Adult Social Care Digital Social Care Record: Minimum Operational Data Standard (MODS): Implementation Guidance

Care plan (page 14 of 9) in Conceptual Model: Adult Social Care Record (chapter 8 of 10) within Adult Social Care Digital Social Care Record: Minimum Operational Data Standard (MODS): Implementation Guidance

A written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive. The person receiving care should have the opportunity to be fully involved in the plan and to say what their priorities are. If the person receiving care is in a care home, home care (domiciliary care), or attends a day service, the plan for their daily care may also be called a care plan.

%%{ init: { 'theme': 'base' } }%% graph TD accTitle: Visualisation of a conceptual data model for Care plan - a written plan typically recorded after an assessment, addressing the needs and risks associated with the person receiving care and setting out goals and instructions for the care they will receive. accDescr: A care plan is like a helpful roadmap designed specifically for you to ensure you get the right support. It is built by listening to your personal wishes and preferences, looking at what you are already good at, and identifying the areas where you might need a hand to stay safe. For any of these plans to start, you—or someone you trust to speak for you—must understand the plan and agree to it, which is known as giving consent. Professional care workers then use this agreement to set clear goals and write down simple instructions for the team to follow. This process makes sure that every action taken is centered on what matters most to you, helping you stay in control of your life while receiving the help you need. subgraph UpperContext [" "] direction LR Consent[Consent] CareActor[Care Actor] end subgraph CoreActors [" "] direction LR Proxy[Subject of Care Proxy] SubjectOfCare[Subject of Care] end subgraph Hub [" "] CarePlan[Care Plan] end subgraph ExternalInfluences [" "] direction LR Observation[Observation] Wishes[Wishes] Preferences[Preferences] end subgraph PlanComponents [" "] direction LR Need[Need] Risk[Risk] Strength[Strength] Goal[Goal] Instruction[Instruction] end CareActor -->|1..* performs| CarePlan CareActor -->|1..* completes| CarePlan CareActor -->|1 authorises| CarePlan Proxy -->|1 expressed by| CarePlan SubjectOfCare -->|1 performed for 0..*| CarePlan CarePlan -->|1 requires 1| Consent SubjectOfCare -->|1 gives 1| Consent Proxy -->|1 states 1| Consent Observation -->|0..* influences 1| CarePlan Wishes -->|0..* influences 1| CarePlan Preferences -->|0..* influences 1| CarePlan CarePlan -->|1 addresses 0..*| Need CarePlan -->|1 addresses 0..*| Risk CarePlan -->|1 evaluates 0..*| Strength CarePlan -->|1 targets 1..*| Goal CarePlan -->|1 determines 0..*| Instruction Instruction -->|0..* targets 0..*| Goal Instruction -->|0..* is performed for 1| SubjectOfCare SubjectOfCare -->|1 has 0..*| Need SubjectOfCare -->|1 has 0..*| Risk

Care Actors perform, complete and authorise Care plans that address the:

Needs Risks Safeguarding concerns that the Subject of care has.

Care plans target Goals for the Subject of care within the context of Observations about the Subject of care, in particular, their:

Strengths Wishes Preferences and [Mental Capacity Care plans determine the set of Instructions for the provision of care based on these Goals.

Observations such as Needs, Risks, Safeguarding concerns, Strengths, Wishes and Preferences can be recorded before, during (and after) care planning and/or assessment. Observations about the Subject of care should be available during the care planning process.

To receive planned care and support the Subject of care is required to give Informed Consent or if the Subject of care does not have Mental Capacity the Proxy for subject of care is required to express Informed Consent for the Care plan.

Page last updated: 13 July 2026