A digital place for people who access services, carers, staff and partner agencies, to share ideas around care co-ordination & care planning in mental health

Are individualised care plans ‘the basics’ in Mental Health care?

This is the essence of a question I was asked recently when visiting a team. This prompted quite a discussion with a range of views presented.  My view is that having an individualised care plan is part of ‘the basics’; that it captures  where someone is now and where they want to get to. Without this ‘basic’ I am unsure how the direction is clear and how reaching the destination is known. I was challenged that this view doesn’t take into account the reality of current practice and that people who use services are mostly not interested in their care plan.

What I hear from people who use the service is that the quality of the relationship with their mental health worker  is the thing that matters most. I hear that people don’t always have a copy of their care plan and that yes, it would be nice to see the care plan but that this doesn’t cause a problem when the relationship is good. Nowadays, people accessing services are aware that they should have a care plan, they know what a care plan is.

As accountable professionals, we are required to ‘plan’ people’s care, support and treatment. We know that if we don’t involve and engage the person, then the likelihood of success of the care, support and treatment is limited. So where does this leave us? Do we involve the person because we have to or because it’s the right thing to do? Does our believe about this impact on the experience that the person has, on the relationship? And how do we demonstrate that we have involved the person?

The current standards in relation to Planning Care come from a range of places, including: Department of Health/ NHS England, CQC outcomes, CQUINS, Nice Guidance and Monitor (in many cases these standards are developed from feedback from and working alongside service user groups). Ultimately, it’s about working in a service user focused way to promote wellbeing and recovery, here are some ‘basics’ to help ensure we get it right:

  • Provide written information about Planning Care (for example, Care Programme Approach)
  • Develop the Care Plan with the individual
  • Write the Care Plan to reflect the person’s involvement and perspectives
  • Include the individual’s own goals
  • Ensure that physical health needs are identified and plans to address these are clear
  • Clearly identify if the person has a carer(s) and any support the carer needs
  • Develop an individualised contingency & crisis plan (early warning, triggers, actions to take – person and services, contact names and numbers )
  • Ensure the person receives a copy of their Care Plan
  • Record when/how the person received a copy of their Care Plan
  • Review to be person centred, flexible approach to engaging the individual and in a timely way
  • Record that the review took place

What is your experience or view of individualised care plans?

Comments on: "Individualised care plans in Mental Health – the basics?" (3)

  1. You make some excellent points Donna. My personal view is that people should almost always have access to their care plan, but in an electronic world that may not be a print out. For some we may need to be able to print out a care plan, but many could have access via computers or portable devices. Design is important to ensure clarity and structure is vital but also individual personalisation for each care recipient. Many professional bodies are encouraging use of structured terminology but free text is vital too. It is establishing balance and ensuring all who need access can access the care plan.

    I encourage all readers to contribute to the national consultation too.

    Liked by 1 person

    • Goals are important to help focus actions and decisions for all people involved – especially the individual. Without clear goals it can be difficult to ascertain when you have ‘got there’ – or near. Goals can help with hope and purpose with SMART goals often being reached from refining and reformulationg a general notion of a goal.

      I would fully support the introduction of goals based plans within the inpatient environment. What are other inpatient areas doing in respect of goals?



  2. Becca Cowburn said:

    One thing I have noticed about the care plans within the inpatient environment is that we don’t often plan for goals – both from the service user’s perspective and from a clinical outcomes perspective. The Inpatient Treatment Plan is holistic in nature, in that is considered many of the area’s identified within the CPA. However, when I undertook my nursing training, we were taught to ‘SMART’ goal our care plans collaboratively with the service user. It could be perceived by staff that goal setting is predominetly an OT intervention, as this forms part of the MOHOST assessment. One way of working during a previous nursing role was to complete a ‘goals for admission’ sheet during the initial MDT review. This way, the goals were discussed with the service user from the start of their admission. In acute areas, this could be more challenging when a person is an acute phase of their illness, although it could be something that is continually reviewed each week by the MDT.

    Liked by 1 person

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Dr. Sally Pezaro

Personal Academic Blog: This is the research blog of Dr. Sally Pezaro. Sally is an academic midwife working to secure excellence in maternity services. Specialist interests include psychological wellbeing in midwifery populations, the use of social media in research, teaching and professional regulation.



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