Personalised Care and Support Plan Standard
More people than ever are living with long-term physical and mental health conditions in the UK. As a result, there has been a national drive towards developing long-term care plans collaboratively between professionals and people.
Personalised care planning standards will help people manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care. This standard will help them and the health and care professionals who support them to get the right information when they need it.
Current release
Version: V2.0 | |
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Release date | December 2021 |
Release notes |  |
Next release date | TBD |
Next release type | Scheduled maintenance update with terminology refinements |
The standard | |
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Full standard – PRSB viewer |   |
Full standard – Excel |  |
Full standard – Json |   |
Supporting documentation | Description/purpose |
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Information standards notice (ISN) | ISNs are published to announce new or changes to information standards published under section 250 of the Health and Social Care Act 2012. |
| This document includes general implementation guidance for all PRSB standards and detailed guidance, specific to the Personalised Care and Support Plan Standard. |
Implementation toolkit | A step-by-step guide to help suppliers and organisations implement the standard. |
 | Rules for implementation of the standard. |
Final report | Describes the purpose, methodolgy and stakeholder engagement for developing the standard, along with the findings and recommendations for further work. |
| Summarises the hazards which could result from implementing the standard. |
| Details the potential hazards from implementing the standard with their risk rating and mitigation. |
Need implementation support?
- Online support form
- Support@theprsb.org
- 020 4551 5225 (9-5 Mon-Fri, excl. bank holidays)
About this standard
The standard supports personalised care and support planning so that individuals have a single shared personalised care and support plan to which all health and care professionals can contribute. The aim is to avoid what currently happens too often, where separate care plans are created by different professionals or teams of professionals and they are not widely visible, don’t join up, and don’t promote a holistic approach to meeting a person’s care needs.
The plan should be developed with the person themselves and/or with their carer where appropriate, based on the person’s strengths and holistic needs.
The benefits:
- Improves continuity of care by ensuring people have a single care plan that shares key information to help them to get the right care and support when they need it.
- Helps people contribute and feel actively engaged in their own care
- Provides a single, holistic picture of their needs, goals and actions, enabling them and their family/carers and health and care professionals to provide appropriate support to improve a person’s health and wellbeing.
Erica, a mental health campaigner has lived with severe mental illness. She talked to PRSB about why a digital personal care plan is essential for her mental health and wellbeing to prevent any relapses.
Scope
The standard is UK wide for use across the whole of health and social care and for anyone requiring a care and support plan, including children, with any health and/or care needs.
How it works
A personalised care plan should be produced from a conversation between the person (and/or their carer) and a care professional, focusing on what’s important to the person and their holistic needs and goals.
The summary view table below shows the main and supporting sections of the standard:
Main sections:
| About Me | Information that the person considers important to share with people caring and supporting them and including what matters to them (their needs, concerns preferences and wishes) |
| Care and support plan | Developed with the person as a single plan to reflect their holistic needs and the goals and actions to support those needs |
| Contingency plans | The things to do and people to contact, should a person’s health or other circumstances get worse |
| Additional support plans | For further detailed plans to support for particular conditions or care and support |
Supported by sections for:
| Person demographics | Details of the person (name, DOB, gender, NHS Number, address, contact details etc) |
| GP practice | Details of the person’s GP practice |
| Professional contacts | Details of the person’s professional contacts |
| Personal contacts | Details of the person’s personal contacts |
| Formulation | Only used where appropriate only and usually for people with mental health problems. An account, shared by a therapist and the person, of the personal meaning and origins of a person’s difficulties. This is viewed in the context of multiple factors including relationships, social circumstances and life events and will indicate the most helpful way forward to support them. |
The standard supports the personalised approach to care and support planning with a single shared care and support plan for all the professionals and people involved in a person’s care, including the person themselves and/or their carers.
It starts with their ‘About Me’ information, then focuses on their strengths and needs, together with their goals, hopes, and aims. It should demonstrate how the person’s aims and goals will be met and who is responsible for delivery of the activities to achieve them. These are the person’s holistic needs (e.g. to recover their mobility or manage anxiety) which may require support from different parts of health and social care.
Additional support plans may be linked to the care and support plan and should be available for others to view. Their format will vary according to the type of plan and can be structured and coded, and some may include diagrams or images. They can be used for detailed plans to support particular conditions such as a dietician’s plan, wound management plan or behaviour support plan, or to set out care plans, for example to support activities of daily living.
Contingency plans, also known as anticipatory, escalation, or crisis plans provide details of how predictable risks associated with health and wellbeing are managed if they get worse’. They are plans of what to do should a person’s health or circumstances get worse and who to contact.
The diagram below shows how addition support plans and contingency plans fit into the PCSP. Please click on the image for a full size version.
Examples
This example demonstrates how the standard works in practice:
Further resources
- Standards explained
PRSB’s guide to standards which sets out the purpose and benefits of using standards and how to support frontline professionals to adopt them.
- IHRIM record correction guidance
Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.
Useful links
Endorsement
The following organisations have endorsed this standard:
- Royal College of GPs
- Royal College of Nursing
- Royal College of Obstetricians and Gynaecologists
- Royal College of Occupational Therapists
- Royal College of Physicians
- Royal Pharmaceutical Society
- Care Providers Alliance
- Institute of Health Records and Information Management
- TechUK
Supporters
The Association of Directors of Adult Social Services – ADASS do not have the capability to endorse standards, but do support the standard.