check, and any hospital passport.

Record the health monitoring the plan requires: weight monthly, blood pressure weekly, blood sugar before meals, whatever the condition needs, and where it is recorded. A health monitoring record that scores MUST and BMI automatically from the weights saves the arithmetic and the transcription error.

Section 4: medication

What the person takes, why, and how they like to take it. Whether they manage any of it themselves and the risk assessment for that. Capacity for decisions about each medicine where it differs. Any PRN medicines and their protocols. Any covert administration and the best interests decision behind it. What to do on refusal. Who the pharmacy and GP are.

Do not copy the MAR chart into the plan; reference it. The plan describes the person's relationship with their medicines. The MAR records what was given.

Preferences belong here as much as anywhere. Some people want their tablets one at a time with water; some want them all together in a spoon of yoghurt; some want to be told what each one is for every morning. Some have a strong view about a medicine they dislike and a history that explains it. Write that down, because it is what turns a refusal on the chart into something a worker can understand and respond to rather than simply record.

Section 5: eating and drinking

What the person likes, dislikes, and needs. Any texture modification with the IDDSI level and the speech and language assessment behind it. Any allergy or intolerance. Cultural or religious requirements. Where, when and with whom they like to eat. What help they need and what they do themselves. Current weight, BMI and MUST score, the weighing schedule, and what happens if the score rises. Fluid needs and how they are monitored.

Preferences here matter more than anywhere. A person who is losing weight because the food is not what they like is a care planning failure, not a clinical one.

Section 6: personal care and dignity

What the person can do and what they need help with, in order: washing, dressing, oral care, hair, shaving, nails, toileting. Preferences: bath or shower, morning or evening, gender of carer, how they like to be spoken to, what they want left private. Products they use. Anything that causes distress and how to avoid it. How dignity is protected: doors closed, covered, explained.

Write it as a sequence a new worker could follow. Assist with personal care tells them nothing. Joan washes her face and hands at the sink, needs help with her back and feet, likes the water hot, and wants the radio on, tells them everything.

Section 7: mobility and falls

How the person moves: independently, with a frame, with one or two staff, with a hoist. The manual handling assessment and the equipment. Falls history, the scored falls risk assessment, what makes falls more likely for this person, and what reduces the risk. What the person gains from moving and what they want to keep doing. Footwear, glasses, lighting, the call bell. Any physiotherapy input and exercises.

Falls are the commonest serious incident in care homes and the plan is where prevention lives. The post-fall process, including the check for injury, the incident record and the review of the assessment, belongs in the plan too, so that staff know what to do before it happens.

Section 8: skin integrity

The Waterlow or equivalent pressure risk score, the date, and what it means for this person. Current skin condition, with a body map. Repositioning schedule if needed, pressure-relieving equipment, moisture and continence management, nutrition. What to look for and what to do if a red area appears. Who to refer to.

Skin is a section that changes fast. A person who scores 12 on admission can be at very high risk after a chest infection and a week in bed. The plan needs to be reviewed when the score is, not six months later.

Section 9: continence

What the person's continence is like, what products they use, what routine helps, what dignity means to them in this area. Any continence assessment and who did it. Bowel monitoring where needed and what triggers action. Fluid intake and its effect. This section is often thin because staff find it awkward; it is one of the sections people themselves care most about.

Write it plainly. Joan uses a pad at night and prefers to manage it herself in the morning; she needs help changing the bed if it is wet and does not want it mentioned in front of others. Joan is prone to constipation and her bowel chart is checked daily; three days without a movement means a PRN laxative under the protocol and a note to the senior. That level of detail is what allows a new worker to protect the person's dignity without asking them awkward questions on the first morning.

Section 10: mental health and emotional wellbeing

Any mental health diagnosis and what it means for the person. Mood, anxiety, sleep. What helps and what makes things worse. Early signs of relapse or deterioration and what to do. Any involvement from a community mental health team, care coordinator, or Mental Health Act status including community treatment orders. Crisis contacts.

For people in mental health services, this section may be the largest in the plan and will link to a recovery plan or a crisis plan held by the community team. Reference those and record how the home supports them. Risk in this section is recorded with the same honesty as anywhere else: what the risk is, what the person gains from the freedom involved, and what the agreed response is.

Section 11: behaviour and positive behaviour support

Where a person's behaviour sometimes challenges, the plan says what the behaviour is, what it communicates, and points to the positive behaviour support plan for the strategies. The PBS plan is a separate document with its own structure: functional assessment, primary, secondary and reactive strategies. The care plan does not repeat it but must not contradict it. ABC charts and incident records are the evidence the PBS plan is reviewed against, and keeping them in the same audit and evidence record as the plan makes the review straightforward.

Restrictive practice of any kind is recorded here: what, why, on what lawful basis, and how it is being reduced.

Section 12: social life, activities and relationships

Who matters to the person and how they keep in touch. What they like to do, in the home and outside it, and how often. Work, education, faith, culture. What they used to do and would like to do again. What they do not want to do, and that this is respected. Sexuality and intimate relationships, handled with the same respect as any other part of life.

Write it as a week: Tuesday the allotment, Thursday the shop, Sunday church with her daughter. Then the daily log can be checked against it.

Section 13: capacity, consent and DoLS

The Mental Capacity Act 2005 requires capacity to be assessed decision by decision, and the plan should show that. List each significant decision the plan relies on: to live here, to take each medicine that is contested, to manage money, to go out alone, to have personal care from staff of either gender. For each, the assessment date and outcome, and where the person lacks capacity, the best interests decision, who was consulted and what less restrictive options were considered.

Record any DoLS authorisation: date, duration, conditions, the relevant person's representative, and how each condition is met. Record any lasting power of attorney or deputyship and what it covers. The Code of Practice sets out the steps, and the plan should show each one was followed.

Section 14: risk assessments

Every risk the plan identifies has a scored assessment: falls, skin, nutrition, choking, self-neglect, going out alone, self-harm, behaviour, fire evacuation with a PEEP, and whatever else is specific to the person. Each says what the risk is, who it affects, what makes it more or less likely, what the person gains from the activity, what controls are in place, the score, the review date, and who agreed it. Positive risk-taking is written down as such.

Risk assessments are versioned. When the score changes, the old version is kept and the new one dated. The risk assessment examples and template show the structure.

Section 15: night-time

Bedtime, routine, what helps sleep, what to do if the person wakes. Whether they want checks and how often, or whether they have said they do not. Night medicines, continence at night, any sensor or monitoring equipment and the consent or best interests decision for it. Who the night staff are and how the person knows.

Night is where care is least visible and where restrictive practice creeps in unnoticed. A door sensor or a two-hourly check is a restriction and needs the same justification as any other.

Ask the person what they want at night before assuming. Many people who are checked hourly have never been asked and would rather be left alone. Others feel safer knowing someone will look in. Either answer is fine; the plan records which it is, and where the person cannot say, the best interests decision records why the chosen level of checking is the least restrictive option that keeps them safe.

Section 16: end of life and advance planning

What the person has said about the future, however little. Any advance decision to refuse treatment, advance statement, ReSPECT form, or DNACPR decision, with dates and where the originals are. Preferred place of care and death. Who should be involved. Faith and cultural wishes. For someone who is well, this may be a few lines from a conversation; for someone approaching the end of life, it becomes the main section, with symptom management, anticipatory medicines and the palliative care team's plan.

Do not leave the section blank because the conversation feels difficult. A single line that says the person did not want to discuss it, with a date, is a record. A single line that says they want their daughter with them and no hospital is a plan. Both are better than nothing, and both can be built on when the time comes, rather than starting the conversation in a crisis.

Writing style: the first-shift test

Every sentence in the plan should pass one test: could a competent worker on their first shift, who has never met the person, act on it? If not, rewrite it. Encourage fluids fails. Offer Joan a cup of tea at ten, twelve, three and seven, in her own china cup, and write it on the fluid chart passes.

Use the person's name, not the service user or the resident. Use the present tense: Joan likes, not Joan would like. Use their words where they gave them, in quotation-free plain text: Joan says the mornings are her best time. Avoid jargon and abbreviations a family member would not understand. Keep sentences short. State what to do, not what to avoid: sit on her left side, rather than do not approach from the right.

The worked examples for a learning disability service show what this reads like across a whole plan.

Goals and outcomes that mean something

A goal is something the person wants, written so that you would know if it was achieved. Maintain independence is not a goal. Walk to the dining room without the frame by Christmas is. Reduce anxiety is not a goal. Go to the Friday social club three times in the next month is.

Each section can have a goal, but not every section needs one, and a plan with twenty goals has none. Three or four, chosen by the person, with a date and the steps to get there, is enough. Record progress at each review, and when a goal is achieved, celebrate it in the plan and set the next one. Goals that were not achieved are not failures; they are information about what to change.

Linking the plan to the daily log

The plan says what should happen. The daily log says what did. They need to be in the same place, or at least readable together, and the log should be structured around the plan so that comparison is easy. If the plan has a section on eating and drinking, the log should record meals under the same heading. If the plan sets a goal, the log should record progress toward it.

A system where the daily log is written against the care plan sections, with body maps and photos where they help, makes the review a matter of reading rather than searching. Kiwi structures its three-tap daily logs that way; paper can do the same with a well-designed sheet.

Writing the plan: the procedure

1. Complete the pre-admission assessment with the person and record it under the plan's headings.
2. Decide whether the service can meet the person's needs and record the decision.
3. Within 24 hours of admission, write a short interim plan covering safety: medication, mobility, skin, nutrition, communication, and any immediate risk.
4. Over the first two to four weeks, get to know the person and gather the professional reports.
5. Sit with the person and write about me first, in their words.
6. Work through each section asking: what does this look like for this person, what do they want, what do staff do.
7. Record capacity for each significant decision and any best interests decisions.
8. Write the scored risk assessments and the goals with the person.
9. Produce the easy-read version where the person would use one.
10. Have a second person apply the first-shift test to every section.
11. Sign, date, set the review date, and brief the team.
12. Review at four weeks against the daily log, and then at least six-monthly and after any change.

Why care plans should be updated regularly

A care plan is a description of a person at a moment. People change. A fall, a chest infection, a bereavement, a new medicine, a new friend, a new fear. If the plan does not change with them, staff are following instructions for a person who no longer exists. That is where harm happens: the person who is repositioned two-hourly because the plan says so, months after they became mobile again; the person whose texture-modified diet was never reviewed after the swallowing improved.

Regulation 9 requires care to be reviewed and the plan updated. CQC expects reviews to be meaningful, not signatures. Commissioners expect the plan they are paying for to reflect the person. And the person expects to be asked. The guide to care plan review frequency sets out a schedule that works.

The care plan checklist

• About me is written first, in the person's voice, and says what matters to them.
• Every section says what it looks like for this person, what they want, and what staff do.
• Every sentence passes the first-shift test.
• Capacity is recorded decision by decision, with best interests decisions where needed.
• DoLS status, conditions and how they are met are recorded.
• Every identified risk has a scored, dated, versioned assessment that records the gain as well as the risk.
• Goals are specific, chosen by the person, dated, and tracked.
• Professional reports are referenced with dates, not copied.
• The plan does not contradict the PBS plan, the PRN protocols or the hospital passport.
• An easy-read version exists where the person would use one.
• Who was involved and when is recorded.
• The plan is available to staff where care happens.
• The review date is set and the last review compared the plan with the daily log.

Common mistakes

• Starting with the diagnosis. The first page is a medical history and the person appears on page four.
• Copying the template. The same phrases in every plan in the building, with the names changed.
• Task lists. Assist, encourage, monitor, support. No detail a new worker could act on.
• Global capacity. Lacks capacity at the top of the plan, applied to every decision.
• Risk without gain. Every assessment says what could go wrong; none says why the person wants to do it.
• Goals that cannot be measured. Maintain, promote, encourage. Nothing with a date.
• Plan and log never compared. The review is a signature and the log tells a different story.
• Plan in the office. Staff on the floor have never read it and work from handover and memory.

What good looks like on inspection day

The inspector picks a resident and asks to see the plan. It opens with about me, and the inspector can tell who the person is from the first page. They pick the personal care section and it reads as a sequence with preferences and the gender of carer. They ask a care worker how the person likes to be washed and the answer matches. They pick the capacity section and find four decision-specific assessments, each dated, with best interests decisions where needed and the DoLS conditions shown as met.

They ask about the last review. The keyworker shows the review notes, which compare the plan with the daily log and record two changes: a shower moved to the evening after repeated morning refusals, and a new goal to visit the garden centre with her daughter, which the log shows happened last week. They ask the resident whether she was involved in her plan and she says yes, and points to her easy-read copy.

They look at the falls risk assessment and see three versions with rising and then falling scores, each explained. They look at the daily log and it is structured around the plan's sections. If you want to see a plan, a log and a review working together in one system, book a demo and bring one of your own plans to compare. That is inspection-ready evidence: not a perfect document, but a true one that the person, the staff and the record all agree on.

Final conclusion

Writing a person-centred care plan is not filling a template. It is getting to know a person well enough to describe how they want to live and what staff must do to make that happen, section by section, in words anyone could follow. Start with the person, write in their voice, be specific, record capacity honestly, treat risk as something to enable, set goals they chose, and review the plan against the daily log until the two agree. Do that and the plan stops being a document for inspectors and becomes the thing that makes the care good.

Frequently asked

What is a care plan in a care home?

It is the provider's written record of how a person will be supported, agreed with the person and covering every area of their life where support is given or a risk exists. It is different from the local authority care and support plan under the Care Act 2014, which sets out the needs being commissioned. The home's plan is how those needs are met day to day.

What should be included in a person-centred care plan?

About me and what matters, communication, health, medication, eating and drinking, personal care, mobility and falls, skin, continence, mental health, behaviour and PBS, social life and relationships, capacity and DoLS, risk assessments, night-time, and end of life wishes. Each section records the person's preferences, the staff actions, the capacity position and any goal.

How do you write a care plan that is person-centred rather than task-led?

Write about me first, in the person's words. In every section, say what this looks like for this person, what they want, and exactly what staff do. Use their name and the present tense. Apply the first-shift test to every sentence: could a competent worker who has never met the person act on it? If not, add the detail.

What is the care planning cycle?

Assess, plan, implement, review. You find out about the person, agree with them how support will look, staff deliver it and record what happened, and you compare the record with the plan and change the plan. The cycle continues for as long as the person is supported. The weak link is usually the review, which must compare the plan with the daily log.

How often should a care plan be reviewed?

At four weeks after admission, then at least every six months, and whenever something changes: a fall, an admission, an incident, a new medicine, a new goal, a change in capacity or a DoLS renewal. Many services review one section a month with the person so the formal review confirms rather than rewrites.

Who should write a care plan?

Usually the keyworker or named nurse, with the person involved throughout, family with the person's agreement, and professionals contributing their parts. The registered manager or deputy signs it off. The plan records who was involved and when, and inspectors will ask the person whether they took part.

How do you write goals in a care plan?

A goal is something the person wants, written so you would know if it was achieved, with a date and the steps to get there. Walk to the dining room without the frame by Christmas is a goal; maintain independence is not. Three or four goals chosen by the person are better than twenty written by the service.

How should capacity be recorded in a care plan?

Decision by decision under the Mental Capacity Act 2005, never as a single statement. For each significant decision the plan relies on, record the assessment date and outcome. Where the person lacks capacity, record the best interests decision, who was consulted and the less restrictive options considered. Record any DoLS authorisation, its conditions and how they are met.

Sources

• GOV.UK: Care Act 2014 statutory guidance
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 9 person-centred care
• CQC: single assessment framework quality statements
• GOV.UK: Mental Capacity Act 2005 Code of Practice, including Deprivation of Liberty Safeguards
• Skills for Care: person-centred care and the Care Certificate standard 5
• NICE guideline NG96 Care and support of people growing older with learning disabilities
• SCIE: person-centred care planning resources