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Person-centred Planning (PCP) Case Study

Residential Care Practice Module


  1. Introduction- the background and importance of PCP.

Person-centred planning (PCP) as defined by The National Disability Authority is a way of discovering how a person wants to live their life and what is needed to make that happen (NDA, 2018). In 2002 PCP for people with disabilities was identified as an area that required attention from the NDA, by the NDA supporting good practice around PCP this will aid the government in delivering on its commitment to improving the quality of services for people with disabilities (NDA, 2018). The Nation Standards for Disability Services 2004 made specific reference to PCP as a vital step in the development and delivery of services for people with disabilities. The purpose of PCP is to provide a plan that ensures a person is in charge of planning all aspect of their life. PCP is a never-ending process that identifies opportunities for a person to develop skills and abilities achieve their goals (Transtion, 2018).

According to the National Disability Authority person centred planning is a tool in identifying how a person wants to live their life and establishes how those desires can be achieved. (Authority, 2005) Person-centred planning is stepping away from focusing solely. On an individual’s disability and how to “manage” that, instead person-centred planning looks at appreciating a person for who they are and providing support and services that help that person live the life they choose. (Authority, 2005)

In comparison in according to Hughes who states the importance of a person-centred plan lies in the life-changing outcomes. Hughes carried out a study that discovered that all participants felt empowered and determined by having control over their life. Successful PCP was achieved by the person having a good support system, which can come from not only staff but also family members, friends, organisations and people in their community. This, in turn, incorporates the micro, mezzo, and macro level of supports. Hughes similarly to the NDA states that PCP is aimed at the persons “abilities versus diagnosis or disabilities” (Hughes, 2013). Person-centred planning is important because it strives for the normalization and independent living for people with disabilities, through strengthening and supporting the individual needs. Person-centred planning enables and supports the individual to pursue and achieve their wishes and dreams which is their human right (Authority, 2005).

2. The Person-Centred Plan

  1. Person’s Background- baseline assessment

Celine was born in Sandyford Dublin; she also lived and grew up in Sandyford along with her younger brother named Richard who she is particularly close with. Celine’s father died when she was a child, her mother passed away 5 years ago that was when Celine was moved to the congregated setting Riverview in Ballymun, because she was unable to live on her own in her family home. Richard lives in Sandyford with his wife and two children; He visits Celine about once a month more if there’s a special occasion ie birthday. He stated he would like to be more involved with her and would be able to offer more support if she was living in Sandyford.  Celine is overweight for her height she binges on chocolate, sweets, biscuits and fizzy drinks. She likes swimming but there is no pool at Riverview so she doesn’t get as much exercise as she’d like. She has no underlying health issues but her weight is a concern. Celine has Down syndrome, she mostly independent she gets up washes and feeds herself and goes to bed herself. Celine doesn’t know how to cook meals however because it’s always been done for her. Celine struggles with going out on her own, she is unsure of taking the bus and shopping by herself.


NAME: Celine Murphy DOB: 25/9/1978

          = Action Plan Required


0= No Support

10 = High support

Getting up/Going to bed 0.
Cooking 5.
Feeding herself 0.
Eating a healthy diet 5.
Washing/Showering 0.
Cleaning/House Work 3.
Money Management 8.
Exercising 0.
Travelling 7.
Safety 0.
Obtaining a Job 8.
Medication 0.
Mobility 0.
Caring for a Pet 5.
  1. Person’s Rights and Involvement

According to the NHS, there has been evidence to support the statement that when people actively participate, in their treatment and care plan it can improve and air their outcome (NHS, 2018). As Celine’s key worker I would include her in identifying what she would like to get out of care plan, not presume I know what she likes. In accordance with the UN convention on the rights of persons with disabilities signed by Ireland in 2005. This ensures that Celine has equal rights to enjoyment and freedom. This convention covers Celine’s civil and political rights that ensure her equal treatment and a life free of discrimination. This convention also covers Celine’s social and economic right to equal education, healthcare transport and employment (Authority, International, 2018)

According to the National Disability Authority, the best way to identify what methods and supports are needed to include a person with disabilities is to “simply ask those you want to include” (Authority, Guidelines for Including People with Disabilities in Research, 2002). The best way to ensure a positive outcome in Celine’s care plan is to ensure the care plan is based on her. To ensure a care plan becomes a reality and keep Celine involved, there are some vital measures that can be taken when planning Celine’s care plan. (Trust, 2012) Speaking to Celine in a way she can understand and is familiar with, avoiding jargon. Realising that person centres plan is in place to benefit Celine and should be based on her needs not on the services available. I also would get Celine involved in the writing of her person-centred plan offer her the opportunity to sign her care plan, and finally being flexible in the format of her care plan so Celine can understand it and refer back to it (Trust, 2012).

  1. Person’s Goals/Dreams/Aims

Celine dreams of living on her own in Sandyford, in a house close to her brother’s home. She aims to be able to do her own grocery shopping and clothes shopping. She wants to get a membership for the local swimming pool and go to the swimming pool as she pleases. She wants to lose a bit of weight but doesn’t want to cut out her treats completely. She hopes to be able to cook three meals a day for herself which is something she has never down. Celine had a dog named Rodger when she lives with her parents. She would like her dog Roger to come and live with her, who currently lives with Richard because animals were not allowed at Riverview as another person in the house was allergic to dogs She would love to get a part-time job the local SuperValu.

The end goal for Celine is for her to live by herself; through my discussion with her on what she would like, we outlined those wishes and goals in her person-centred plan. She has identified and prioritised these goals in order of the most important to her. For Celine to live independently with her community she will need certain skills. For Celine to achieve her number one goal of living on her own in Sandyford she’ll have to learn how to take care of herself skills such as cooking, and shopping are aims she must achieve to get her number one goal. Another valuable tool that will be used in making a person centred plan for Celine is ensuring her goals are SMART. Specific, measurable, achievable, realistic and time based.

House in Sandyford

Care or Rodger






  1. Plans and Personal Outcomes

Overall Action Plan


  Goal /Aim Time Frame Person’s Responsible
1. Cooking/Healthy diet 3 – 6 months Keyworker & Dietician & Social Worker, Richard
2. House work 1- 2 months Keyworker & Richard &Social Worker
3. Money management 3 – 6 months Keyworker & Richard &Social Worker
4. Travelling to shops, pool, work 6 months – 1 year Keyworker & Richard &Social Worker
5. Getting a job 1 – 2 years Keyworker &Social Worker
6. Caring for a Pet 3 – 6months Keyworker, Richard &Social Worker




Action Plan 1. – Cooking/Healthy Eating

Aim For Celine to be skilled in cooking healthy meals every day, as well as understand the importance of eating health.


Action Task Begin with cooking 3meals a day alongside Hayley Swanton (keyworker) with support from Richard Murphy (brother). One of these meals will be a casual cooking lesson with keyworker on a new dish, which will be compiled into a recipe book written/drawn by Celine, so she can understand it. The aim is to decrease supervision and assistance meal by meal until Celine is cooking all of her meals by herself.

Secondly, Celine will be taught the food pyramid, portion size and the effect of certain foods on the body, but most importantly how to live a good balanced and healthy life with Susan Buckley (dietician). She will also give her info on what food she needs to buy weekly at the supermarket.

Time/Sessions 6 months
Person/s Responsible: Celine Murphy, Hayley Swanton, Susan Buckley
Signature 1:
Signature 2:
Signature 3:
Current date: 3/12/2018
Review date: 3/6/2019


Action Plan 2. – House Work/Cleaning

Aim For Celine to be able to perform adequate housekeeping on her home, ie hoover, mop, dust and wipe down surfaces.
Action Task To support Celine in learning how to clean her home. She will be supported in cleaning her home in the way she chooses. Firstly we establish why it is important to clean your home regularly, particularly if Celine has Rodger (dog) living with her, this will increase the amount of cleaning Celine will have to do.

After an understanding of why housework has to be done, Hayley and Celine will start with one room in the house, see which areas have to be cleaned, and clean them together.

Following this, we will draw up a weekly activity board and Celine can decide if she wants to do all the housework on one day ie Sunday or spread it out through the week and keep herself flexible. A list of choirs/housework can be drawn upon a whiteboard, kept in a book to help jog the memory or act as a “to do list” so to speak.

While Hayley and Celine are shopping with I will talk about common cleaning products that are needed to do housework, and also to safely store these products like bleach

Hayley will do the cleaning with Celine and then week by week Celine will take over the cleaning of her home more and more until she is cleaning the home herself. She can refer back to her to do/chore list at any time.

Time/Sessions 2 months
Person/s Responsible: Celine Murphy, Hayley Swanton
Signature 1:
Signature 2:
Current date: 3/12/2018
Review date: 3/2/2019

Action Plan 3. – Money Management 

Aim For Celine to make a budget and stick to it, have a pan for what she’d like to spend money, and be a conscious consumer on what she’s purchasing. As well possible setting a goal of something she would like to save her money for if that what she wants (Quicken, 2018)
Action Task Celine and Hayley (keyworker) will assess Celine’s monthly and then weekly income. Based on her net income, Celine will then allocate an amount of money for clothes, food, etc. She can decide to save some or use it on leisurely on activities, for example, ie cinema.

Celine will set up a credit union account to manage her money that she can walk to lodge or withdraw money.

Time/Sessions 6 months
Person/s Responsible: Celine Murphy, Hayley Swanton
Signature 1:
Signature 2:
Current date: 3/12/2018
Review date: 3/6/2019

Action Plan 4. – Travelling

Aim For Celine to be able to travel to the pool, the supermarket, the credit union.
Action Task To start with Hayley and Celine will walk the route that Celine would take from her home to the supermarket, to the pool, to the credit union, to Richard house. We also familiarise Celine with the route to the post office, the cinema, the clothes shops, the Gardaí station and the doctor.

Following this Celine will draw a map that she can understand. Hayley will also provide Celine with a map of Sandyford with these locations marked on the map.

Celine will also be provided with contact numbers for taxis. Celine will also be provided with bus and Luas timetables if she’d like to go into the city, however, everything is within walking distance to her home so she would seldom have to use public transport unless Celine chooses to travel somewhere outside of Sandyford.

Time/Sessions 12 months
Person/s Responsible: Hayley Swanton, Celine Murphy
Signature 1:
Signature 2:
Current date: 3/12/2018
Review date: 3/12/2019


Action Plan 5. – Getting a Job

Aim To get Celine a job in the local SuperValu or a possibly another local supermarket.
Action Task Celine has not prioritized this an immediate aim/goal because getting settled in the house and taking on the work she has at home is a lot to first get used. However, having said that even though there is a 2-year time frame on getting the job the preparation for the jo can begin right away. Celine and I will begin by making her CV I can meet her at her home with the laptop or we can go to the local library. Celine would also be able to go to the Library and use the computer there if she had some free time and wanted to work on her CV, cover letter or look at job websites for vacancies.

I will show Celine how to make a CV and she can pick what kind of skills and qualities she would like to put on it. I would suggest to completing the CV first because you need that first to apply to jobs. Then using

Public Celine can be showed how to filter the job search for Sandyford so she can check it daily for updates if she wishes.

I will also help Celine work on her interview skills and preparing for an interview, we discuss what she might wear or what she’d like to say about herself. Possibly stage a practice interview to help prepare her for when she does go for an interview.

Researching the supermarket, she’d like to work in as well would be a huge advantage, Celine is from the area and SuperValu likes to hire locals to work in their store so Celine is at an advantage there. I will print off information on a task she might be required to do if working in a supermarket so when she does get a job she won’t be surprised.

Time/Sessions 24 months
Person/s Responsible: Celine Murphy, Hayley Swanton
Signature 1:
Signature 2:
Current date: 3/12/2018
Review date: 3/12/2020


Action Plan 6. – Caring for a Pet 

Aim For Celine to have the skills to care for her dog Rodger
Action Task Hayley and Celine will go shopping for pet supplies for Rodger(dog) things such as dog bowls, food dog shampoo, walking lead, a travel cage a brush and dog bed. So, Celine has all the necessary supplies at her home, Rodger is a small jack russel so he won’t take up much room in her home.

Celine’s brother Richard has Rodger house trained so he just needs to be let out in the back garden when he needs to use the toilet.

Hayley will mention the idea of getting a dog flap at the back door to the garden if that’s something Celine would like.

Celine will set a time each day to feed Rodger possibly after her dinner in the evening might be a convenient time and one a day to walk him possibly the same time she is going out so she has company on her walk.

Hayley will show Celine how to give Rodger a bath, or she can provide her with dog grooming numbers in the area whichever suits.

Celine has the travel case if she wants to bring Rodger with her on any trips.

Celine has put having Rodge live with her as the 2nd goal to achieve so it will be worked on immediately from moving into the house because it would bring Celine a lot of happiness.

Time/Sessions 6 months
Person/s Responsible: Hayley Swanton, Celine Murphy
Signature 1:
Signature 2:
Current date: 3/12/2018
Review date: 3/6/2019
  1. Measures of Outcomes, Monitoring and Review


Outcome, Monitoring and Review of Action Plan 1. – Cooking/Healthy Eating

  Outcome Monitoring Review
  Since moving into her new place

Celine picked up her cooking skills very fast she is able to cook lots of different dishes by herself with little to no help. However Celine has not been eating as healthy as her dietician would like. She makes her breakfast and lunch everyday which is a huge success but Cline has told her keyworker Hayley in the evening is often very tired and usually just orders in food from a take away restaurant unless she goes to her brother Richard for dinner .

I will monitor Celine’s progress with her dinner time cooking. Hayley is very happy with how far she’s come and for her to be cooking her own breakfast and lunch is fantastic progress with in 6 month. I will discuss possible effect of eating take away every evening with Celine both to her health and financially

She has stated that the reason she doesn’t cook in the evening is because she is tired.  There may be a solution to that maybe she could prepare he dinner at lunch time and put in the fridge as well as going to Richard house maybe twice a week for dinner.

The next review date for Celine’s cooking and eating will be in 3 months on the 3/9/2019



Outcome, Monitoring and Review of Action Plan 2. –  House Work/Cleaning

Outcome Monitoring Review
Celine has made good progress with the house work. She has said that she doesn’t like it but that it has to be done. The first month the dogs hairs made more cleaning for Celine so she has shown great intuitive in brushing rodger after his walk to take off any loose hair before he comes into the house this allow Celine to push out the hoovering to once a week but she said this one of the biggest jobs in cleaning the house. She does the rest as she goes along though out the day Hayley is very happy with Celine’s cleaning and house work when I visited her I could see how spotless the kitchen was but I did notice what Celine was talking about in regards to the dogs hair I will pop in to see Celine 2 more times a week I might give her hand with the hoovering. But over all very good job  Celine has handled the house work task well, The next review date will be in a 1 months’ time on the 3/3/2019 to see if brushing Rodger outside makes a difference or if taking him to the groomers may be an option.


Outcome, Monitoring and Review of Action Plan 3. –  Money Management 

Outcome Monitoring Review
Celine has found it difficult to stick to a budget that was set out for her, although she did have a few once off big expenses when getting set up in her home such as the dog supplies and he membership and the local pool. She has said a bigger portion than shed like goes on the take away dinners she et 3 or 4 times a week.

Celine has however has set up a credit union account and has lodged some money in it she is saving up for next Christmas.

Hayley is pleased with Celine’s effort she has showed great organisation and intuitive she keeps everything she spend her money on written down in the book. Celine and I will monitor her spending in the book she keeps and strive for improvement. She has stated she’s doesn’t want to spend her money on the take away so if we could a solution o that it might quiet possibly solve this for Celine The next review date will be in a 2  months time on the 3/8/2019. However I will set up a daily budget for Celine that may help her see how te money can add up when spending it on a few things here and there like take away and possibly help her decide on something she’d like to buy herself so she can save and work towards that.


Outcome, Monitoring and Review of Action Plan 4. –  Travelling

Outcome Monitoring Review
Celine has found it easy to get around Sandyford after a few walks around the village jogged her memory of growing up there she has found it easy to get around. She walks to the credit union, the shop, the pool, and her brothers. She bought a big umbrella for walking when it rains but said she really enjoys getting out because she gets to run into people and have a chat. I am very pleased with Celine’s progress in travelling and getting out and about. I will however be reminding to always keep herself safe and not to go out late. I will be visiting Celine weekly and we could possibly pop out for coffee and she could show me around the village to where she likes to go. I will review Celines travel with her again in 12 months on the 3/12/2020 and in the meantime see if she like might to venture outside of Sandyford possibly into Dublin city for an after and encourage her to travel as much as possible.


Outcome, Monitoring and Review of Action Plan 5 . –  Getting a job

Outcome Monitoring Review
Celine started going to Library with her brother to make a CV but has grown to love the Library she goes there daily to go on the computer and to check out books to read at home. She doesn’t want a job at the moment and as she feels she would be able to manage it. I will monitor Celine weekly when I visit her. Celine seems to be enjoying going to library and it it great that one goal she had led to something she really enjoy the opportunity to apply for and get a job will always be there I am happy that Celine knew herself what she could take on right now. I will ask Celine if getting a job is something that she would like if it comes up in conversation but I will not make her feel pressure to get a job if that’s not what she wants this will be review in 12 months  on the 3/12/2021


Outcome, Monitoring and Review of Action Plan 6 . –  Caring for a Pet 

Outcome Monitoring Review
Rodger and Celine have settled in to their home very quickly. Celine is taking great care of Rodger. Celine brings Rodger everywhere except to the swimming pool when Celine goes to the pool Rodger get left behind. Celine thinks the dog flap would be a good idea for when she is at the pool at can’t let Rodger out to go to the bathroom or during the night. I will monitor how Rodger and Celine are getting on weekly when I visit and offer support o Celine as caring for a dog can be difficult task. I will follow up with some to fit the dog flap in the next week or two. And that can be fitted to make things a bit easier for Celine and Rodger. I will review this plan in 2 months on the 3/8/2019.



  1. Reflection, Discussion and Evaluation- May include importance on PCPs/HIQA Standards Being Met, Legislative entitlements, Ethics.

After completing the person-centred plan with Celine who lived in a congregated setting but wanted to live independently I questioned if there might be others like Celine. I discovered that many like Celine with intellectual disabilities are housed in congregated settings away from their community. With over 4,000 people living in congregated settings in Ireland. According to the time to move on from a congregated setting report of 2011 (HSE, 2011). With one as little as “a third of units residents having  limited access to person‐centred planning or no person‐centred planning” (HSE, 2011) Reflecting on the person-centred care plan I had just created for Celine to enable her to live independently within her community as she wished, and enabling her to part take in community activities compared to a staggering 40% of residents in a congregated setting who stay on campus for  their day activities which isolated them from their community (HSE, 2011). Since the introduction of HIQA and its residential care settings for individuals with disabilities, there has been a lot of improvement particularly towards inspections and record keeping but one area that has suffered is the clients, the staffs have less time to take them on an outing and support them in doing things they enjoy. (HIQA, Easy to read guide to the National Standards for Residential Services for Adults with Disabilities, 2013)

Although living within a community is not for every person I think the option and opportunity are vital from an ethics point of view.  However, from a legislative point of view, there have been concerns expressed by the United Nations Convention on the Rights of Persons with Disabilities committee that some people that require high support won’t be able to live within their community. This I strongly do not agree in article to make this statement goes against article 19 of the convention which states “the right to live independently and be included in the community to all persons with disabilities, regardless of their level of intellectual capacity, self-functioning or support requirement” People with high support needs may require more support but it is their right to decide how they no one else. (Ireland, Independent Supported Living, 2018)


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