HCPA Members Zone

Care Planning


Involving people in decisions about their care is intrinsic to the principles of the MCA and should be evident in every care and support plan. Research on mental health and wellbeing demonstrates that involvement leads to improved service outcomes and enhances mental wellbeing. People who use services and their carers are experts by experience. By bringing their knowledge and ideas, they give a fresh perspective on how their particular needs for care and support can best be met.

Providers and commissioners must challenge assumptions about how care plans are developed that limit the level of active involvement by the user. Supporting people to be involved in decisions about their care and treatment should be reflected in the ethos, management, policies and care practice of each service. All services should be able to show how they do this.

Care Planning Toolkit

HCPA, HCC, Herts and West Essex ICB and CQC have collaborated to put together a best practice toolkit to enable managers to do a self-assessment on care plans. This document can be used as an audit tool or can be utilised to put together training for staff as it will give guidance on best practice. Once you and your team have finished the toolkit you will be able to recognise any areas of care planning where you may want to consider changes.

HCPA brought together all the bodies who are likely to come to your service and look at care plans and asked them to add any areas where they have seen ‘issues’ in the past or where they would look for very best practice. Do please use this toolkit as a working document and always download the latest version on the website as it is regularly updated.

Please email HCPA if you feel you need support with care planning training in your service and we will be happy to support you.

» Care Planning Toolkit

Electronic Care Planning

Use of Electronic Care Records in Homecare Providers

Hertfordshire County Council (HCC) have received an increased number of concerns and queries relating to providers’ use of electronic care records. HCC are aware that many of our contracted providers are choosing to use such systems to support their businesses.

Whilst the Council supports the use of such systems, providers must be mindful that going entirely paperless will not be appropriate for every service user and their family/carer and the provider will need to facilitate access to information where this is required, this may for example be by secure email or in some circumstances through continued use of paper versions of diary records etc in the home of the person you support.

As a minimum the Council expects the following information to be in a service user’s home:

  • A Service User Guide
  • A care plan so that the service user and/or their legal representative and any visiting professionals are able to see the care support that an individual has


Here are some other things that should be considered when using electronic care records:

  • People using a service must be able to access and contribute to their own records in their preferred format, which is in line with the Accessible Information Standard.
  • Providers must ensure systems are robust and secure with contingency in place should systems go down.
  • Individuals and their family/carers should not be charged to access information for example via an app.
  • Providers will need to evidence that they have discussed choices relating to information and documentation with the person they support and their family/carer (where appropriate).
  • It is not sufficient to assume individuals are happy with electronic care records because they have not specifically raised a concern or requested alternative options.
  • Individuals MUST be made aware of the options open to them and this will be monitored by the Council through reviews and monitoring visits.
  • Providers need to be mindful of confidentiality and steps will need to be undertaken to support the individual to decide who can have access to what information.
  • Social Care Professionals and Monitoring Officers employed by HCC will require access to information to support statutory reviews and quality assurance processes. Providers therefore will receive requests for data and information, and the must be responded to within 24 hours or sooner where requested.

If you have any queries relating to the use of electronic care records please speak to your Monitoring Officer in the first instance.


Eclipse is a care management solution allowing staff to capture what matters and builds a person centres profile for each client. Assessment and care plans are available on every carers phone so everyone can keep up to date. All this makes it easier to record your clients’ needs consistently and effectively.

» Click here for more information about Eclipse

Improving personalisation in care homes – Action planning tool

This action planning tool from the Social Care Institute for Excellence (SCIE) is for managers and owners of care homes for older people. It will help you to:

  • Build a shared understanding of what personalisation (or person-centred care) means in a care home setting
  • Identify and plan practical improvements that will make your home more personalised

It has been designed to also be used for wider groups of people including those with complex conditions. Care home managers will be able to use the tool to support good conversations with residents and staff, and identify the improvements that will make the most difference to people’s quality of life.

Personalisation means building services and support around people so they can lead fulfilling lives. Towards the end of people’s lives, personalised care and support helps ensure people spend their time in ways that matter to them and with the people they want to share time with.

Because the focus of personalisation has been on supporting people in community settings, not enough has been done to support people who are working to make personalisation happen in care homes.

We recognise that care homes are an important and valuable part of the care economy and that much great work is going on to interpret what personalisation means to people living in homes.

This action planning tool will help you explore what personalisation means for care homes and more importantly help you have conversations together about where you are now and what you could do to improve things.

» Care Home Action Plan

Advance Care Planning

Advance Care Planning allows a person to plan their future care and support. This can include medical treatment, DNAR’s and any forms of care that may be required as they reach the later stages of their life. Advance care plans should be done while the person in question has capacity to make their own decisions.

Whilst not everyone will want to make an advance care plan, it may be especially relevant for people at risk of losing mental capacity (i.e. through progressive illness) and people whose mental capacity fluctuates (i.e. through mental illness.)

For more resources, please refer to the NICE Guidelines and Toolkit

» Click here to watch a video from Garden House Hospice Care which answers questions around Advanced Care Planning

Positive Behaviour Support (PBS)

Positive Behaviour Support (PBS) is a ‘person centred framework’ for providing long-term support to children and adults with learning disabilities, autism, or dementia, who have, or may be at the risk of displaying distressing behaviours. PBS helps adult social care professionals, including managers understand the reason for the behaviour so they can better meet people’s needs, enhance their quality of life, and reduce the likelihood that the behaviour will happen.

The bild have created a short introductory video about PBS. Watch it here.

There are 4 main reasons someone may start to present behaviour which challenges:

  1. Attention – could be positive or negative.
  2. Escape – they are trying to avoid something.
  3. Sensory stimulation – they like the feeling of the behaviour.
  4. Tangibles – they desire a social reaction.

Positive Behaviour Support framework

The framework is divided into three main areas, each of which details specific competencies that need to be achieved to deliver effective support. These are:

Area Reason for area
Creating high care and support environments Aims to ensure organisations and those providing support operate from a person-centred support. Person-centred support ensures a high quality of life for all concerned, which includes assessing the risk factors for the development and maintenance of behaviour that challenges.
Functional, contextual, and skills-based assessment Aims to ensure that the support outlined for each person is based on a thorough understanding of that person’s needs, preferences, abilities, communication style, the function for them of any behaviour that challenges and how this is maintained, and the context and resources in which and with such support may be given.
Developing and implementing a Behavioural Support Plan (BSP) Aims to provide a detailed and personalised description of how best to support each person with developmental disabilities and their behaviours of concern.


All the competencies listed are necessary for the person being supported. However, not all competencies will need to be demonstrated by every individual involved in the provision of care. While there are certain core competencies which will be applicable to everyone, there are also specialist competencies which will be the focus of experts within that area.

For this reason, the framework details three levels of competencies by function which can be identified in the diagram below.


» Click here to view full details about the framework.

HCC have advice, research and resources relating to Positive Behavioural Support for professionals, citizens and individuals, providers, families, and carers on their website.

» Visit the HCC PBS website link here.




Training should be certified by the Restraint Reduction Network

From April 2021, it is expected to see all services across Health and Social Care use training in restrictive practices that is certified as complying with the Restraint Reduction Network Standards. The standards apply to all training that has a restrictive intervention component and provides a benchmark for training in supporting people who are distressed in education, health and social care settings. The standards apply across child and adult services, and to all populations, including people using services with mental health conditions, those living with dementia, people with a learning disability and autistic people.

Due to the coronavirus pandemic, CQC acknowledge that the face-to-face training required to comply with these standards is not always possible. However, since April 2020 any training provider that wants to supply training should be certified by the Restraint Reduction Network. CQC expect providers of services to commission training accordingly.

CQC have published the final report in their review of restraint, seclusion and segregation.

This report describes what they found about the experiences of care for children, young people and adults who are subject to restrictive practices.

» Click here to read and find out more


Document Name  Description  Link
CQC Guidelines for PBS  Brief description on PBS and the support for people with behaviours that challenge. Click here
Find the Reasons for Challenging Behaviour: Part 2 info sheet Information about what may lead to challenging behaviour and the different stages. Click here 
Positive Behaviour Support Planning: part 3 info sheet Practical tool to support family carers to understand how to reduce the behaviour that challenges. Click here 
Positive and Proactive Care: Reducing the need for Restrictive Interventions Guide prepared by the Department of Health focusing on PBS and restrictive interventions. Click here 
Physical Restraint Information on physical restraint and when it is appropriate to use. Click here 
Glossary of Terms A document that explains commonly used terms associated with PBS. Click here 
10 Things you can do to support a person with Difficult Behaviours List of ideas for uncovering the real things that a person may need so that you can be more supportive with their challenging behaviour. Click here 
Support Worker Competence Checklist A checklist for you to record and demonstrate your competence in delivering PBS. Click here 
PAL Guide for Activity Provision A simple, effective tool enabling participation, person-centred care and well-being of people living with all stages of dementia Click here
PAL Sensory Activity Level Guide PAL asks users to develop a profile of a person’s interests and likes and dislikes and complete a simple checklist that reveals the level of ability of an individual. Click here
PAL Checklist The PAL instrument consists of a quick yet reliable checklist to complete for each individual resident. The checklist determines an ability level for each resident – Planned, Exploratory, Sensory or Reflex. Click here
Positive and Proactive Support Plan This plan should be implemented alongside a risk management plan. Click here 
Observational Checklist Provides practical tools for those observing or inspecting services which provide PBS. Click here 
Behaviour Support Planning Audit Tools Questionnaire to help evaluate where the service is now and prompt action planning. Click here 
Scatter Plot Assessment Tool Tool to help discover patterns related to the behaviour and specific time periods. Click here 
Antecedent Behaviour Consequence (ABC Analysis Chart) An ABC recording is a way of collecting information to help determine the function of a person’s behaviour. Click here 


Additional Resources

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