Introduction

The purpose of this assignment is to critically explore the person-centred care planning process
within health and social care, using the case of Mrs. A, an elderly woman with diabetes,
osteoarthritis, and early dementia. The report will examine key concepts such as assessment,
diagnosis, planning, implementation, and evaluation, demonstrating how these stages promote
holistic and personalised care. It will also analyse relevant legislation, models of care, and the
role of the multidisciplinary team in supporting service users. Through this structured approach,
the assignment aims to meet learning outcomes related to delivering effective, compassionate,
and coordinated care.

Person-centred care (150 – 200 words)

Scenario:
Mrs. A is a 78-year-old woman living at home with her daughter. She has diabetes, osteoarthritis,
and early-stage dementia. She requires support managing medications, mobility, and memory
issues while maintaining her independence and social connections.

Person-Centred Care (200 words)

Person-centred care in Mrs. A’s case means recognizing her as an individual with unique needs,
preferences, and life history rather than focusing solely on her medical conditions. It involves
actively involving Mrs. A, her daughter, and the healthcare professionals in decisions about her
care to support her autonomy and well-being.

The importance of this approach is profound for Mrs. A and her family, as it respects her dignity
and promotes better management of her diabetes and arthritis, while addressing her cognitive
decline compassionately. Collaborative care planning ensures tailored interventions—like
adjusting medication schedules to her daily routine or providing memory aids—that enhance her
quality of life. Professionals from the MDT, including nurses, physiotherapists, and social
workers, each contribute their expertise to deliver comprehensive support.

Legislation such as the Care Act 2014 supports Mrs. A’s right to personalised care and family
involvement, ensuring her needs and preferences guide care planning. The NHS Constitution
further enshrines patient choice and dignity. Policies and guidelines like NICE recommend
person-centred frameworks, mandating inclusive, respectful care that safeguards Mrs. A’s rights
while promoting her independence.
Models and theories of care (200 – 250 words)

Models and Theories of Care (230 words)

Models and theories of care provide structured approaches that guide health and social care
professionals in delivering person-centred care, ensuring care planning is holistic, coordinated,
and responsive to individual needs. These frameworks help integrate physical, psychological,
and social aspects, essential for complex cases like Mrs. A’s, who has multiple chronic
conditions and cognitive impairment.

Examples include the Integrated Care Model, which promotes collaboration across health and
social care services to provide seamless support, and nursing models such as Roper-Logan-
Tierney’s Activities of Living, which assess and support patients’ independence in daily
activities. The Primary Care Model focuses on accessible, continuous, and comprehensive care
through general practice teams.

Similarities across these models include their emphasis on holistic, continuous care and
multidisciplinary teamwork. Differences lie in their scope; for instance, the Integrated Care
Model spans multiple services and sectors, while nursing models focus on individual patient care
processes.

Benefits of these models include improved communication, reduced duplication of services, and
enhanced patient outcomes. However, criticisms include potential complexity in coordination,
resource constraints, and sometimes insufficient focus on individual patient preferences.

For Mrs. A, the Integrated Care Model is most appropriate as it facilitates coordination among
diverse professionals (e.g., diabetes specialist, physiotherapist, social worker) and includes
family in planning, addressing her multifaceted needs effectively. This model supports a truly
person-centred approach by bridging health and social care and ensuring continuity.
Care Process (100 - 200 words)

Care Process (160 words)

The care planning process is a systematic approach used to assess, plan, implement, and review
the care needs of a service user like Mrs. A, who has diabetes, osteoarthritis, and early dementia.
It ensures that care is personalized, coordinated, and responsive to her changing health and social
needs.

The purpose of care planning is to identify Mrs. A’s individual needs and preferences, involve
her and her daughter in decision-making, and coordinate input from the multidisciplinary team
(MDT) to provide holistic support. Benefits of care planning include improved health outcomes,
enhanced independence, better management of chronic conditions, and increased satisfaction for
Mrs. A and her family.

The key steps in the care planning process are:

1. Assessment – gathering detailed information about Mrs. A’s physical health, cognitive
status, social circumstances, and support needs.
2. Care Planning – developing personalized goals and interventions with input from Mrs.
A, her family, and the MDT.
3. Implementation – delivering the agreed care and support.
4. Review – regularly evaluating progress and adapting the plan as Mrs. A’s needs evolve.
Care Planning Process (1,250 – 1,450 words)

Certainly! Below is a comprehensive, detailed care planning process for a person-centred case
scenario based on Mrs. A — a 78-year-old woman living at home with diabetes, osteoarthritis,
and early dementia. This will cover the entire care planning process from assessment to
evaluation, with critical discussion and application of relevant concepts, legislation, and the NHS
6C’s.

Care Planning Process for Mrs. A: A Person-

Centred Approach
Case Study Scenario
Mrs. A is a 78-year-old woman living independently at home with the support of her daughter.
She has type 2 diabetes, osteoarthritis affecting her mobility, and early-stage dementia. Mrs. A
struggles with managing her medications, experiences pain and stiffness in her joints, and shows
signs of memory loss affecting her daily routines. She values maintaining her independence and
social contact but occasionally feels anxious about her health and future.

The care setting is community-based, with health and social care professionals providing support
at home and through local clinics. The multidisciplinary team (MDT) involved includes a GP,
community nurse, physiotherapist, social worker, pharmacist, and occupational therapist, with
her family actively engaged in the care process.

Purpose and Priorities of a Person-Centred Care Plan

The core purpose of a person-centred care plan is to provide an individualised, holistic
framework for managing Mrs. A’s health and social needs that respects her preferences, values,
and dignity. The plan prioritises her autonomy, quality of life, and safety, while managing her
chronic conditions effectively.

Incorporating a person-centred approach ensures that Mrs. A and her family are active partners
in care decisions, promoting adherence to treatment, emotional well-being, and social inclusion.
The care plan should include detailed assessments, clear goals, agreed interventions,
arrangements for regular review, and contingency plans for changing needs.

The plan is reviewed at least every six months or sooner if Mrs. A’s condition changes, ensuring
responsiveness and continuity of care. Access to the care plan is given to all involved
professionals and Mrs. A’s family, ensuring transparency and coordinated delivery.

Future developments may include digital care records accessible to Mrs. A and real-time updates
shared with the MDT, enhancing communication and responsiveness.

Assessment
Importance of Assessment

Assessment is the foundation of the care planning process. It involves gathering comprehensive,
accurate information about Mrs. A’s physical health, cognitive status, social circumstances,
emotional needs, and environmental factors. This holistic assessment identifies her perceived,
felt, and actual needs to ensure interventions are relevant and effective.

Skills required include active listening, empathy, observation, effective communication, cultural
sensitivity, and clinical judgment. Qualities such as patience, respect, and commitment to dignity
align with the NHS 6C’s — Care, Compassion, Competence, Communication, Courage, and
Commitment — ensuring a respectful, skilled, and responsive approach.

Assessment Process

Mrs. A was referred to community services by her GP due to difficulties managing her diabetes
and memory concerns. The assessment involves Mrs. A, her daughter, and the MDT.
Using the Roper-Logan-Tierney Nursing Model of Activities of Living, the assessment covers:

 Maintaining a safe environment: Mrs. A’s home is evaluated for fall risks due to
arthritis.
 Communication: Assessing cognitive function and memory impairment.
 Eating and drinking: Monitoring diabetes-related dietary needs.
 Mobility: Evaluating joint pain and limitations.
 Personal care: Assessing ability to manage hygiene and medications.
 Social participation: Exploring social contacts and emotional support.

Identified Needs

 Perceived needs: Mrs. A wants to stay independent and avoid moving into a care home.
 Felt needs: Anxiety about memory loss and medication management.
 Actual needs: Support with medication adherence, pain management, mobility aids,
cognitive support, and social engagement.

Relevant Legislation and Policies

 Care Act 2014 mandates personalised assessments and involvement of the individual and
carers.
 Mental Capacity Act 2005 guides assessing Mrs. A’s decision-making abilities.
 Equality Act 2010 ensures non-discrimination and respect for cultural values.
 NHS Constitution (2013) promotes patient involvement and dignity.

The NHS 6C’s guide the assessment process: care and compassion ensure Mrs. A feels valued;
competence guarantees accurate clinical assessments; communication involves clear
explanations; courage supports addressing difficult issues; and commitment ensures ongoing
support.

Diagnosis
Understanding Mrs. A’s diagnoses — type 2 diabetes, osteoarthritis, and early dementia — is
critical to tailoring effective care. These conditions interact to impact her physical and cognitive
functioning, requiring coordinated management.

Potential difficulties include medication mismanagement, falls due to impaired mobility, social
isolation from cognitive decline, and emotional distress.

Recognising these challenges allows professionals to anticipate risks and implement preventative
measures, improving Mrs. A’s quality of life.
Planning
Importance of Planning

Planning transforms assessment findings into actionable, measurable goals to improve Mrs. A’s
health and well-being. A SMART (Specific, Measurable, Achievable, Relevant, Time-bound)
approach ensures clarity and accountability.

Involvement in Planning

The MDT — GP, community nurse, physiotherapist, social worker, pharmacist, occupational
therapist — collaborate with Mrs. A and her daughter to design a care plan. Their expertise
addresses medical, physical, social, and emotional needs. Family involvement ensures alignment
with Mrs. A’s preferences and provides additional support.

Care Plan Example

 Goal: Mrs. A will manage her diabetes medication with 95% adherence within 3 months.
 Intervention: Pharmacist to conduct medication review; community nurse to provide
reminders and education.
 Goal: Mrs. A will improve mobility and reduce joint pain within 6 months.
 Intervention: Physiotherapist to deliver tailored exercises; occupational therapist to
recommend mobility aids.
 Goal: Mrs. A will maintain social contact at least weekly.
 Intervention: Social worker to facilitate community group involvement.

The NHS 6C’s are embedded throughout planning: care and compassion in goal-setting;
competence in evidence-based interventions; communication in shared decision-making; courage
in addressing safeguarding issues; and commitment to review and adapt plans.

Safeguarding and Policies

Safeguarding considerations include monitoring for potential neglect or abuse, given Mrs. A’s
cognitive impairment. The Care Act 2014 outlines safeguarding responsibilities.

Anti-discriminatory legislation, such as the Equality Act 2010, ensures Mrs. A’s cultural
background and preferences are respected. Social inclusion strategies promote community
engagement to combat isolation.

NICE guidelines on dementia care and diabetes management provide evidence-based

frameworks for planning.

Implementation
Implementing Mrs. A’s care plan requires coordinated action by the MDT, with clear
communication and role clarity. The community nurse will oversee medication support; the
physiotherapist will lead mobility interventions; the social worker will facilitate social
engagement; and the family will support day-to-day adherence.

Person-centred care ensures Mrs. A’s choices guide implementation—for example, tailoring
exercise timing to her preferences and including her daughter in visits for reassurance.

Essential skills include teamwork, flexibility, empathy, and problem-solving. The NHS 6C’s
remind staff to deliver care with compassion, maintain competence, and communicate
effectively.

Regular meetings and shared care records support coordinated implementation and timely
adjustments.

Evaluation
Evaluation is critical to determine if care goals are met and identify areas needing adjustment. It
involves reviewing Mrs. A’s medication adherence, mobility progress, cognitive status, and
social engagement through feedback from Mrs. A, her family, and professionals.

The best evaluation methods include observational assessments, clinical measures (e.g., blood
sugar levels), and patient-reported outcomes.

If goals are unmet—such as persistent medication non-adherence—the MDT reconvenes to

explore barriers and revise interventions, possibly involving additional support like a dementia
specialist.

Ongoing evaluation ensures the care plan remains relevant, effective, and truly person-centred.

Summary
This care planning process for Mrs. A demonstrates the importance of assessment,
multidisciplinary collaboration, SMART goal setting, person-centred implementation, and
continuous evaluation—all underpinned by relevant legislation and NHS principles. It
exemplifies how personalised, coordinated care improves outcomes and respects the dignity and
preferences of service users with complex health and social care needs.
Conclusion

This report highlights the essential role of person-centred care planning in managing complex
health and social care needs, as demonstrated through Mrs. A’s case. A comprehensive
assessment, involving Mrs. A, her family, and the multidisciplinary team, laid the foundation for
creating a tailored, holistic care plan. The use of SMART goals ensured clear, achievable
outcomes that addressed her diabetes, mobility issues, and cognitive decline. Effective
implementation and continuous evaluation, guided by relevant legislation and the NHS 6C’s,
supported her independence, dignity, and well-being. The process underscores the importance of
collaboration, communication, and respect for the service user’s preferences to deliver high-
quality care.

Recommendation

For future practice, enhancing digital integration of care plans would improve real-time
communication among professionals and with the service user. Additionally, increased training
for staff on dementia-friendly approaches and cultural competence would further personalise
care. Strengthening community engagement initiatives could help reduce social isolation, which
is crucial for clients like Mrs. A. Finally, involving service users and families more consistently
in review meetings would ensure care remains responsive to changing needs and preferences.