Effective care plan reviews help ensure that care and support remain person-centred, responsive to changing needs, and focused on achieving positive outcomes. Reviews should be planned, meaningful, and proportionate to the individual’s circumstances.
Purpose
The purpose of a care plan review should be clearly understood before it takes place.
A review may be:
- A full review of the individual’s care and support plan.
- A focused review following a change in needs, circumstances, risks, or support arrangements.
- A routine key worker review or monthly monitoring discussion.
It is important to recognise that a care plan review is not a reassessment of needs. Under the Care Act, the purpose of the review is to:
- Identify what is working well and what is not working well.
- Determine whether any changes are needed to the care and support being provided.
- Ensure the care plan remains current, relevant, and person-centred.
- Confirm that risks are appropriately managed while safeguarding the individual’s wellbeing and rights.
What Should the Review Establish?
Care plan reviews should be viewed as an ongoing process rather than a one-off event.
The review should consider:
- Whether there have been any changes to the person’s needs, support requirements, circumstances, environment, or community involvement.
- How any changes may affect the individual.
- Whether new outcomes or goals need to be identified.
- Whether existing outcomes are being achieved and whether appropriate plans are in place.
- Whether the individual’s level of risk has changed and whether risk management measures remain appropriate.
Who Should Carry Out and Participate in the Review?
Person Conducting the Review
The person leading the review should be competent to undertake the task and have the appropriate knowledge, skills, and experience relevant to the individual’s needs.
For example, they should be able to adapt their communication approach when supporting someone with a learning disability, sensory impairment, or communication need.
People Who Should Be Involved
The review should involve:
- The individual receiving care and support.
- Anyone the individual wishes to include.
- Professionals involved in the person’s care, such as District Nurses, Dietitians, Social Workers, or Speech and Language Therapists (SALT).
- The individual’s key worker or named support worker.
- A representative where the individual lacks capacity, such as an Attorney under a Lasting Power of Attorney (LPA), Deputy, or Independent Advocate.
When Should Reviews Take Place?
Care plan reviews should be completed in a timely manner and in line with organisational policies and procedures.
Good practice includes:
- An initial review approximately 6 to 8 weeks after the care package begins.
- Formal reviews at least every 3 to 6 months, depending on the person’s needs and organisational requirements.
- Additional reviews whenever there is a significant change in circumstances, such as a hospital admission or discharge, deterioration in health, safeguarding concern, or change in support arrangements.
- Regular key worker sessions to identify and record any changes or concerns.
- Using approaches such as a “Resident of the Day” system within residential settings to ensure reviews are undertaken consistently and systematically.
- For domiciliary care services, using regular monitoring calls to review care arrangements and confirm that needs continue to be met.
How Should a Care Plan Review Be Conducted?
Reviews should be person-centred, proportionate, and focused on achieving positive outcomes.
When conducting a review:
- Encourage and maximise the individual’s involvement in the process.
- Gather information from relevant sources to support decision-making.
- Be flexible and responsive to the person’s communication and support needs.
- Ensure the review is proportionate to the complexity of the care and support being provided.
- Use a robust review template that reflects the individual’s current care and support arrangements.
- Clearly explain the purpose of the review, the agenda, and how long the meeting is expected to last.
- Ensure all participants understand and agree to their involvement.
- Record all attendees and their contribution to the review.
- Hold the review in a suitable environment that promotes privacy, dignity, and the secure discussion of confidential information.
Key Principle
A care plan review is not simply a compliance exercise. It is an opportunity to ensure that care remains safe, effective, person-centred, and responsive to the individual’s changing needs, preferences, outcomes, and aspirations.