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Development of Person-Centred Care Plan in Residential Care

Info: 2922 words (12 pages) Nursing Assignment
Published: 8th Jun 2020

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Tagged: residential care

As part of the module Residential Care Practice we have been asked to complete an assignment regarding devising a person-centred plan for one of the two case studies provided with the main outcome to be aimed for in the person-centred plan is achieving living independently in the community. I have been asked to act as a keyworker to my chosen person. I must provide a fictitious background on the person based on the elements I plan on working on, the personal plans and the outcomes and how they are to be measured. Those involved in the person- centred plan are to be noted throughout. For the purposes of this assignment I will refer to myself as the keyworker and will refer to other individuals involved along the way.

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A person-centred plan -more commonly referred to as a PCP- is a plan developed to support a person in care in relation to supporting them to live the lives that they wish to live and what staff can do to make these wishes a reality. Person centred planning is planning that focuses primarily on the person being supported rather than planning for the general area of the service such as disability, youth, etc (Natioanl Disability Authority, 2014). Person centred plans allow for ‘whole person’ orientated plan.

Person-centred care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs. This means putting people and their families at the centre of decisions and seeing them as experts, working alongside professionals to get the best outcome. The ever-increasing demand on healthcare often causes caregivers to lose sight of the person behind the condition they’re treating. Therefore, person-centred care is so important. It helps carers refocus on a crucial aspect of care: fulfilling a patient’s needs beyond their disability or ailment (Burton, 2018).

Person centred planning can be developed by the individual whom the plan is intended to support. Sometimes, the plan may be developed by parents, family, spouses, friends, or advocates on the persons behalf- this usually occurs where “it is not possible for a plan to be guided entirely by an individual due to extreme difficulties with insight, awareness and cognition” (Natioanl Disability Authority, 2014). Most plans are developed by one or more individuals acting independently on the behalf of an individual or with their family or service staff specially trained for the development of the plan.

There are six key principles that underpin person centred planning. These are:

  1. Person centred planning is planning from an individual’s perspective on his or her life.
  2. Person centred planning entails a creative approach to planning which asks, ‘what might this mean?’ and ‘what is possible?’ rather than assuming common understandings and limiting itself to what is available.
  3. Person centred planning takes into consideration all the resources available to the person – it does not limit itself to what is available within specialist services.
  4. Person centred planning requires serious and genuine commitment and co-operation of all participants in the process
  5. Person centred planning is an art – not a science.
  6. The development of a plan is not the objective of person-centred planning (National Disability Authority, 2014).

My Support Network


My Father

My Key Worker


My Sister (Alex)

My Friends

My Medical Professionals

My Likes

Going Shopping

Meeting with my family


Meeting with my Key Worker

Going for walks

Drinking tea with friends


My Dislikes

New places

Not seeing my friends


Being restricted with my activities

Not being listened to


Short Term Goals –

–         To increase my activities of daily living to help me get closer to living independently

–         To go shopping independently

–         To stay at my sister’s house for a week

Long Term Goals –

–         To go on a weekend trip with my friends

–         To visit another country 

–         To move into independent living

My Person-Centred Plan Meeting

People Attending –

Celine Duggan (Person being supported), Heather O’Leary (Key Worker), John Murphy (Unit Manager), David Duggan (Celine’s Father) and Alex (Celine’s Sister).

Date – 23rd June 2019

Purpose of the meeting –

 This meeting looked at Celine’s progress in relation to the preparations that are taking place currently to aid and support Celine’s wish to transfer from a residential setting into the community, in independent living, a home of her own.

Signed – _____________________ (Celine Duggan)

Signed – _____________________ (Heather O’Leary)

Signed – _____________________ (John Murphy)

Signed – _____________________ (David Duggan)

Signed – _____________________ (Alex Duggan)

Independent Living – Baseline Assessment

Activity of Daily Living Under-Developed In Process Developed Any Comments
Washing Clothes   See Action Plan 1
Handling Money  
Cleaning the Bathroom  
Handling Money  
Emergency Plans  
Garden Maintenance   See Action Plan 2
Medical Needs  

Overall Action Plan

This action plan is put in place to aid Celine in developing the necessary skills to leave the residential setting and move to independent living. This is the fifth action plan we have created working towards this move, the other four action plans have all been successful in achieving their goal already.

Objectives of Action Plan

  1. To learn, with the support of staff, how to wash clothes independently. (See action plan 1).
  2. To learn, with the support of staff, to maintain the garden independently. (See action plan 2).

Time Frame

The objectives of this action plan will be reviewed in 3 months (12/11/2019). The objectives will then be separated further into individual sessions in the actions plans. Heather O’Leary (The Key Worker) will develop the action plans for the required objectives. These sessions will require a review after each one to see if the goal was met. The objectives for each session shall be set out in the relevant action plan.

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 Celine will have 1 session each week with her key worker, Heather O’Leary, to work on the objectives stated above. as she has had up to this point. These sessions will take place each Thursday at 2 o’clock. In the event that Celine or Heather are unavailable at this time, an alternative time shall be agreed upon by both Celine, John, and Heather.

Action Plan One – Learning to Wash Clothes Independently

When Celine moves into independent living, she will need to be able to wash her own clothes. As Celine has not had to care for her own clothing, she is unaware of how to wash her clothes and what the steps involved are. Celine wants to be fully prepared to live independently and is eager to learn. Celine will practice by using the washing machine in her community setting as it is a standard washing machine. This objective will be split into 4 sessions that will get Celine to wash her own clothes independently. These sessions are –

  1. Discuss what a washing machine is used for

In this session, Heather and Celine will sit down and discuss what a washing machine is and see what it looks like.

  1. How to use the washing machine

In this session, Heather will show Celine the washing machine and explain about the different buttons and symbols presented. Celine will be showed which button turns the machine on and off and then will try it herself. Heather will explain which functions Celine will be using commonly and guided on using them. Heather will use clothes as an example to show Celine and then Celine will try independently while supervised by Heather. 

  1.  Discuss what clothes get washed together

In this session, Heather and Celine will sit down and discuss about not mixing colourful clothes with whites and such. Heather explains how you put whites together and darks together and colours together. They discuss reading labels on clothes and have a look at them. When comfortable, Celine reads a label independently.

  1. Using the washing machine from beginning to end

Celine will use the washing machine independently, supervised by Heather. Heather will not help Celine unless there is a healthy and safety risk or Celine requests her assistance.

Review of Sessions

Session Date Comment Signed

Action Plan Two – Learning to Maintain Garden Independently

Celine has expressed that she would like to improve her knowledge and skills in garden maintenance ahead of living independently as she plans on having a garden. As all lawnmowers differ in some respects, David, Celine’s father, has purchased a lawnmower for Celine to learn and use in her new home. The objectives will be broken down into 4 sessions that will get Celine to use the lawnmower independently. These sessions are –

  1. Discuss what a lawnmower is

In this session, Heather and Celine will sit down and discuss what a lawnmower is and its purpose and have a look at it.

  1. How to use the lawnmower

In this session, Heather and Celine will examine the lawnmower and discuss the different functions of the machine. Heather will show Celine how it is turned on and off, what fuel powers it, and the different levels the blades go to. Celine will then be guided by Heather in using these functions and shown to refuel it.

  1. How to clean out the lawnmower

In this session, Heather will explain to Celine about emptying the bag on the back of the lawnmower. Celine will then be guided in doing this and then will independently complete the task while Heather supervises.

  1. Using the lawnmower from beginning to end

In this session, Celine will use the lawnmower independently and demonstrate all the functions as Heather supervises.

Review of Sessions

Session Date Comment Signed


Monitoring, Review and Evaluation

Activity of Daily Living Under-Developed In Process Developed Any Comments
Washing Clothes  
Handling Money  
Cleaning the Bathroom  
Handling Money  
Emergency Plans  
Garden Maintenance  
Medical Needs  

Reflection, Discussion and Evaluation

In completing this assignment, I found it extremely educating to complete as it was one of the first assignments that we have been assigned that I can see myself completing when I will be working as a social care worker in the future. I found that it took quite a lot of concentration and time to conjure up the plan as there was so much thought that goes into it. While completing this assignment, I found it slightly difficult to do because I had to create fictitious material. However, I doubt that it will be much easier when it comes to making a person-centred plan on a real person in the future.

 When it came to creating this assignment, I went through some of the sample care plans we have been shown and the cases we have been taught about and made my own version.  I tried to include as much personal information regarding Celine as I found it important to incorporate everything about Celine in her PCP.

  These plans are a very important part of the service that we are providing. The PCP should be the most updated document used to a residential service as it is focused totally on the person being supported. It also shows that we are helping them to reach their goals and live their lives the way they choose.


  • Natioanl Disability Authority, 2014. So what is ‘person centres planning’? Definition and brief history. [Online]
    Available at: http://nda.ie/Good-practice/Guidelines/Guidelines-on-Person-Centered-Planning/Guidelines-on-Person-Centred-Planning-format-versions/2-What-is-Person-Centred-Planning-/
    [Accessed 12th August 2019].
  • National Disability Authority, 2014. Key Principles. [Online]
    Available at: http://nda.ie/Good-practice/Guidelines/Guidelines-on-Person-Centered-Planning/Guidelines-on-Person-Centred-Planning-format-versions/3-Key-Principles/
    [Accessed 12th August 2019].


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Care homes, also known as adult family homes, residential care or personal care homes offer personalised service to small groups of adults. These residential care homes provide food, meal service and assistant with personal care activities such as bathing, feeding and cleaning.

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