Module Number: HSO5007

Module Name: Person-Centered Health and Social Care

Student Name:

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 TABLE OF CONTENTS

Introduction......................................................................................................................................3

Person-centred care..........................................................................................................................3

Models and Theories of Care ………………………………………………………………………………………………………………….3

Care Process …………………………………………………………………………………………………………………………………………..4

Care planning Process ……………………………………………………………………………………………………………………………5

Assessment……………………..…………………………………………………………………5
Diagnosis …………………………….……………………………………………………….…..7
Planning:……………………………………………………………………………………….….7
Implementation…………………………………………………………………………………..,8
Evaluation ……………………………….……………………………………………………….8

Conclusion and recommendation …………………………………………………………………9

References……………………………………………………………………………..................10

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Introduction

The reason for this assignment is to discuss the person-centered care planning approach in health
and social care by using Mrs. as an example. A woman over sixty who copes with diabetes,
osteoarthritis and starting to develop early dementia. Key aspects of assessment, diagnosis,
planning, implementation and evaluation will be explored in the report, to show how they
contribute to both overall and individualized care. It will further review related laws, models of
providing care and the job of the multi-professional team for service users. With this method, the
assignment tries to help students reach the objectives for providing care that is effective,
compassionate and coordinated (Jones et al., 2025).
Person-centered care

Scenario:
Mrs. A is 78 years old and lives at home with her daughter. She deals with diabetes,
osteoarthritis and early-stage dementia. She needs help with using her medicines, staying on her
feet and remembering things while she maintains her independence and enjoys social life.

Person-Centered Care

Person-centered care in Mrs. to understand A’s case, we should recognize her individuality
instead of just focusing on her health-related conditions. It involves actively involving Mrs. A,
along with her daughter and the health professionals, made decisions that valued her
independence and health.

This way of thinking matters a lot to Mrs. Thanks to A and her family, dignity is respected and
her diabetes, arthritis and decline in mental ability are properly looked after, with empathy.
Using a team approach for her care plan lets us design practical steps such as changing her
medication times or using memory tools, to help her enjoy a better quality of life (Lydahl et al.,
2022). The team includes nurses, physiotherapists and social workers, who use their expertise to
give good MDT care.

Laws such as the Care Act 2014 work to help Mrs. Personalized care and keeping her family
involved in planning care so A’s wishes are met. Patient choice and dignity are reaffirmed by the
NHS Constitution. NICE and similar policies say that person-centered care models must ensure
that Mrs. A’s right to independence along with basic personal rights.

Models and Theories of Care

Using different care models and theories helps health and social care workers give personalized
care that covers every need, stays coordinated and is planned well. They make it easier to focus
on the physical, mental and social needs which play a key role in facing difficult cases like
Mrs.’s. A is a patient with several long-term illnesses and cognitive problems.

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The use of the Integrated Care Model allows different services to cooperate for better support
and examples of nursing models include the Roper-Logan-Tierney activities which help people
with their daily functions. Primary Care aims to ensure effective, regular and thorough care for
all patients through teams in general practice (Gliedt et al., 2023).

Expressive therapy models all focus on providing ongoing, team-based treatment while
considering a client as a whole. Differences lie in their scope; The Integrated Care Model brings
together different services and sectors, whereas nursing models pay attention to individual
patient care processes.

These models help to improve the way doctors and patients communicate, save on unnecessary
services and lead to better patient results. Even so, people criticize it for being hard to
coordinate, the limited availability of resources and sometimes not considering the patient’s own
preferences carefully enough.

For Mrs. A, the Integrated Care Model helps diverse professionals to work together and includes
the family in addressing her many health concerns. The model encourages a person-centred
approach by uniting health and social care teams and ensuring there is no gap in care (Mudd et
al., 2020).

Care Process

Before Mrs. receives care, the process systematically checks her needs and plans, provides and
checks the success of her care. Someone with diabetes, osteoarthritis and early dementia is
identified as A. It guarantees that care meets her needs personally, is coordinated and is ready to
adapt to her changing well-being and life situations.

The main aim of care planning is to recognize Mrs. A attends to her daughter’s personal
demands and choices, lets the daughter participate in planning and organizes MDT input to
ensure full support. Mrs. will soon have better health results, increased ability to care for herself,
better care for her chronic diseases and greater happiness. A and her family (Keating et al.,
2021).

The following steps are the most important in creating a care plan:

1. Gathering all the facts about Mrs. How A is physically, mentally, and socially and what kind
of support they require.

2. Goal setting and action plans are made for her, using her and her family’s suggestions. A and
her family, alongside the MDT.

3. Delivering the help and care decided on by the plan.

4. Regularly check your advance and change the plan if necessary according to what Mrs. A’s
needs evolve (Alliman et al., 2019).

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Care Planning Process
Certainly! Below you’ll find the main steps in making a detailed care plan for Mrs. A — a 78-
year-old who lives at home and has diabetes, osteoarthritis and early dementia. You will work
through the whole care planning process, from initial assessment to concluding evaluation,
discussing and using necessary concepts, laws and the NHS 6C’s.

Care Planning Process for Mrs. A: A Person-Centred Approach

Case Study Scenario

Mrs. A is an independent 78-year-old woman who lives at home with the assistance of her
daughter. She has diabetes, a mobility issue from osteoarthritis and dementia. Mrs. She has
difficulties controlling her medicines, complains about aching and stiff joints and shows signs of
not being able to remember some things during the day. She likes to be independent and enjoy
social life, yet sometimes worries about her health and upcoming years.
The care provided is done in people’s homes or at nearby clinics by both health and social
professionals. Members of the MDT are a GP, community nurse, physiotherapist, social worker,
pharmacist and occupational therapist, while her family is an active part of her care process
(McBride and M., 2024).

Purpose and Priorities of a Person-Centered Care Plan

The basic goal of a person-centered plan is to give Mrs. an individual, well-rounded approach to
care. A’s physical and social needs are met in a way that honors what A thinks, feels and values.
Her autonomy, the quality she enjoys and safety are prioritized in the plan and her chronic
conditions are managed correctly.
Making this an individualized program gives Mrs. A and her family participate in making
decisions about care, support her taking her medications, help with her feelings and make sure
she stays connected with others. The plan must detail each assessment, state the main aims, agree
on actions, set up reviews and make ready for any changes to needs.
You should review the plan every six months at the very least and earlier if Mrs. The treatment
changes with A’s condition in order to keep care on track. The care plan is available to all the
professionals as well as Mrs. The family of A should work together, making sure everything is
open and delivered appropriately.
Developments in the near future might allow Mrs. to look at her own digital care records online.
Sending A and real-time details to the MDT makes everyone in the team more aware and quick
to respond (Damant et al., 2025).

Assessment

Importance of Assessment

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Care planning is built on the process of assessment. The process requires you to collect complete
and correct data about Mrs. The state of A’s body, mind, social life, feelings and surroundings.
The assessment considers what the client feels she needs, what she really requires and what she
actually requires so that any help offered is effective.

Being able to listen, feel empathy, observe, communicate clearly, be culturally aware and make
clinical judgments are needed skills. Being patient, respectful and dedicated to dignity goes
along with NHS 6C’s Care, Compassion, Competence, Communication, Courage and
Commitment to make the approach kind, knowledgeable and responsive (Stogiannos et al.,
2022).

Assessment Process

Mrs. Her GP sent a referral to community services as A had difficulties managing her diabetes
and remembering things. The assessment involves Mrs. A, along with her daughter and the
MDT.

Based on the Roper-Logan-Tierney Nursing Model of Activities of Living, we observe:

 Maintaining a safe environment: Mrs. The environment of A’s home is looked at for
any fall hazards related to arthritis.
 Communication: Evaluating problems with thinking and memory.
 Eating and drinking: Monitoring diabetes-related dietary needs.
 Mobility: Evaluating joint pain and limitations.
 Personal care: Reviewing someone’s ability to take care of cleanliness and use
medications.
 Social participation: Considering how well people connect and help each other (Da
Costa et al., 2020).

Identified Needs

 Perceived needs: Mrs. A desires to stay independent and keep living independently.
 Felt needs: There is a lot of anxiety about storing and taking medication correctly.
 Actual needs: Support for taking medicine correctly, controlling pain, using assistance to
move, memory aids and interacting with others.

Relevant Legislation and Policies

Under the Care Act 2014, local authorities must make sure the individual and carers are involved
and assessments are tailored to each person.
Assessment of Mrs. is governed by the Mental Capacity Act 2005. A’s decision-making abilities.

 The Equality Act 2010 protects people from being discriminated against because of
culture.
 The NHS’s Constitution from 2013 puts importance on ensuring patients are respected
and equal.

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The NHS 6C’s shape how a case is assessed. care and compassion ensure Mrs. A feels valued;
Being competent helps you assess patients accurately, clear communication makes things easy to
explain, courage helps handle tough situations and commitment ensures you will always provide
help (Squires et al., 2024).

Diagnosis

Understanding Mrs. Each diagnoses present in A type 2 diabetes, osteoarthritis and early
dementia matters in organizing good care. Because these issues affect her brain and body, they
must be managed together.
Problems that can happen include mistakes in taking medications, falls because of lack of
movement, social isolation because of thinking issues and stress.
When professionals understand these obstacles, they are able to avoid risks and make her
lifestyle healthier. A’s quality of life.

Planning

Importance of Planning

Instead of leaving assessment results as findings alone, planning allows us to set goals for Mrs.
A’s health and well-being. Following a SMART (Specific, Measurable, Achievable, Relevant,
Time-bound) method provides both definition and responsibility.

Involvement in Planning

Mrs. Meets with the MDT team members which includes the GP, community nurse,
physiotherapist, social worker, pharmacist and occupational therapist. They worked with A to
plan how to help her with her care. They help meet the medical, physical, social and emotional
needs of patients. Being active in the family will help you align with Mrs. Support systems are in
place to meet A’s needs as desired (Scobbie et al., 2025).

Care Plan Example

 Goal: Mrs. In 3 months, the woman is expected to follow her diabetes medication 95% of
the time.
 Intervention: Have the pharmacist check all medications and ask the community nurse
to remind the person about them and teach how they’re used.
 Goal: Mrs.A you can see increased movement and less joint pain within 6 months after
starting.
 Intervention: A physiotherapist will recommend exercise suited to the patient and an
occupational therapist can suggest mobility aids.
 Goal: Mrs. A will reach out to at least one person in the family on a weekly basis.
 Intervention: The social worker should play a key role in linking people to community
groups.

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You will see the NHS 6C’s throughout the planning process. Having care and understanding
when planning goals, being skilled in evidence-based care, talking people through decisions,
being brave when it comes to safety and having dedication to review the plan.

Safeguarding and Policies

Mrs. A’s cognitive impairment. The Care Act 2014 explains what safeguarding involves.
Laws like the Equality Act 2010 make sure that Mrs. A’s cultural traditions and likes are
respected. Strategies that include society in public life prevent people from feeling alone.
Guidelines from NICE offer information for planning dementia and diabetes care (Ahmed et al.,
2022).

Implementation

Implementing Mrs.A It is important that the members of the MDT cooperate, communicate
clearly and have clear roles in A’s care plan. Giving medication will be under the supervision of
the community nurse. Physiotherapy involves helping the individual move, social work ensures
that the patient feels a part of the group and the family offers daily support.
Person-centered care ensures Mrs. By adjusting the time of her exercises and letting her daughter
join visits, A is following her own instincts as a caregiver.
Teamwork, flexibility, empathy and problem-solving are some of the important skills you need.
NHS 6C’s make sure staff care with kindness, are up-to-date in their skills and speak clearly.
Meeting frequently and using the same patient records allow everyone to work together and
make changes in a timely way.

Evaluation

Evaluating the care is necessary to know if objectives are achieved and to make needed
improvements. It involves reviewing Mrs. The drugs A is given, how A is moving, cognitive
capabilities and social life were all assessed through Mrs. A, her family, and professionals.
The best way to evaluate includes watching patients, taking laboratory tests and listening to what
they have to say.
Should goals be ongoing issues, the MDT gathers again to consider options and provide
additional backing through a dementia specialist?
By regularly checking the care plan, it can stay current, work well for the patient and follow the
person-centered approach (Hewis et al., 2024).

Summary

This way of planning care for Mrs. A suggests the use of assessment, cooperation across
disciplines, making goals that can be achieved, adapting help to each person and frequent
reviews to match the rules in NHS legislation and principles. It stands as an example of how
appropriately planned and delivered care can result in better outcomes for service users and
remain respectful of their choices and preferences.

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Conclusion

It is emphasized in this report that people-centered care planning is important for handling
complex health and social care problems, illustrated by Mrs. A’s case. A comprehensive
assessment, involving Mrs. A, her family and a team of experts developed the base for creating a
unique care plan. Merely using SMART goals allowed for achievable outcomes that took care of
her diabetes, physical impairments and mental difficulties. Thanks to the right use of laws and
NHS core principles, her freedom, privacy and health were well looked after by caring
professionals. By going through this process, we see that it helps to work as a team,
communicate well and take the user’s views into account to give the best care.

Recommendation

By increasing digital integration of care plans, professionals and service users can all stay
informed about current arrangements. Also, by offering more training in dementia-friendly
techniques and cultural awareness to staff, care can be personalized further. Reaching out to the
community more would help lessen Mrs. A’s loneliness. It would help if service users and their
families took part in regular review meetings to address shifts in their needs and likes.

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References:

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