Care home care plan review

The rule: where the duty to review a care plan comes from

A registered care provider in England must keep each person’s care plan under review because Regulation 9, person-centred care, requires care that meets the person’s needs and reflects their preferences, and CQC’s guidance on Regulation 9, which providers must have regard to, spells out what that means for reviews. Assessments “should be reviewed regularly and whenever needed throughout the person’s care and treatment”, including “when they transfer between services, use respite care or are re-admitted or discharged”; reviews “should make sure that people’s goals or plans are being met and are still relevant”; “plans should include an agreed review date”; and “staff providing care must be kept up to date with any changes to a person’s needs and preferences”.

The record of the review comes from Regulation 17 of the same Regulations, which requires a provider to “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”. CQC’s Regulation 9 guidance joins the two: “A record must be kept of all assessments, care and treatment plans, and decisions made by people who use the service and/or those acting on their behalf.”

No regulation sets a fixed interval for a care home’s own reviews. The interval is the one agreed and written into the plan, shortened by any change that makes the plan out of date. Where a local authority arranges or funds the care, it has its own separate duty to review its care and support plan under section 27 of the Care Act 2014, covered below; the care home’s review does not replace it, and the local authority’s review does not replace the home’s.

When a care plan should be reviewed

There are three kinds of review, and a care home needs all three. The Care and support statutory guidance names them for local authorities, and the same shape works for a provider: “a planned review (the date for which was set with the individual during care and support or support planning, or through general monitoring)”; “an unplanned review (which results from a change in needs or circumstance … for example, a fall or hospital admission)”; and “a requested review”, made by the person, their carer, family member, advocate “or other interested party”.

In a care home, the triggers for an unplanned review usually include:

• a fall, an injury, a new pressure area or significant weight loss
• a hospital admission or discharge, a stay in respite care or a move between services, all of which CQC’s guidance names
• a change in physical or mental health, mobility, continence, eating and drinking, mood or behaviour
• a change in medication, or a medication review by the GP or pharmacist
• a change in the person’s capacity to make a decision covered by the plan
• a safeguarding concern, an incident or a complaint about the person’s care
• new advice from a GP, district nurse, speech and language therapist, physiotherapist or other professional
• the person, their family or an advocate asking for a review, or saying that something in the plan is not working
• the approach of the end of life, when the person’s wishes for the future, including care and place of death, need to be recorded

For planned reviews, set an interval with the person and write it in the plan. For home care, NICE guideline NG21, Home care: delivering personal care and practical support to older people living in their own homes, recommends: “Undertake an initial review of the home care plan within 6 weeks, then review regularly, at least annually.” Some care homes review each plan monthly, and parts of it, such as risk assessments for falls or nutrition, more often; that is a local standard rather than a legal one, and a monthly review is only worth doing if it can find something.

Commissioning contracts with a local authority or the NHS may set review intervals of their own, so check the contract for each funded resident.

Who takes part, and what a review covers

The resident is the first participant. CQC’s guidance says each person, or someone lawfully acting on their behalf, “must be involved in an assessment of their needs and preferences as much or as little as they wish to be”, and that they “must be involved in the planning, management and review of their care and treatment”. Ask the resident who else they want involved, and record the answer. Family members take part because the resident wants them to, or, where the resident lacks capacity for a decision, because the Mental Capacity Act 2005 requires their views to be considered; CQC’s summary refers to “the duty to consult others such as carers, families and/or advocates where appropriate”. A family member’s view becomes the decision only where they have the legal authority to make it, and the mental capacity assessment records guide covers what to record.

The professionals involved in the person’s care contribute too: the key worker and the carers who know the resident, a nurse in a nursing home, and the GP, district nurse or therapists whose advice may have prompted the review. CQC’s guidance says that where care is shared with other services, providers “should also take into account information from all relevant teams, staff and services”.

The statutory guidance lists the questions a local authority review should cover, and they translate well to a care home: “have the person’s circumstances and/or care and support or support needs changed?”; “what is working in the plan, what is not working, and what might need to change?”; “have the outcomes identified in the plan been achieved or not?”; “does the person have new outcomes they want to meet?”; and “could improvements be made to achieve better outcomes?”. Add the questions the home’s own records raise: what do the daily notes, charts and incident records since the last review say, and does the plan still match the care actually being given?

Risk assessments are part of the plan and are reviewed with it. A plan that has been reviewed while its falls or choking risk assessment still describes the person as they were six months ago has not been reviewed.

What the review record should show

A review record is the evidence that the review happened and that it mattered. Each one should show:

1. The date, and why the review took place: planned, or the trigger, with a reference to the incident, admission or request that prompted it.
2. Who took part and how: the resident, and how their views were obtained if they could not take part in a conversation; family members, advocates and professionals, and whether they attended, phoned or sent their views.
3. What was looked at: the sections of the plan and the risk assessments reviewed, and the records read, such as daily notes, food and fluid charts, weights, incident reports and professional letters.
4. What the resident said, in their own words where possible, including any preference that has changed.
5. What changed and why, section by section; and what did not change and why, where someone suggested a change that was not made.
6. Any preference that cannot be met, with the reason and the alternative offered: CQC’s guidance says providers “must fully explain why” and show “how the provider has considered the impact of this on the person”.
7. Capacity and consent: whether the resident consented to the changes, and if they lacked capacity for a decision, the capacity assessment and best-interests record.
8. The updated plan, with a new version date, and the superseded version kept rather than overwritten.
9. How staff were told: handover, a staff briefing or a note on the electronic system, so that the change reaches the people giving care.
10. The next review date, agreed with the resident.

The point of all this is personalised care that keeps pace with the person: a plan that still describes how they want to be supported, including the ways they keep their dignity and independence, rather than how they were on admission. A review that changes nothing is still a review, but the record has to show that it was a real one. “Reviewed, no change” written on the same date every month is the weakest evidence a home can produce, especially when the daily notes show a fall, a urinary infection and a week of poor eating since the last entry. Inspectors who read daily records against the care plan notice the gap, and so do families.

Keep superseded plans and review records as part of the person’s care record, under the same retention period, so that the plan in force on any given date can be shown later.

Care plan review example (fictional)

The example below is invented to show the shape of a useful review record. The resident, the home and the staff do not exist. It is not a template to copy, because every plan should be written for the person.

Notice what makes it useful: the trigger is traceable to an incident report, the resident’s reasons are in her words, the choice she made is recorded with her capacity for it, the change reaches night staff through a named handover, and anyone reading it later can tell which version of the plan applied on which night.

The agreement that happened in a message

Look at where the conversations behind a review like Mrs E’s usually happen. The son who could not come in is told about the sensor mat his mother has chosen, and says he is happy with it, in a text to the deputy manager on the Sunday. The physiotherapist’s advice arrives as a message to the senior carer’s phone before the letter does. The night carer who noticed the resident was getting up at five said so in the staff group chat, which is how anyone knew to review the continence plan at all.

The review record then says “son consulted, agrees” and “night staff report early rising”. Both are true, and neither can be shown. The conversation that proves the family was consulted, what they were told and what they agreed sits on a member of staff’s personal phone, in an app the home cannot open, and it leaves with the member of staff.

ComplyChat gives those conversations a channel the provider owns: a mobile number verified by SMS is the identity, so a son, a visiting therapist or a bank carer without a work account can be in it; everyone in it is told it is on the record; and messages are recorded on the server as they are sent. On paid plans the lasting record files into the provider’s own Microsoft 365 once the tenant is connected, under its own retention rules. It is not a care planning system and does not hold or review care plans; it keeps the conversation that the review record refers to.

A question for the next leadership or governance meeting: for the last care plan this home changed after a fall, could we show who agreed the change, what they were told, and when?

Questions people ask

How often should a care plan be reviewed?

A care plan should be reviewed on the date agreed with the person and written into the plan, and whenever their needs or circumstances change; no regulation sets one interval for care homes. CQC’s Regulation 9 guidance says plans “should include an agreed review date” and assessments should be reviewed “regularly and whenever needed”. For local authority care and support plans, the statutory guidance expects a review “no later than every 12 months”, with a light-touch review considered 6 to 8 weeks after sign-off, and NICE NG21 recommends a first home care plan review within 6 weeks and then at least annually.

What happens in a care plan review?

In a care plan review the person, and anyone they want involved, look at whether their needs have changed, what is working and what is not, whether the outcomes in the plan have been met, and what should change. The provider then updates the plan and its risk assessments, records who took part and what was decided, tells the staff who give the care, and sets the next review date.

What is covered under a care plan?

A provider’s care plan covers the person’s assessed needs and preferences and how care will meet them, with agreed goals, ways to maintain independence and a review date, as CQC’s Regulation 9 guidance describes. A local authority’s care and support plan under section 25 of the Care Act 2014 must specify the needs identified, whether they meet the eligibility criteria, the needs the authority will meet and how, and the personal budget, with advice and information about reducing or preventing needs.

Can a family member ask for a care plan review?

Yes. Under section 27 of the Care Act 2014 a local authority must review its care and support plan on a reasonable request by or on behalf of the adult, and the statutory guidance says the right to request a review “applies not just to the person receiving the care, but to others supporting them or interested in their wellbeing”. A care home should treat a family’s request as a trigger for its own review too, with the resident’s agreement where they have capacity.

Official guidance and your next step

The primary sources are CQC’s guidance on Regulation 9 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; section 27 of the Care Act 2014 and chapter 13 of the Care and support statutory guidance for local authority reviews; and NICE guideline NG21 for home care. Quotations are from those pages as published on 3 October 2026.

This guide is a summary for care providers in England, not legal or clinical advice about a particular person’s care.

Then do one thing: take the last three falls in the home and, for each, find the care plan review that followed it. Check that the review names the fall, records what the resident said, and shows a change that reached the night staff.