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A person can, of course, develop his or her own plan and take the lead in getting it implemented. Sometimes, parents, family, spouses, friends, advocates or others will do so on their behalf for example: where it is not possible for a plan to be guided entirely by an individual due to extreme difficulties with insight, awareness and cognition.

Person-centred planning - Wikipedia

In Ireland, in practice, at present, person centred plans tend to be developed within services, though some parents and families have begun to develop plans independently. In practice, the development and implementation of plans usually requires the co-operation of quite a range of individuals, services and the broader community network, if they are to be really effective. Facilitators may also work as agents of plan realisation, liasing with relevant support or other service providers.

They should, normally, be formally trained and experienced in person centred planning philosophy, methodology, tools and techniques.


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It is particularly important that diversity and individuality across focus persons should be acknowledged and accommodated, in compliance with Equality legislation. It is essential that a plan facilitator operate entirely independently of any potentially vested interest in the process. Where a plan is being facilitated within a service, the autonomy of the plan facilitator in his or her role as plan facilitator must be adequately assured. It is also imperative that a plan facilitator should adopt, encourage and project an equal partnership approach to working with the person or family at the centre of the planning process.

Where for whatever reason an individual is not happy to work with a particular facilitator, another should be found. The initial and continuing involvement of any particular individual, group or organisation in any part of the planning process should be in accordance with the wishes of the person at the centre of the planning endeavour - and that particular individual, group or organisation. Clearly, some individuals may fulfil more than one role. Recommendations People have the right to be involved in discussions and make informed decisions about their care, as described in your care. Aims and principles This guideline is based on the principle that children, young people and adults with a learning disability and behaviour that challenges should have the support they need to live where and how they want.

The guideline recommends ways of designing and delivering services that aim to: help people to have a good quality of life support people to have good physical and mental health and emotional wellbeing maximise people's choice and control promote person-centred care and support help children, young people and adults take an active part in all aspects of daily life that they choose, based both on what they can do and what they want to do respect people's cultural, religious and sexual identity identify when children, young people and adults are at risk of developing behaviour that challenges, so that support can be offered as early as possible promote continuity of relationships take a 'whole life' approach.

Joint commissioning and funding Recommendations for the lead commissioner acting on behalf of local authorities and clinical commissioning groups 1.

Person centred planning and care management with people with learning disabilities

These should be pooled: across health, social care and education and with neighbouring authorities. Planning and delivering services according to local need Recommendations for the lead commissioner acting on behalf of local authorities and clinical commissioning groups 1. Managing risk Recommendation for local authorities and clinical commissioning groups 1. Quality assurance Recommendations for commissioners and service providers 1.

This evidence could include: satisfaction and quality-of-life ratings of children, young people and adults who have used the service, and their family members, friends and carers outcomes measured by personalised and validated tools such as the 'measure of processes of care' MPOC tool, or the 'patient feedback questionnaire' PFQ a reduction in duration and frequency of behaviour that challenges stability of placements participation in education by children and young people reports on the use of restrictive interventions, including medication contact time with specialist professionals evidence from quality reviews and spot checking involving experts by experience quality checks by user-led organisations.

Involving people in commissioning and service improvement Recommendation for commissioners 1. Give them support that: is person-centred, reflecting their individual needs and choices, and maximising their control helps them take an active part in all aspects of daily life that they choose, based both on what they can do and what they want to do takes into account the severity of their learning disability; their developmental stage; any communication difficulties or physical or mental health problems; and their life history respects their cultural, religious and sexual identity helps them before problems occur or as soon as they emerge, not just when crisis has been reached encourages people to speak out if they have any worries promotes continuity of relationships.

Recommendation for commissioners and practitioners working with children, young people and adults 1. Advocacy Recommendations for local authorities 1. Coordinating care and support Recommendations for local authorities, clinical commissioning groups and service providers 1. Recommendations for the named worker 1.

Care and support planning Recommendations for community learning disability teams and service providers 1. Develop a care plan that: meets the person's needs and preferences works to support and maximise the person's mental capacity takes into account people's fluctuating mental capacity and needs adopts a 'whole life' approach that covers what they want to achieve in both the short and long term, and supports smooth transitions takes a positive approach to managing risk sets out what to do to prevent or respond to a crisis.

Supporting people to use personal budgets Recommendations for local authorities and clinical commissioning groups 1. Delivering care and support Recommendations for staff in all settings 1. Recommendations for local authorities 1. Recommendations for community learning disability teams and service providers 1.

They should work with children, young people and adults, and their family members and carers, in a way that is: personalised flexible responsive accessible reflective. Specialist behavioural support Recommendations for the lead commissioner acting on behalf of local authorities and clinical commissioning groups 1. Intensive behavioural support during a crisis Recommendations for local authorities, clinical commissioning groups, community learning disability teams and specialist services 1.

Services for people in contact with, or at risk of contact with, the criminal justice system Recommendation for local authorities and clinical commissioning groups 1. Recommendations for service providers, including forensic services 1. Recommendations for local authorities, service providers and practitioners 1. Exploring alternatives to residential placements for children and young people Recommendations for the lead commissioner, service providers and practitioners 1.

Living in residential placements Recommendations for local authorities, clinical commissioning groups and service providers 1. Planning and review to support children and young people leaving a residential placement Recommendations for local authorities, clinical commissioning groups and practitioners 1. Providing information Recommendations for local authorities, clinical commissioning groups and service providers 1. When a placement is needed Recommendation for local authorities and clinical commissioning groups 1.

Recommendations for inpatient services and community learning disability teams, including the named worker 1. Planning and review to support discharge Recommendations for inpatient services and community learning disability teams 1. Include in these reviews: the person and their family members or carers the practitioner responsible for agreeing discharge a specialist in behaviour that challenges.

This includes: the skills and knowledge recommended in staff training, supervision and support in NICE's guideline on challenging behaviour and learning disabilities: prevention and interventions being resilient and compassionate showing that they care understanding and respecting the person's human rights, faith, culture, identity and values.

Terms used in this guideline The Think Local, Act Personal care and support jargon buster explains many of the social care terms used in this guideline. Behaviour support specialist A practitioner who has training in helping people and their family members and carers to understand and change their behaviour if it is causing problems for them.

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Behaviour that challenges Behaviour of such an intensity, frequency or duration that the physical safety of the person, or others around them, is likely to be placed in serious jeopardy. Carer Someone who provides informal care and support to a child, young person or adult with a learning disability. Multimedia techniques are becoming more popular for this type of planning as development costs decrease and the technology used becomes more readily available. Plans are updated as and when the individual wishes to make changes, or when a goal or aspiration is achieved.

If part of a regular planning process in the US, regular plan updates are usually required by regulatory agencies e.


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  • Person-centred planning can have many effects that go beyond the making of plans. It can create a space during which someone who is not usually listened to has central stage.


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    • It can insist that discussion is centred on what the person is telling us is important to them, with their words and behaviours, as well as what others feel is important for the person. It can engage participants personally by allowing them to hear of deeply felt hopes and fears. It can assist people in a circle of support to re-frame their views of the person it is focused on. It can help a group to solve difficult problems. In the US, person-centered planning can help to create new lifestyles, new homes and jobs, diverse kinds of support informal and formal and new social relationships.

      Many of the limitations discussed below reflect challenges and limitations in the implementation of Person-Centered Planning approaches in the context of formal human service systems. Another approach to this question is to envision Person-Centered Planning as an approach that is anchored in the person's natural community and personal relationship network.

      In this view, the Person-Centered Plan PCP offers a platform for the person and their trusted allies to identify and express their vision and commitments without limiting that expression to what can or will be provided by the service system. Some time later, the formal system can develop a plan for service delivery that may be based on and consistent with the person's plan, that recognizes and supports the contributions of the person, family and community, and that clearly acknowledges the limitations of what the system is prepared to provide.

      John O'Brien sums up the problem of trying to deliver person centredness through formal service systems that have a very different culture thus:. Many human service settings are zones of compliance in which relationships are subordinated to and constrained by complex and detailed rules. In those environments, unless staff commit themselves to be people's allies and treat the rules and boundaries and structures as constraints to be creatively engaged as opposed to simply conforming, person centred work will be limited to improving the conditions of people's confinement in services.

      Most service organisations have the social function of putting people to sleep, keeping them from seeing the social reality that faces people with disabilities People go to sleep when the slogan that "we are doing the best that is possible for 'them'" distracts from noticing and taking responsibility for the uncountable losses imposed by service activities that keep people idle, disconnected and alienated from their own purposes in life. One way to understand leadership is to see it as waking up to people's capacities and the organisational and systemic practices that devalue and demean those capacities.

      A key obstacle to people achieving better lives has been the risk averse culture that has been prevalent in human services for a variety of reasons. Advocates of person centred thinking argue that applying person centred thinking tools to the risk decision making process, and finding strategies that are based on who the person is, can enable a more positive approach to risk that doesn't use risk as an excuse to trap people in boring and unproductive lives.

      The key advocates of PCP and associated Person Centered Approaches warn of the danger of adopting the model in a bureaucratic way — adopting the 'form' of PCP, without the philosophical content. By changing it to fit existing practices rather than using it in its original form, most or all of its effects are lost.

      The hope of funding it in the USA was to influence the processes, such as planning through the Medicaid home and community-based waiver services for people moving from institutions to the community. The philosophical content expects services to be responsive to the needs of people that use the service, rather than prescriptive in the types of services offered. These principles are reliant on mechanisms such as individualised funding packages and the organisational capacity to design and deliver "support" services.

      It is essential that organisations and agencies providing services make a commitment to strive for person-centredness in all of their activities, which can result in major changes in areas of practice such as recruitment, staff training, and business planning and management. While secondary users may debate the use of person-centered approaches to achieve the myriad goals it attempts to achieve, i. The world's largest study into person centred planning described how it helps people get improvements in important parts of their lives and indicated that this was at no additional cost".