Person-Centred Care Planning: Can You Actually Find the Person in the Care Plan?

I've reviewed rather a lot of care plans recently, and I've discovered that person-centred care is apparently much easier than I thought. Take a fairly generic sentence, insert the person's name, and there we are. Person-centred. "Susan likes to be offered a choice of drinks." Excellent. We've established Susan drinks. What I still don't know is what she actually likes, how she makes her choice or whether she needs any support to do so. Those are probably the bits I'd find useful if I were actually looking after Susan.

The same applies to writing everything in the first person. I've read plenty of care plans containing phrases such as "I like staff to support me with my personal care." Perhaps they do, but I'm yet to meet many people who naturally describe getting washed and dressed as "being supported with my personal care". Writing I instead of they doesn't automatically make something person-centred either. What matters is whether the record actually reflects the person.

Could I actually care for this person from their care plan?

That's one of the tests I use when reviewing care records. If I walked into the service tomorrow, knew nothing about the person and had to support them safely, would their care plan actually help me? I should be able to understand what matters to them, rather than simply finding a list of tasks that need completing. I need to know how they communicate, including how I might recognise that they're uncomfortable, frightened, in pain or simply fed up. Their usual routines should be clear, along with the things they enjoy, the things they dislike and the things guaranteed to put them in a bad mood before breakfast. Just as importantly, the care plan should tell me what the person can do for themselves. Person-centred care isn't about documenting everything staff can do for somebody. Sometimes it's about knowing when to leave well alone and give the person the time, support or equipment they need to do something themselves.

By the time I've read the care plan, I should have some sense of the person behind it. I should know what a good day looks like for them and what might indicate that something isn't right. I should also understand which decisions they make themselves, how they make them and what support they might need. And that's where some of the mental capacity assessments I've been reading become a problem.

"Has dementia. Lacks capacity."

I've seen variations of this far too often and, I'll admit, it's something that really annoys me. It's much more than poor wording. A diagnosis of dementia doesn't, in itself, mean somebody lacks capacity. Neither does a learning disability, brain injury, mental health condition or difficulty communicating. Yet you still come across records where a diagnosis seems to have become shorthand for a conclusion about someone's ability to make decisions. The Mental Capacity Act is clear: we must start with the presumption that a person has capacity. Where there is reason to question capacity, we aren't assessing whether somebody simply "has capacity" or "lacks capacity" in general. We're considering their capacity to make a specific decision at the time it needs to be made.

Which is why an assessment headed "mental capacity regarding care and treatment" doesn't really get us very far. Which care? Which treatment? What exactly is the person being asked to decide?

Whether somebody agrees to take a particular medicine is a decision. Whether they consent to the use of bed rails is another. Where they live may be another entirely. Each involves different information and different consequences, so one broad assessment can't conveniently cover everything because it's easier for the paperwork.

What did we actually do to help them decide?

Before concluding that somebody cannot make a decision, we should be able to see what was done to help them make it themselves. That might mean explaining something differently, using pictures or other accessible information, choosing a better time of day, making sure glasses or hearing aids are available, involving someone who understands how the person communicates or simply giving them more time.

And of course, none of this works particularly well if we don't actually know the person.

If somebody communicates through gestures, behaviour, facial expressions or a communication aid, that should be reflected in how we assess their capacity. If they become overwhelmed when given lots of information at once, perhaps giving them lots of information at once isn't the best way to establish whether they understand it.

"Information explained to resident" doesn't tell me very much about what actually happened. I want to know what information was given, how it was explained and how the person responded. If they didn't appear to understand it, I want to see whether another approach was tried. Otherwise, it's very difficult to tell whether we've supported the person to make the decision or simply told them something and recorded that we did.

I've also seen a surprisingly short journey between "capacity questioned" and "best interests decision made", with very little recorded about what happened in between. There should be rather more to it than that.

A completed form can still be a poor assessment

Having an MCA form in the person's records is obviously important. But the presence of the form doesn't, on its own, tell us whether the assessment was any good.

One phrase that crops up in various forms is some version of "unable to understand, retain, weigh or communicate the information." But that's essentially repeating the functional test back at me. I still don't know what actually happened. I want to be able to see what information the person was given, what they understood and whether they could retain it for long enough to make the decision. If there were difficulties using or weighing that information, the assessment should explain what those difficulties actually were and how the person communicated their views. The record should allow somebody else to follow the assessor's reasoning. Otherwise, all we really have is a conclusion with a form wrapped around it.

There is another important point here too. A person making a decision we think is unwise isn't evidence that they lack capacity. If questionable decisions were enough to trigger a finding of incapacity, I suspect most of us would have had an MCA completed at some point, I know I would have several!

When the records don't agree with each other

This becomes particularly obvious when you review the whole care record rather than individual documents. One section says the person makes their own choices. Somewhere else it says the family make decisions for them. There's an MCA saying they lack capacity, although it's difficult to work out exactly which decision was assessed. Then you find a best interests decision in another part of the system and, just to keep things interesting, another care plan says the person has consented to something.

Individually, those records can look perfectly respectable. Read them together and it becomes very difficult to establish what the person can actually decide for themselves, yet staff are expected to use this information to provide care.

Family involvement is another area where records can become muddled. Families of course often know the person really well and their contribution can be invaluable, particularly when we're trying to understand someone's wishes, feelings, beliefs and values. But being someone's daughter, son, husband or wife doesn't automatically give you authority to make decisions on their behalf. We need to be clear about the person's capacity for the particular decision, whether anybody has legal authority to act for them and, where they don't, how the family is being consulted as part of the best interests process.

If the record doesn't clearly explain what the person decides independently, where they need support to make a decision and where a proper best interests process is required, we shouldn't be particularly surprised when staff interpret things differently.

Person-centred care planning doesn't mean writing more

Some of the longest care plans I've reviewed have told me surprisingly little about the person. Pages and pages of generic text don't become more useful simply because we've added another ten. Copying the same information into four different sections doesn't make it four times as important either, although it can make finding the useful bit significantly more irritating. A good care plan needs enough detail to support safe and consistent care, but that information needs to tell staff something useful. It should help them understand the individual, recognise their preferences, support their independence and communicate with them in a way that works. It should tell us what matters to the person as well as what professionals have decided matters for them.

If capacity is in question, the person doesn't suddenly disappear from the process either. Their wishes, feelings, values and beliefs remain relevant. They should still be involved as far as possible, and we should still be supporting them to make the decisions they are able to make.

Read it as though you've never met them

When auditing care plans, it's very easy to concentrate on whether all the expected sections have been completed. I understand why we do it, but completion isn't really the test I'm interested in. I want to know whether, having read the record, I actually know anything meaningful about the person. Could I support them in a way they would recognise as their care? Do I understand what they can do for themselves, what matters to them and how they communicate their choices?

And if somebody has questioned their capacity, can I work out exactly which decision was being assessed, what was done to help them make it and how the eventual conclusion was reached? If I can't, adding their name another six times probably isn't going to fix it.

Person-centred care isn't about how often the person's name appears in the care plan. It's whether I can actually find the person in it.