Person centred care plan example: What good looks like in practice

In health and social care, person centred planning is a key concept that makes sure individuals are not simply receiving support but are actively involved in deciding how that support is provided. Whether it’s supporting older people, individuals with learning disabilities, or those with complex needs, the goal is always the same: to place the individual at the centre of their care.

For care providers, developing a genuinely person centred care plan means going beyond just meeting regulatory standards. It focuses on achieving better outcomes, promoting independence, and enhancing overall wellbeing. In this blog, we’ll explore what makes a strong person centred care plan and share a detailed person centred care plan example based on someone with autism and high support needs.

What is a person centred care plan?

A person centred care plan is a customised, collaboratively developed document that details an individual’s needs, preferences, routines, and aspirations. Unlike more traditional, medically-focused plans, person centred care plans prioritise what is most important to the individual.

These plans should remain adaptable, evolving as the person’s needs and life circumstances change. They also play a crucial role in fulfilling the Care Quality Commission’s (CQC) expectations for tailored, results-oriented care as part of the new Single Assessment Framework.

Key components of a person centred care plan

A strong care plan should:

• Be developed in collaboration with the individual and their support circle
• Reflect the person’s voice, abilities, and ambitions
• Use clear and accessible communication tailored to the person’s preferences
• Contain risk assessments and forward-thinking support strategies
• Include SMART goals to monitor progress and outcomes
• Promote physical, emotional, and social wellbeing
• Be readily available to all care staff to ensure consistency

When these elements are in place, care teams can provide support that is not only safe and effective but truly meaningful and personalised.

Why person centred planning matters

A strong person centred approach improves:

• ‍Wellbeing: People feel seen, heard and valued
• ‍Independence: Plans help people do more for themselves
• ‍Continuity of care: Staff understand routines, preferences, and triggers
• ‍Regulatory outcomes: Providers demonstrate compliance and quality
• ‍Crisis prevention: Risks are managed through proactive planning

Example: Jake’s person centred care plan

To illustrate how these principles come together in practice, here’s an example of a care plan for Jake, a 24-year-old autistic man with high support needs.

Jake lives in a supported living service and requires significant support with daily tasks, communication, and emotional regulation. His care plan draws from PBS (Positive Behaviour Support), SMART goals, and proactive care practices.

About Jake

Name: Jake Reynolds
Age: 24
Diagnosis: Autism Spectrum Condition, Sensory Processing Difficulties, Learning Disability
Living situation: Shared supported living home with 24-hour staffing
Support needs: High – requires 1:1 support during the day, 2:1 support in the community
Likes: Train timetables, classical music, playing memory games
Dislikes: Sudden loud noises, unplanned changes to routine, crowded spaces

Communication style

• Uses gestures, vocalisations, and a picture exchange communication system (PECS)
• Understands short, clear sentences
• Staff should always use visual cues alongside spoken communication
• Avoid abstract language or sarcasm

Daily routine

Jake thrives on routine. His visual schedule is updated daily, and changes must be explained in advance using social stories. His morning routine includes brushing teeth with staff support, preparing his favourite breakfast (toast with jam), and checking the weather app before planning his outdoor walk.

Goals (using SMART framework)

Goal 1: Increase independence in personal care
SMART version: Jake will learn to brush his teeth independently with visual support over the next 8 weeks, aiming to complete the task 4 days per week with only verbal prompts.

Goal 2: Engage in social activities
SMART version: Jake will attend a weekly music group with 2:1 support, remaining for at least 30 minutes each session for a period of 3 months.

Goal 3: Reduce incidents linked to unexpected change
SMART version: Jake will use a coping toolkit (headphones, sensory toy, and quiet space) during changes to his routine. Support staff will track reduced distress indicators over a 6-week period.

Risk assessments

Behaviour that challenges

• Triggered by noise, unfamiliar settings, or disrupted routines
• Proactive strategies:
  
  • Use of traffic light system (green: calm, amber: signs of distress, red: escalation)
  • Use of quiet room when signs of agitation appear
  • Keep headphones accessible and offer breaks from overstimulating environments

Community access

• Requires two support workers for safety
• Staff to carry visual communication tools and remain calm and predictable

PBS planning

Jake’s PBS plan focuses on understanding his preferences, avoiding known triggers, and promoting positive behaviours through consistency and engagement. Activities are structured with plenty of preparation and positive reinforcement.

His plan also emphasises the importance of positive engagement, not just managing incidents. Jake responds well to being involved in choosing activities, especially when related to his interests, such as train stations or music. A “capable environment” is maintained where he feels safe and empowered to make choices.

Family and support involvement

Jake’s parents are closely involved in his care. They join monthly review meetings and contribute to planning holiday visits or family outings. Their insights help staff understand Jake’s history, preferences, and early signs of distress.

Staff notes

• Build trust by using the same team of carers wherever possible
• Always introduce yourself and show the day’s visual schedule
• Avoid overcrowding and allow time for transitions between activities
• Use calm tones and body language; avoid rapid speech or instructions

The role of technology in person centred planning

Digital care management tools are increasingly important in delivering reliable and proactive support. With systems like Log my Care, providers are able to:

• Update and manage care plans in real time
• Monitor progress towards SMART goals
• Record behaviours, incidents, and patterns
• Use scheduling tools to pair people with familiar carers
• Securely share care records with families and professionals

This approach not only enhances care delivery but also supports compliance and continuous quality improvement.

Embedding person centred planning in your service

To build and maintain effective care plans, try the following:

Co-create with the individual
Use accessible communication and tools to involve the person as much as possible in developing their plan.

Apply SMART goals
Steer clear of vague objectives. Focus on making goals clear, measurable, and relevant to the person.

Take a proactive approach to documentation
Include preventive strategies, signs to watch for, and elements of Positive Behaviour Support to reduce crisis situations.

Involve family members and support networks
These individuals often know the person best and can contribute to creating consistent and holistic plans.

Keep plans flexible
Review them frequently and adjust based on results, progress, or changes in needs.

Final thoughts

Person centred care planning isn’t something done just once. It is an evolving process that respects individuality and encourages collaboration. As shown in Jake’s person centred care plan example, thoughtful planning helps people live with greater confidence, safety, and purpose—even when support needs are complex.

Whether you're supporting autistic adults, older individuals, or those with physical disabilities, the approach remains the same: listen carefully, plan together, and act intentionally.