Person-Centred Planning in Dementia Services: Turning “What Matters” Into Daily Practice
Person-centred planning in dementia services is often described well but implemented inconsistently. A plan can read beautifully and still fail the person if staff cannot translate it into predictable routines, respectful communication, and day-to-day decision-making. The best dementia plans are operational tools: they help staff anticipate distress, tailor support, enable choice safely, and evidence outcomes over time.
This article sits within Dementia – Person-Centred Planning & Strengths-Based Support and links directly to Dementia – Service Models & Care Pathways, because what “good” planning looks like differs across homecare, supported living, extra care and residential dementia pathways.
What person-centred planning must achieve in dementia services
In dementia care, person-centred planning is not a single assessment event. It is a living process that should do four practical things:
- Stabilise daily life: create predictable routines that reduce anxiety and confusion.
- Preserve identity: keep roles, relationships, preferences and culture visible in daily support.
- Enable safe choice: manage risk without defaulting to restriction or “best for them” decisions.
- Evidence impact: show how support changes outcomes (distress, independence, safety, wellbeing).
Plans that only list “likes and dislikes” are not enough. Staff need “how to” detail: what to do, how to say it, what to avoid, what to monitor, and how to review.
Commissioner expectation: plans must translate into deliverable, outcomes-led support
Commissioner expectation: commissioners expect care plans to be specific enough that any competent worker can deliver consistent support. They also expect planning to connect to outcomes and risk management, not just activity lists. Typical expectations include:
- Clear outcomes that reflect what matters to the person and what commissioners are purchasing (stability, independence, reduced avoidable escalation).
- Deliverable routines aligned to the commissioned model (visit lengths, staffing, assistive tech, family roles).
- Evidence of review and adaptation as dementia progresses or circumstances change.
Regulator / Inspector expectation: person-centred care evidenced in practice, not paperwork
Regulator / Inspector expectation (CQC): CQC commonly tests whether person-centred planning is actually used. Inspectors look for consistency between:
- What the plan says matters to the person.
- What staff describe in interviews and how they explain “how we support them.”
- Observed practice: communication style, choice points, dignity, risk enablement.
- Records showing learning from incidents, feedback and changing needs.
If staff rely on “that’s just how we do it,” the plan is not functioning as a real tool.
What a dementia plan needs to include to be operational
High-quality dementia planning usually contains the following practical components:
1) Identity and “what matters” that changes day-to-day decisions
This is not a biography paragraph. It must include cues that change staff behaviour, for example: “Former lorry driver—values being asked first, hates being rushed, needs time to process.”
2) Communication and consent approach
Include exact approaches: preferred name, tone, pace, key phrases that calm, and triggers that escalate distress. Also include how staff check consent in the moment and what to do if the person appears to refuse.
3) Routine map
Document preferred wake times, meal patterns, meaningful activity, rest, and personal care sequences. Dementia support often fails because staff impose institutional timings that increase confusion and resistance.
4) Distress prevention and response plan
Include early signs (pacing, repetition, facial expression), likely meaning (pain, fear, overstimulation), and step-by-step responses. This reduces reactive “crisis management” and promotes least restrictive practice.
5) Risk enablement and positive risk-taking
Capture the risks the person accepts (walking outside, making a hot drink), the controls that enable it safely, and what evidence is monitored (near misses, falls, capacity fluctuations, safeguarding signals).
Operational Example 1: Homecare dementia planning that reduces refusal of care
Context: A domiciliary service supported a person with dementia who repeatedly refused morning personal care, leading to missed visits and family complaints.
Support approach: The provider reworked the plan with the person and family to focus on routine, communication, and choice points rather than “task completion.”
Day-to-day delivery detail:
- Visits were moved 30 minutes later to match the person’s natural waking pattern.
- Staff used a consistent opening script: “Morning John, it’s Mary from the care team—shall we have a tea first?”
- Personal care was offered in steps: wash face/hands first, then reassess willingness for full wash.
- Refusal was treated as information: staff recorded what the person said and what was happening (noise, hunger, pain signs).
How effectiveness is evidenced: Missed personal care reduced, recorded refusals fell, and family feedback improved. The service evidenced change through visit notes, a simple refusal tracker, and a review entry showing what was changed and why.
Operational Example 2: Supported living dementia planning that preserves independence
Context: In supported living, staff were doing too much “for” a person with early-stage dementia, causing skills decline and increased dependency.
Support approach: The plan was rewritten using a strengths-based “do with, not for” model with clear prompts and safeguards.
Day-to-day delivery detail:
- Staff stopped taking over meal preparation and instead used visual prompts (labelled cupboards, step cards).
- A timed check-in replaced constant supervision: staff checked at agreed times and used a welfare call if concerns arose.
- Shopping was supported through a predictable list routine and accompaniment only where needed.
- Risk enablement controls were documented (hob timer, smoke alarm checks, medication prompts).
How effectiveness is evidenced: The person maintained daily living skills, with progress recorded through outcome notes (e.g., “prepared lunch with prompts”). Commissioners could see that support hours were being used to enable independence rather than create dependence.
Operational Example 3: Residential dementia planning that reduces distress during personal care
Context: A resident became distressed during personal care, leading to repeated incidents and staff calling for support to “get it done.”
Support approach: The provider treated this as a planning and practice issue, not “challenging behaviour,” and built a step-by-step distress prevention plan.
Day-to-day delivery detail:
- Care was scheduled at the resident’s calmest time of day rather than the unit routine.
- Staff used one-to-one rapport first: showing clothing options and offering choice (“shirt or jumper?”).
- Noise and interruptions were reduced; the bathroom was warmed and towels prepared to avoid delay.
- A stop rule was added: if distress escalated, staff paused, stepped back, and tried again later with a different approach.
How effectiveness is evidenced: Incident frequency reduced, staff confidence increased, and audits showed staff were following the plan. The provider could evidence least restrictive practice through records showing fewer reactive interventions and better outcomes.
Governance: how to keep person-centred plans “alive”
In dementia services, plans quickly become outdated unless governance keeps them current. Strong governance usually includes:
- Planned reviews: set frequencies aligned to risk and change (e.g., monthly for unstable situations, quarterly for stable).
- Event-triggered reviews: after incidents, safeguarding concerns, hospital admissions, repeated distress episodes, or family complaints.
- Practice observation audits: supervisors observe whether staff follow communication and routine guidance.
- Outcome tracking: simple measures (falls, refusals, distress episodes, sleep disruption) linked to plan changes.
Plans should not be rewritten for the sake of compliance; they should change when practice needs to change, and the reason for change should be documented.
Common failure points (and how to fix them)
Most person-centred planning failures are practical:
- Too generic: replace “needs reassurance” with what reassurance looks like and what words work.
- Task-led routines: rebuild plans around the person’s natural rhythm and preferences.
- No risk enablement: document how independence will be supported safely rather than prevented.
- No audit trail: ensure changes are recorded with evidence of impact.
When person-centred plans become operational tools, dementia services become more stable, safer, and more defensible to commissioners and inspectors.