Individual Care Plans

Care planning and the individual care plan document are essential to person-centred recovery-based care within in-patient and community residential settings. 

A care plan documents a set of goals developed, reviewed and updated by a multi-disciplinary team and where possible and practical, in consultation with each service user. It includes details around treatment and care required for each individual. It can also be used to identify necessary resources and specifies appropriate goals.

For children and adolescents his or her individual care plan should also include education requirements. 

Why are care plans important?

A good care plan will:

  • make sure everyone is working towards the same goals
  • lead to better treatment by focusing on the service user needs
  • identify the supports the service user needs for their recovery
  • involve the service user, their family and other support people in the recovery process
  • reflect the service user’s views and preferences

Care planning is an on-going process which starts when the service user is admitted to hospital.

  • The process starts with an assessment of the service user’s mental health and other needs, as well as their strengths and abilities
  • The service user and their team agree a plan to achieve the patient’s recovery goals
  • The plan is monitored during their stay
  • The plan is reviewed and updated as the needs and goals of the service user change
  • The plan will be reviewed by the service user’s community mental health team when they go home and this will support the service user’s progress in their recovery

Guidance for Individual Care Plan

In order to support mental health services be compliant with the Regulation, HSE Mental Health Operations have developed a guidance document on writing a person centre individual Care plan.

The purpose of this guidance document is to support good multidisciplinary team practice in individual care planning and measure progress of the service user throughout our mental health services. It includes the key elements of the care planning process and how these meet the criteria for compliance for Regulation 15 Individual Care Plan of the Mental Health Act 2001. 

The document is divided into two parts:

  • Part 1 - A step by step guide on the components required for care planning
  • Part 2 - Practical examples on how to develop a person-centred individual care plan 

The Mental Health Act 2001, (Approved Centres) Regulation 2006, Regulation 15, Individual Care Plan, requires that “each resident has an individual care plan”. “Each service user has an individual care and treatment plan that describes the levels of support and treatment required in line with his/her needs and is co-ordinated by a designated member of the multi-disciplinary team, i.e. a key-worker”. 

In order to be compliant, every resident must have a care plan in place, and care plan is assessed against nine separate criteria (ten for children). During the course of an inspection, a sample of individual care plans is reviewed. Failure to meet just one of the nine criteria for compliance (ten for children), in one care plan, will result in a rating of non-compliance on inspection.

Only if each of the above criteria is fulfilled for each resident’s individual care plan and for each service user, then the mental health service provider will be fully compliant with Regulation 15 of the Mental Health Act 2001, (Approved Centres) Regulations 2006.

Guidance for Individual Care Plans (PDF, 928 KB, 60 pages)