Person-centred care plan examples for learning disability services

A person-centred care plan for someone with a learning disability describes the person, not the tasks. It says who they are, what matters to them, how they communicate, what good support looks like from their point of view, and what staff need to do so that the person's life goes the way they want it to. The examples below are drawn from one composite person, section by section, so you can see the difference between a plan that lists needs and a plan that someone could actually be supported from.

The short answer

A good person-centred care plan example in a learning disability service reads like a description of a person written by someone who knows them well. Every section answers three questions: what does this look like for this person, what do they want, and what do staff do about it. It uses the person's own words wherever possible, it has an easy-read version the person can hold, it links to the hospital passport and any positive behaviour support plan, and it records capacity, consent and risk honestly. The sections that follow show worked examples for each area of a plan, using a composite person we will call Daniel, and finish with a checklist of what should be included, a procedure for building the plan with the person, and what good looks like on inspection day.

What person-centred care means in a learning disability service

Person-centred care is a phrase that has been used so much it has lost its edge. In a learning disability service it means something concrete. The person is the expert on their own life. Support is organised around what they want to do, not around the home's routine. Choice is real, not offered and then overridden. Communication is in the person's language, whatever that is. Family and friends are part of the picture unless the person says otherwise. Risk is managed so the person can live, not so the home can avoid blame.

The Care Act 2014 statutory guidance puts wellbeing at the centre of every assessment and plan and lists the things that make it up: control over day-to-day life, participation in work and education, relationships, dignity, and more. The CQC single assessment framework asks whether care is person-centred under the responsive key question and whether people are treated as individuals under caring. Right support, right care, right culture, the CQC guidance for learning disability and autism services, goes further: it expects services to show that people have choice, control and independence, and that support is not built around the convenience of the service.

A care plan is where all of that either happens or does not. The rest of this guide is about making it happen on the page.

At a glance: task-led wording versus person-centred wording

Meet Daniel: where these examples come from

Daniel is a composite. He is 34, has a moderate learning disability and autism, lives in a six-bed registered care home, and has been there four years. He uses some Makaton, a photo book and a few spoken words. He has epilepsy that is well controlled, and a history of distress that sometimes leads to him hitting his own head. His mum visits every Sunday and his sister rings on Wednesdays. He loves the allotment, buses and the colour green. He lacks capacity for some decisions about his health and finances and has capacity for most decisions about his daily life. He is under a DoLS authorisation because of the level of supervision he needs.

Every example below is written as if it were a section of Daniel's plan. Names and details are invented, but the structure and the wording are what I would expect to see in a plan I could sign off.

Example: about me and what matters to me

This section comes first because it is the one that makes everything else make sense. It is written in Daniel's voice, with his mum and his keyworker helping.

My name is Daniel. I am 34. I like to be called Dan by people I know well and Daniel by people I do not. I love the allotment, going on buses, and anything green. My favourite person is my mum and I see her on Sundays. I do not like loud noises, being rushed, or people standing behind me. I am good at growing things and remembering bus routes. I want to get a job on the allotment and I want to go to the gym. The most important thing for staff to know about me is that if you give me time I will do it myself.

Notice what is here. Preferences, relationships, aspirations, and the one thing staff most need to know. Nothing about diagnosis, nothing about risk. That comes later and it comes second.

Example: communication

Daniel communicates with about forty Makaton signs, a photo book with pictures of people, places and activities, and a handful of spoken words: yes, no, mum, bus, no thanks. He understands far more than he can express. Speak to him in short sentences, one idea at a time, and wait. Do not fill the silence. If he does not respond after ten seconds, show him the choice in his photo book.

His signs for the things he wants most are listed in the appendix with photographs. Two taps on his chest means he wants a hug. Turning away means he has finished. Humming and rocking means he is becoming anxious, and that is covered in his PBS plan. He does not like being asked questions in a row. If you need to know something, offer two choices rather than asking an open question.

The speech and language therapist reviewed his communication in March and her report is attached. Her main recommendation was that all staff learn his top twenty signs, and the training record shows who has.

Example: health and the hospital passport

Daniel has epilepsy, controlled on lamotrigine, with no seizures for eighteen months. His last seizure was tonic-clonic and lasted under two minutes. His epilepsy care plan and emergency protocol are in section 12 and staff are trained on them. He has an annual health check with his GP every October and a health action plan that lists three goals for this year: keep seizure-free, lose some weight, and see the dentist without needing sedation.

His hospital passport is kept in the front of his file and a copy is in his bag. It says how he communicates, what frightens him, that he will not tolerate a cannula without preparation, and that his mum should be called. It was updated after his last outpatient appointment. The hospital passport guide explains what should be in it.

Daniel does not like the doctor. The GP practice knows this and gives him the first appointment of the morning so the waiting room is empty. His mum or his keyworker goes with him.

Example: medication and consent

Daniel takes lamotrigine twice a day and a multivitamin. He has lorazepam prescribed as required for severe distress, with a protocol that sits inside his PBS plan. He lacks capacity to decide about his epilepsy medicine; the capacity assessment dated in section 15 explains why, and the best interests decision, made with his mum and the GP, is that staff give it. He takes it willingly with a glass of squash after breakfast and after tea. He does not need it hidden and it is never given covertly.

He can decide whether to take the multivitamin and usually says yes. If he refuses any medicine, staff record it, offer again after half an hour, and if he still refuses, record that too and tell the senior. Two refusals of lamotrigine in a row means the GP is called the same day. The eMAR holds his protocol and flags refusals to the manager.

Example: eating and drinking

Daniel eats a normal diet with no swallowing difficulties. His speech and language therapy assessment confirmed this and there is no IDDSI level. He is overweight, with a BMI of 31 at his last monthly weigh-in, and his MUST score is 0. His health action plan goal is to lose a little weight, and he has chosen to do that by going to the gym and having fruit instead of biscuits at supper.

He eats best at the small table by the window with one other person, and not with the television on. He likes toast with jam, roast dinners, and anything from the allotment he has grown. He hates sauces and will not eat food that is mixed together. He drinks squash and will not drink plain water; staff offer squash through the day and record it on hot days. He can make his own toast and likes to.

He is weighed on the first Monday of the month and the weight goes into the health monitoring record, which calculates his BMI and MUST automatically.

Example: personal care and dignity

Daniel can wash, dress and use the toilet independently but needs prompting to start and time to finish. He prefers a shower to a bath, in the evening, with the door closed and nobody in the room. Staff knock, say what they are going to do, and leave him to it, checking after ten minutes by knocking again. He chooses his own clothes from two options his keyworker lays out the night before; if he is given the whole wardrobe he cannot choose and becomes anxious.

He shaves himself with an electric razor on Sundays before his mum comes. He will not have his hair cut in a barber's and a mobile hairdresser comes every six weeks; he tolerates this best if it is done in the garden. He does not like his nails cut and the podiatrist does his feet every eight weeks.

He would be embarrassed if a female member of staff supported him in the shower and has said so. His plan says male staff only for personal care and the rota reflects that.

Example: mobility and physical health

Daniel walks independently, including outside, and has no falls history. He walks quickly and does not always look at kerbs, so a staff member walks on the road side of him in town. He can use buses independently on two routes he knows and is learning a third; the risk assessment for this is in section 16 and is reviewed every three months as he gains confidence.

His last annual health check found nothing new. His weight is covered above. He has a dental check every six months and the last one was done in the chair with no sedation, which was his health action plan goal for last year and was achieved. His eyes were tested in April and he does not need glasses.

Example: emotional wellbeing and behaviour that challenges

Daniel is usually content. He becomes anxious when there is loud noise, when he is rushed, when plans change without warning, and when someone stands behind him. His early signs are humming and rocking. If those are missed, he may hit his own head with his hand, and on rare occasions he has hit out at staff. In the last twelve months there have been four incidents, all recorded on ABC charts, and three of them happened when the day's plan changed.

His positive behaviour support plan is section 14 and was reviewed with the community learning disability team in June. Its main primary strategy is a visual timetable for each day, agreed with him the night before, and no changes without showing him the new picture. Its secondary strategies for humming and rocking are: reduce noise, one person only, offer the garden. Its reactive strategy is the lorazepam protocol, used once in the last year. The PBS plan example shows how that document is structured.

Example: relationships, family and sexuality

Daniel's mum, Carol, visits every Sunday afternoon and takes him for lunch. His sister, Amy, rings on Wednesday evenings and he holds the phone himself. Both are named in the plan with their contact details and the level of information they may be given, which Daniel agreed. Carol is his mum and is consulted on best interests decisions; she is not his deputy or attorney, and the plan says so.

He has a friend, Mark, in the house, and they go to the allotment together. He has said he would like a girlfriend. Staff have talked with him about relationships using an easy-read resource and this is recorded. He has capacity to make decisions about friendships and has been supported to join a social group for adults with learning disabilities on Friday evenings. His privacy in his room is respected and staff knock and wait.

Example: activities, work and community

Daniel goes to the allotment on Tuesdays and Thursdays, all day, with a support worker. He has asked for a job there and his keyworker has spoken to the allotment association about a volunteer role, which starts next month. He wants to go to the gym and a taster session is booked. He does not want to go to the day centre and stopped going eighteen months ago after saying so repeatedly; that decision is recorded and respected.

He goes to the shops on Saturday mornings on the bus and buys his own magazine. He goes to church with his mum sometimes and likes the singing. He likes to watch buses from the window in the afternoon and staff do not interrupt that.

What he does each week is written on his visual timetable, and what he actually did is recorded in the daily log so that the review can compare the plan with the reality.

Example: money and tenancy

Daniel lacks capacity to manage his benefits and his mum is his appointee. He has capacity to decide how to spend his weekly personal allowance and does so, mostly on magazines, plants and bus fares. Staff support him to keep his money in his wallet, record what he spends in his personal money record, and reconcile it weekly. He signs the record with his mark.

His placement is funded by the local authority and the funding review is due in November. He does not have a tenancy because this is a registered care home; the plan records that he has been told about supported living and has said he wants to stay here for now.

Example: capacity, consent and DoLS

Daniel's capacity has been assessed for six specific decisions and each assessment is in section 15 with its date and its outcome. He has capacity to decide about his daily activities, his friendships, his personal allowance, and whether to take his multivitamin. He lacks capacity to decide about his epilepsy medicine, his finances, and whether to live somewhere with less supervision. Each of those has a best interests decision recorded with who was consulted.

He is under a standard DoLS authorisation, granted in February for twelve months, because he needs continuous supervision when out and cannot leave the home alone. The authorisation has two conditions: that he is supported to use the bus independently on routes he knows, and that his mum is kept informed of any restriction. The plan shows how each condition is being met. His relevant person's representative is his mum, and the review date is in the diary.

Example: risk and positive risk-taking

Daniel has three current risk assessments: using the bus independently, working at the allotment with tools, and the risk of self-injury when distressed. Each is scored, each has a review date, each was discussed with him in easy read, and each says what he gains as well as what could go wrong.

The bus assessment is the best example of positive risk-taking. The risk is that he gets lost or gets off at the wrong stop. The gain is independence, confidence, and the thing he loves most. The controls are: routes he has practised with staff, a card in his wallet with the home's number, a phone he can answer, and a check-in call when he arrives. The assessment has been reviewed three times and each time his independence has increased. The risk assessments are scored and versioned so that the history is visible.

Example: night-time and sleep

Daniel goes to bed at about ten after watching a programme about buses. He likes his door closed and his lamp on. He sleeps through most nights. If he wakes, it is usually because of noise from the road, and he will come and find staff; he does not become distressed at night unless the plan for the next day is uncertain, which is why the visual timetable is agreed before bed. There is one waking night staff member and Daniel knows who it is because the picture is on the board. He does not need checking in the night and has said he does not want it.

Example: end of life and future planning

Daniel is 34 and well, and this section is short, but it is not empty. He has talked with his keyworker, using an easy-read resource, about what he would want if he were very ill: his mum with him, his green blanket, and no hospital if it could be avoided. He does not have an advance care plan or a ReSPECT form and there is no reason for one at present. His mum knows his wishes and they are recorded here so that they are not lost.

The point of keeping the section, even for a young and healthy person, is that the conversation has been had and can be picked up again. If Daniel's health changes, the plan already holds his words, and the review can build on them rather than starting from nothing at a difficult time.

Making it easy read: the HAP and the PCP

Every section above has an easy-read version. Daniel has two documents he holds himself. His health action plan is the easy-read record of his health goals, with a photo for each one and a tick when it is done. His person-centred plan is the easy-read version of the whole care plan: one page per section, a photo or symbol, and a few words in large print. He keeps them in a green folder in his room and brings them to his review.

The easy-read version is not a summary for show. It is how Daniel takes part in his own plan. When his keyworker reviews a section with him, they use the easy-read page, and what he says goes back into the full plan. A care plan system that produces the easy-read HAP and PCP from the same record saves writing everything twice; Kiwi does this from its 24-section plan, and other systems have similar features.

What should be included in a care plan: the checklist

• About me and what matters to me, in the person's own words.
• Communication, with the person's signs, symbols or words and how staff should respond.
• Health, with the hospital passport, health action plan and any condition-specific plans such as epilepsy.
• Medication, with the capacity position for each medicine and any PRN protocols.
• Eating and drinking, with any IDDSI level, MUST score, weight and preferences.
• Personal care and dignity, including gender of staff and privacy.
• Mobility, falls and physical health monitoring.
• Emotional wellbeing and the PBS plan where there is one.
• Relationships, family, friends and sexuality.
• Activities, work, education and community.
• Money, benefits and tenancy or placement.
• Capacity assessments for specific decisions, best interests decisions, DoLS status and conditions.
• Risk assessments, including positive risk-taking.
• Night-time and sleep.
• End of life wishes and advance decisions, however brief.
• Who was involved in writing the plan, the date, and the review date.
• An easy-read version the person holds.

How to build the plan with the person

1. Start with about me. Sit with the person, their family and the people who know them best, and write it in their words before you write anything else.
2. Gather the existing documents: hospital passport, health action plan, PBS plan, capacity assessments, risk assessments, professional reports. Do not rewrite them; reference them.
3. Work through each section asking three questions: what does this look like for this person, what do they want, what do staff do.
4. Write in plain English, in the present tense, using the person's name and describing what happens rather than what should happen.
5. Record the capacity position for each decision the plan relies on, and the best interests decision where the person lacks capacity.
6. Make the easy-read version of each section with the person and check they recognise themselves in it.
7. Have a second person read the whole plan and mark anything that could not be followed by a new worker on their first shift.
8. Sign it, date it, set the review date, and train the team on it, not just file it.

Reviewing the plan

The plan is reviewed formally at least every six months and whenever something changes: a new diagnosis, a hospital admission, an incident, a new goal, a change in capacity, a DoLS renewal. Daniel's keyworker reviews one section with him each month using the easy-read pages, so by the time the formal review comes round, most of it is already current.

The review compares the plan with the daily log. If the plan says allotment on Tuesdays and Thursdays and the log shows he went once in the last month, something is wrong, and the review finds out what. If the log shows he has started refusing his shower, the plan needs to change. The guide to writing a person-centred care plan covers the review cycle in more detail.

Common mistakes

• Writing about the diagnosis, not the person. The plan opens with moderate learning disability and autism and never says what Daniel likes.
• Task lists dressed as care plans. Assist with personal care, encourage fluids, monitor behaviour. Nothing a new worker could act on.
• Capacity assumed globally. Lacks capacity written once at the top, with no decision-specific assessments.
• Easy read as decoration. A laminated sheet on the wall that the person has never seen or been asked about.
• Plans that contradict each other. The care plan says one thing about distress and the PBS plan says another.
• Risk without gain. Every risk assessment says what could go wrong and none says why the activity matters.
• Family named but not involved. Mum is a contact number, not a person who helped write the plan.
• Reviewed by signature only. The review date is filled in and nothing in the plan has changed in two years.

What good looks like on inspection day

The inspector asks to meet Daniel and to see his plan. Daniel shows them his green folder with his easy-read pages and his health action plan, and points to the picture of the allotment. The keyworker brings up the full plan. The inspector reads about me and then asks a support worker what Daniel likes. The support worker says the allotment, buses and green things, and that you have to give him time. The plan and the worker agree.

The inspector looks at the medication section and asks about capacity. The keyworker shows the decision-specific assessment for lamotrigine, the best interests decision with Carol and the GP, and the assessment showing Daniel decides about his multivitamin himself. They look at the DoLS authorisation and the two conditions, and the plan shows how each is met. They look at the bus risk assessment and see three reviews, each one extending his independence.

They look at the daily log for last week and it matches the plan: allotment Tuesday and Thursday, shops Saturday, church Sunday with mum. One entry shows he refused his shower on Wednesday and the plan was updated the next day to note that he prefers it after tea, not before. That is inspection-ready evidence of person-centred care: the plan, the record and the person all telling the same story.

Final conclusion

The best person-centred care plan example is not a template; it is a person on a page. Every section should say what life looks like for this person, what they want, and what staff do about it, in words the person and a brand-new worker could both understand. Build it with the person, keep the easy-read version in their hands, link it to the hospital passport and the PBS plan, record capacity decision by decision, treat risk as something to be enabled as well as managed, and review it against what actually happened. Do that and the plan becomes what it is meant to be: the way the person's life gets lived the way they want.

Frequently asked

What is a person-centred care plan example for a learning disability?

It is a plan that describes the person rather than their needs: who they are, what matters to them, how they communicate, what good support looks like to them, and what staff do in each area of life. It uses the person's own words, has an easy-read version they hold, links to the hospital passport and any PBS plan, and records capacity decision by decision.

What should be included in a care plan for someone with a learning disability?

About me, communication, health and the hospital passport, medication and consent, eating and drinking, personal care, mobility, emotional wellbeing and PBS, relationships, activities and work, money, capacity and DoLS, risk assessments, night-time, end of life wishes, and the review record. Each section should say what this looks like for the person, what they want, and what staff do.

What is the difference between a care plan and a health action plan?

The care plan is the full record of how the person is supported in every area of life. The health action plan is an easy-read document, usually produced after the annual health check, that lists the person's health goals for the year in a form they can hold and understand. The health action plan sits inside the care plan and is reviewed with it.

How do you make a care plan easy read?

Take each section and reduce it to a page with one photo or symbol, a few words in large print, and the person's own phrases. Build it with the person, check they recognise themselves in it, and let them keep it. It is not a summary for display; it is how the person takes part in their own plan and review.

How often should a person-centred care plan be reviewed?

Formally at least every six months and whenever something changes: a hospital admission, an incident, a new goal, a change in capacity, a DoLS renewal. Many services review one section a month with the person so the formal review is a confirmation rather than a rewrite. Compare the plan with the daily log at every review.

How should capacity be recorded in a learning disability care plan?

Decision by decision, never globally. Each decision the plan relies on, such as taking a particular medicine, managing money, or going out alone, has its own capacity assessment with a date and outcome. Where the person lacks capacity, the best interests decision is recorded with who was consulted. Where the person has capacity, the plan says so and respects their choice.

What does CQC look for in learning disability care plans?

Under the single assessment framework and the right support, right care, right culture guidance, inspectors look for choice, control and independence; plans written with the person in their words; decision-specific capacity assessments; DoLS conditions being met; positive risk-taking; and a daily record that matches the plan. They will ask staff about the person and expect the answers to match the document.

Sources

• GOV.UK: Care Act 2014 statutory guidance
• CQC: Right support, right care, right culture guidance for providers supporting autistic people and people with a learning disability
• CQC: single assessment framework quality statements
• GOV.UK: Mental Capacity Act 2005 Code of Practice, including Deprivation of Liberty Safeguards
• NICE guideline NG11 Challenging behaviour and learning disabilities
• NHS England: Annual health checks and health action plans for people with a learning disability
• Skills for Care: person-centred care and the Care Certificate standard 5