Facilitate Personcentred Assessment, Planning, Implementation and Review

Learning outcomes

1 Understand the principles of person-centred assessment and care planning

1.1 Explain the importance of a holistic approach to assessment and planning of care or support

1.2 Describe ways of supporting the individual to lead the assessment and planning process

1.3 Describe ways the assessment and planning process or documentation can be adapted to maximise an individual’s ownership and control of it

2 Be able to facilitate person-centred assessment

2.1 Establish with the individual a partnership approach to the assessment process

2.2 Establish with the individual how the process should be carried out and who else should be involved in the process

2.3 Agree with the individual and others the intended outcomes of the assessment process and care plan

2.4 Ensure that assessment takes account of the individual’s strengths and aspirations as well as needs

2.5 Work with the individual and others to identify support requirements and preferences

3 Be able to contribute to the planning of care or support

3.1 Take account of factors that may influence the type and level of care or support to be provided

3.2 Work with the individual and others to explore options and resources for delivery of the plan

3.3 Contribute to agreement on how component parts of a plan will be delivered and by whom

3.4 Record the plan in a suitable format

4 Be able to support the implementation of care plans

4.1 Carry out assigned aspects of a care plan

4.2 Support others to carry out aspects of a care plan for which they are responsible

4.3 Adjust the plan in response to changing needs or circumstances

5 Be able to monitor care plans

5.1 Agree methods for monitoring the way a care plan is delivered

5.2 Collate monitoring information from agreed sources

5.3 Record changes that affect the delivery of the care plan

6 Be able to facilitate a review of care plans and their implementation

6.1 Seek agreement with the individual and others about:

Who should be involved in the review process

Criteria to judge effectiveness of the care plan

6.2 Seek feedback from the individual and others about how the plan is working

6.3 Use feedback and monitoring/other information to evaluate whether the plan has achieved its objectives

6.4 Work with the individual and others to agree any revisions to the plan

6.5 Document the review process and revisions as required