Writing a good care plan

A care plan is a jointly agreed, written plan between you and your care co-ordinator or lead professional which outlines:

• your assessed needs
• any risks to you or others
• personal goals
• support available
• your progress towards recovery.

You will be given a copy of your care plan. Your family, carers and supporters will receive a copy of your care plan with your permission.

A care plan should include your personal goals towards recovery and self-care as well as treatment and intervention goals.

This guide is not aimed at:

• providing a step-by-step instruction, every care plan is personalised to you
• giving advice on information sharing and confidentiality, this is something that you and your care co-ordinator need to talk about and agree.

Responsibilities of your care co-ordinator

• develop and write your care plan with you
• talk to the people involved in your pathway to recovery
• send the care plan to the people involved in your care
• review your care plan with you at least every 6 months
• be optimistic, compassionate, proactive and  believe in your strengths and resilience
• give relevant, timely advice to you and your carers, providing time for your carers to understand and make their own care and support decisions, including using advocates and interpreters if needed.
• ask the relevant questions to help you discover your strengths and needs, for example asking questions about:
  • what are your hopes and goals?
  • how do you feel these can be achieved?
  • what has worked for you in the past?
• who you are comfortable sharing information with and when this information may need to be shared without your consent.

Making sure that the information and details in your care plan are clear about explaining the responsibilities for other agencies involved in your care particularly if you have:

• been discharged from hospital in the last seven days
• a learning disability
• substance misuse problems
• safeguarding issues
• cognitive problems.

Crisis and contingency plan

The purpose of this plan is to provide you, your family, carers and supporters with timely advice and for you to know what to do when your mental health deteriorates or you are having a bad day.

The plan is based on individual needs looks at what has worked well for you in the past, who you respond/work well with, who to contact and relapse indicators.

This plan may not have been written with your full involvement if your first contact with mental health services was during a crisis.

This plan should have:

• contact details of your care co-ordinator or lead professional, community team telephone number and who to contact if they are not available
• an Out-of-Hours urgent advice contact telephone number
• GP contact telephone number
• contact telephone numbers for family and friends
• useful information and contact numbers
• any caring responsibilities (children, family or pets)
• medical conditions or allergies/ medication
• preferred method of communication
• preferred languages (to communicate)
• particular ways of behaving when distressed
• what helps or doesn’t help in an emergency or crisis?

How and where should a care plan be written?

This is an ongoing process. Plans and discussions will take place about your recovery and what it is you and your family want to get out of the care plan.

Consideration will be given to whom and what services will be supporting you on your pathway to recovery and what support is available. Self-management skills, positive risk taking and support needs for your family, carers and supporters will also be discussed.

A realistic time scale to write your care plan will be agreed with you and your care co-ordinator or lead professional.

Writing a care plan that everyone will understand

• you will be involved in developing  and writing your care plan with your care co-ordinator or lead professional
• if your care co-ordinator or lead professional was not at work could other people understand your care plan
• make sure that the actions in your care plan are realistic and achievable
• explain what each action means in the care plan and who will be doing what rather than it just being an instruction
• your family, carers and supporters can be involved in writing your care plan with your permission
• think about putting ‘I’ into the care plan so it is personal to you
• you may not always agree with your care co-ordinator or lead professional and a plan about  how to take this forward will be added to the care plan.

A care plan should…

• be a written record of ‘who, what, when, where, how and why’ identifying needs, personal goals, hope, actions, interventions and anticipated outcomes
• reference to your staying well plans, recovery star, my shared pathway or CHIME framework (connectedness, hope, identity, meaning and purpose in life and a sense of empowerment)
• be written in plain and simple language that can easily be understood
• identify your strengths
• reflect your cultural and ethnic background and spirituality needs
• identify any risks to you or others, including family, carers, supporters or anyone else involved in your care and support
• include contact details for your care co-ordinator or lead professional and everyone involved in providing support
• have any provisions of direct payments or individual budgets
• the next planned review date of your care plan
• include a transfer date if appropriate from one service to another
• include information on staying well and coping skills in times of difficulty
• have any specific provisions and entitlements to aftercare  under section 117 of the Mental Health Act 1983
• include contact information on what to do in a mental health crisis
• include contact details for local mental health services.

Tips to make the text easy to understand in your care plan…

• avoid using jargon, and use simple words
• sometimes medical terms have to be used but make sure you understand what they are
• use short sentences of no more than 15-words
• use positive statements (avoid using negative statements)
• use small blocks of text
• typed information should usually be in Arial font, font size should be between 12 and 16 point.
• large bold font to emphasises text
• try not to use UPPER CASE letters, italics and underlining as these make the text more difficult for you to read. 
• make sure the bullet points make sense on their own
• use active sentences not passive sentences, for example; ‘your appointment is on…’ not ‘your appointment has been made for …’.

Examples of a way to write a personalised care plan….

• ‘I will attend therapy sessions for support with my anxiety every Wednesday’
• ‘My husband will support me with my breathing exercises if I have a panic attack’
• ‘I will work with my GP to reduce the amount of tablets I take for my anxiety at my next appointment on 5/10/15’
• ‘At the end of the treatment I will talk to my care co-ordinator Julie, about a discharge plan from the current team’    

This information is also available as easy read;

L882, v3, 15/03/21, archive 14/03/24