A care plan in a care home should be reviewed at least monthly as a light-touch check, immediately after any significant change, and formally with the person and their family or representative at least once a year. There is no single statutory frequency in England, but Regulation 9 requires care to be reviewed with the person, the Care Act statutory guidance expects local authority plans to be reviewed no later than every twelve months, and inspectors expect to see review dates that are met and reviews that change something.
This guide is for registered managers, deputies and owners. It sets out how often to review, what triggers an early review, who should be involved and who signs, what a good review records, how reviews differ across residential, nursing, learning disability and mental health services, and how to keep review dates under control across a whole home.
The short answer
Review every care plan monthly, briefly, checking the daily logs against the plan and updating anything that has changed. Review immediately after a fall, a hospital admission, a new diagnosis, a safeguarding concern, a change in weight, skin, behaviour, mood or capacity, a medication change or a family concern. Hold a full review with the person present, and their family or advocate where appropriate, at least annually and more often where needs are changing. The person signs where they can; where they cannot, record who was consulted and why they could not sign. Every review records what was checked, what changed, what did not and why, the evidence used, the decisions made, who was involved and the next review date. A review that changes nothing and involves nobody is a signature, not a review.
What is a care plan in a care home?
What is a care plan in a care home, and why does its review matter so much? The care plan is the written agreement between the person and the home about how they will be supported: what they need, what they can do, what they want, what the risks are and what the home has agreed to do. It is the document the shift works from and the document inspectors, commissioners, safeguarding teams and coroners read when they want to know what the home knew and what it agreed.
Care plans in care homes cover personal care, mobility, nutrition and hydration, medicines, health conditions, communication, mental health and wellbeing, activities and relationships, risk, capacity and consent, night time, end of life wishes and more. A person-centred plan is organised around the person rather than the tasks and written with them where possible. Our guide to how to write a person-centred care plan covers the content.
A plan is only as good as its last review. People change, sometimes slowly and sometimes overnight, and a plan that describes the person as they were six months ago is a plan that will lead staff to do the wrong thing.
The care planning cycle
The care planning cycle has four stages: assess, plan, implement and review. Assessment gathers what the person needs and wants. Planning turns that into the written plan. Implementation is the shift delivering it and recording what happens. Review compares what was planned with what happened and what has changed, and feeds back into assessment and planning.
The cycle is continuous. Every daily log is a small piece of review evidence, because it shows whether the plan was followed and whether it worked. The monthly review reads those logs. The annual review steps back and asks whether the whole plan still describes the person. An incident or a change triggers the cycle to start again for the affected area.
Managers who think of review as an event rather than a stage of the cycle end up with plans that are reviewed on paper and unchanged in practice. The care planning process should make review the natural consequence of recording, not a separate administrative task.
How often should care plans be reviewed?
The regulations do not set a number. Regulation 9 requires the provider to review the care and treatment with the person, and Regulation 17 requires accurate, complete and contemporaneous records. Local authority contracts often specify a frequency, commonly monthly or quarterly for the home's review and annually for the authority's own Care Act review. The Care Act statutory guidance says a person's care and support plan should be reviewed no later than every twelve months, and the first review within a reasonable period, often suggested as six to eight weeks, after the plan is first agreed.
In practice, a three-tier rhythm works across most services. A monthly review by the key worker or senior, reading the logs against the plan and updating what has changed. An event-triggered review whenever something significant happens. A full annual review with the person, family, key worker and manager, and any professionals involved, that goes through every section.
Where needs are changing quickly, for example in the weeks after admission, during illness, at end of life or during a mental health relapse, the monthly rhythm is too slow and reviews should follow the change. Where a person is stable, a monthly check may take ten minutes. The point is that the date is set, met and recorded.
At a glance: review types
| Review type | Frequency | Who | What it covers | Record |
|---|---|---|---|---|
| Monthly review | Every month, to a set date | Key worker or senior | Logs against plan; changes in any area; risk tools | Short note per section: no change or what changed |
| Triggered review | Within days of a significant event | Senior or manager with key worker | The area affected, plus anything the event touched | Event, assessment, change, actions, next date |
| Annual review | At least yearly | Person, family or advocate, key worker, manager, professionals | Every section; goals; capacity; consent; risk | Full review record, signed or reason recorded |
| Local authority review | Within twelve months, then annually | Social worker with the home and person | Eligibility, outcomes, funding, placement | Authority's review, copied to the file |
| Clinical tool review | As the tool specifies, often monthly or on change | Nurse or trained senior | MUST, Waterlow, falls risk, pain | Score, date, action |
Why should care plans be updated regularly?
Why should care plans be updated regularly, beyond because the inspector will check? Because the plan is what staff follow. A plan that says the person walks with a frame when they now need a wheelchair leads to a fall. A plan that says level 7 diet when the speech and language therapist has changed it to level 5 leads to choking. A plan that says the person has capacity to refuse medication when they no longer do leads to unlawful practice either way.
Regular updating also keeps the plan honest. Preferences recorded at admission drift. The person who said she liked a bath on Tuesdays may now prefer showers. The man who wanted to eat in the dining room may now want a tray in his room since his friend died. The review is where the home asks again.
Finally, review is where outcomes are measured. A goal set at admission, to walk to the garden unaided, to manage his own money, to reduce PRN use, has to be checked. Without review, goals are wishes.
Triggers for an early review
The monthly date is the minimum. These events should trigger a review of the relevant section, and often the whole plan, within days.
- A fall, with or without injury
- A hospital admission or attendance, and discharge
- A new diagnosis or a change in an existing condition
- A change in weight, skin integrity, swallowing, continence or mobility
- A change in behaviour, mood, sleep or engagement
- A medication change, a medicines error or a new PRN pattern
- A safeguarding concern, an incident or a complaint involving the person
- A change in capacity for a relevant decision, or a new DoLS authorisation or condition
- A concern raised by family, an advocate or a professional
- A change in the person's circumstances: bereavement, a new relationship, a change of room
- The start of end of life care or a change in the person's wishes
- A change in the home: a new key worker, a change in staffing that affects the plan
The trigger should be visible in the record. An incident report that does not lead to a review note is an incident that taught the plan nothing.
Who should be involved in a review
The person comes first. Every review, monthly or annual, should involve them to the extent they are able and willing, in the format they can use. Family, friends or an advocate should be involved with the person's consent where they have capacity, and as part of best interests where they do not. The key worker, who knows the person's daily life, should lead or contribute. The senior or manager should oversee and sign off. Professionals involved in the person's care, the GP, district nurse, community learning disability team, community mental health team, dietitian, speech and language therapist, should be consulted or invited where the review touches their area.
Not everyone needs to be at every review. The monthly review is often the key worker and the person over a cup of tea. The annual review is the meeting. The triggered review involves whoever the event requires. What matters is that involvement is real and recorded: who was there, who was consulted, what they said.
Where the person has no family or friends and would have substantial difficulty being involved, the Care Act entitles them to an independent advocate for assessment and planning, and the home should support the referral.
Who signs a care plan review
The person signs where they have capacity to agree the plan and are willing. Their signature, or a mark, or a recorded verbal agreement, shows consent to the care described. Where the person has capacity but declines to sign, record that they were involved and declined, and why if they said. Where the person lacks capacity to agree the plan, record the capacity assessment, who was consulted in their best interests, and have the family member with relevant lasting power of attorney or the advocate sign where appropriate. A family member without legal authority can sign as having been consulted, not as consenting on the person's behalf.
The key worker or senior who carried out the review signs as the author. The manager or deputy signs as having checked it. Where the review was triggered by a clinical event, the nurse or professional involved may sign the relevant section.
Signatures matter less than the record of involvement. A plan signed by the person who was never actually asked is worse than an unsigned plan with a clear note of who was consulted and what they said. Digital records make this cleaner: a timestamped entry showing who reviewed, who was present and what was agreed, with the person's consent recorded in the way they can give it.
Consent and capacity in reviews
Every review should ask two questions about capacity. Does the person have capacity to agree this plan? And has anything changed since the last assessment? Capacity is decision-specific and time-specific, and a person may have capacity to agree their activity plan but not their medication plan, or to agree in the morning and not the evening.
Where capacity is in doubt, assess it, record the assessment and, if the person lacks capacity, make the decision in their best interests with the people who know them, choosing the least restrictive option. Where the plan involves restrictions that may amount to a deprivation of liberty, check that an authorisation is in place and its conditions are reflected in the plan. Our Mental Capacity Act and DoLS checklist sets out the steps.
Consent to care is ongoing, not a signature at admission. A person with capacity can withdraw consent to any part of their plan at any time, and the review is where the home checks that consent still stands.
What a good review records
What was checked
Which sections were reviewed and what evidence was read: daily logs, charts, incident reports, professional letters, feedback from the person and family.
What changed and why
For each change, the reason and the evidence. Not: mobility updated. Instead: now uses a wheelchair for distances over ten metres following the fall on the third and the physiotherapist's assessment on the tenth.
What did not change and why
A note that a section was reviewed and remains accurate, with a reason, is evidence. A section with no note is a section nobody read.
Decisions and actions
Referrals made, equipment ordered, risk assessment updated, capacity assessed, family informed, staff briefed. Each with an owner and a date.
Who was involved
Present, consulted, informed, and what each said. The person's own view in their words.
Next review date
Set, recorded and visible to the team.
Monthly review versus annual review
The monthly review is a working check. The key worker reads the month's logs and charts against each section of the plan, speaks to the person, notes any change and updates the plan. In a stable month it may produce a note that says reviewed with the person, no change, on most sections and a change on one or two. It should take between ten and thirty minutes and be done to a set date each month.
The annual review is different in kind. It asks whether the plan still describes the person: their history, their goals, their preferences, their relationships, their capacity, their risks, their wishes for the future. It is a meeting with the person and their family or advocate, the key worker and the manager, and the professionals who matter. It should revisit the About me section, not just the needs. It should produce a plan the person recognises as theirs.
Homes that do monthly reviews well sometimes let the annual slip, because nothing seems to have changed. That is exactly when the annual review finds that the person's goals were never revisited, that the family have concerns they never raised, or that the plan describes someone who no longer exists.
The local authority review
For people whose care is arranged or funded by the local authority, the authority has its own duty under the Care Act to review the care and support plan, no later than every twelve months and sooner if requested or if circumstances change. That review is about eligibility, outcomes, funding and whether the placement is still right. It is not a substitute for the home's review, and the home's review is not a substitute for it.
The two should inform each other. The home's annual review, with its evidence of outcomes and changes, is what the social worker needs. The authority's review, with its funding decisions and outcome statements, should be copied to the file and reflected in the plan. Where the authority's review is overdue, the home should chase it in writing and keep the correspondence; a missing authority review is not the home's failure, but a home that never asked will struggle to show it noticed.
Self-funders have no authority review, so the home's annual review carries the full weight.
Reviews after hospital discharge
A hospital stay changes people. Mobility, continence, cognition, weight, medication and mood can all be different on discharge, and the discharge summary rarely says so in the terms the care plan needs. The plan should be reviewed on the day of return, section by section, against the discharge summary and what staff observe, and again within a week once the person has settled.
The review should update medicines against the discharge letter, reassess falls, pressure and nutrition risk, check mobility and transfers, note any new diagnosis or follow-up, and record the person's own account of their stay. It should also update the hospital passport with anything learned, so the next admission goes better.
Homes sometimes wait for the monthly date after a discharge. That is too late. A person returning from hospital is at their highest risk in the first week.
Reviews in learning disability services
In learning disability and autism services, the review structure has extra layers. The person-centred plan, written with the person about their life and goals, usually has an annual review meeting led by the person with their circle of support. The health action plan is reviewed alongside the annual health check the GP should offer to everyone with a learning disability aged fourteen and over. The positive behaviour support plan is reviewed against the behaviour data, often monthly, and after any use of restrictive practice. The hospital passport is reviewed whenever health or medication changes.
All of these should be in easy read where the person needs it, and the person should be supported to take part in a way that is meaningful, not to sit through a meeting about them in language they cannot follow. Reviews are a good moment to check that restrictive practices are still the least restrictive option and that the reduction plan is progressing.
Review dates for the care plan, PCP, HAP, PBS plan and hospital passport should be tracked together, because a person with a learning disability may have five documents that each need a date and each tell a different story if they drift apart.
Reviews in mental health services
In mental health rehabilitation and residential services, the home's care plan sits alongside the NHS care and support plan from the community mental health team, which NHS England has been moving from the Care Programme Approach towards personalised care and support planning. The home should know who the care coordinator is, when the NHS review is due, and how the two plans relate.
The home's review should focus on the person's recovery goals and progress, mental state and early warning signs, medication and the person's view of it, risk and the safety plan, and any Mental Health Act status including section 117 aftercare and leave. Relapse, self-harm, a change in medication or a change in risk should trigger a review immediately, with the community team involved.
The person should lead where they can. Recovery-focused reviews are the person's assessment of their own progress, with staff contributing evidence, not staff assessing the person.
Reviews in nursing homes
Nursing homes carry clinical risk tools with their own review cycles. The MUST nutrition score is typically reviewed monthly and on change. Waterlow or another pressure risk score is reviewed at least monthly and after any change in mobility, continence or nutrition. Falls risk, pain assessment, oral health assessment and continence assessment each have a cycle. Wound care plans are reviewed at each dressing change. Advance care plans and ReSPECT forms are reviewed with the person and family as their condition changes.
The care plan review should draw these together, so that a change in Waterlow score leads to a change in the repositioning plan, and a change in MUST leads to a change in the nutrition plan and a dietitian referral. Tools reviewed in isolation, with the score updated and the plan untouched, are a common inspection finding.
Nurses lead clinical reviews, but the person's preferences and the care staff's observations remain central. A wound care plan the person does not understand or agree to is not a person-centred plan.
How to run a care plan review
- Set the date in advance and tell the person, and their family or advocate where involved, what the review is for and how they can take part.
- Gather the evidence: the month's or year's daily logs, charts, incident reports, professional correspondence, risk tool scores and any feedback.
- Speak to the person first, in their format, about how things are, what is working, what is not and what they want.
- Go through each section of the plan against the evidence and the conversation. Note no change with a reason, or the change with a reason.
- Reassess capacity where a decision is in question, and record it.
- Update risk assessments where anything has changed, recording benefit as well as hazard.
- Record decisions, referrals and actions with owners and dates.
- Confirm consent: the person signs or agrees, or the reason and the best interests process are recorded.
- Set the next review date and any earlier triggers specific to this person.
- Brief the shift on what changed, and check within the week that the logs reflect it.
Review evidence checklist
- Every care plan has a next review date and none are overdue
- Monthly review notes exist for every section, with no change or the change recorded
- Triggered reviews follow every fall, admission, incident, safeguarding concern and medication change
- Annual reviews record the person and family present or consulted, with the person's view in their words
- Capacity assessments and best interests records exist where the person could not agree the plan
- Consent is recorded in the way the person could give it, or the reason it could not be
- Changes in the plan can be traced to evidence in the logs, charts or professional correspondence
- Actions from reviews have owners, dates and completion recorded
- Clinical tool scores lead to plan changes, not just score updates
- Local authority reviews are on file or chased in writing
Tracking review dates across the home
A home with forty residents and five documents each has two hundred review dates. Tracking them on a wall chart or a spreadsheet works until it does not. The manager needs a single view of what is due this week, what is overdue and who owns it, and the key worker needs a prompt.
A care record system with review dates on every section and a dashboard of overdue reviews turns this into a routine morning check. It also lets the manager see patterns: one key worker whose reviews are always late, one section that is never updated, one resident whose plan has not changed in a year despite three incidents. The compliance view should show review completion as a live figure, because it is one of the first things an inspector will ask for.
Where records are on paper, the same discipline applies with more effort: a review register updated weekly, a standing item in the manager's meeting, and a monthly audit of a sample of plans against their dates.
Version control and the audit trail
A reviewed care plan has a history, and that history is evidence. Inspectors, safeguarding teams and coroners may need to know what the plan said on a particular date, who changed it and why. Paper plans achieve this with dated, signed amendments and archived versions. Digital records achieve it with an audit trail that records every change, who made it and when, and lets the previous version be read.
Managers should check that their system, paper or digital, can answer the question what did the plan say on the fourth of March. If the answer is that the old page was thrown away, the home cannot defend a decision made on that day. A system where every record is audited and prior versions are retained closes that gap, and it is worth seeing that audit trail demonstrated before choosing one. Our guide to daily logs covers how point-of-care recording feeds the review with evidence rather than memory.
Common mistakes
- Reviews that are a date and a signature on the same plan, with no evidence read and nothing changed.
- Waiting for the monthly date after a fall, admission or incident instead of reviewing immediately.
- The person absent from their own review, or present but not involved in a format they can use.
- Family members signing as if consenting when they have no legal authority, with no capacity assessment on file.
- Clinical tool scores updated without the plan changing.
- Annual reviews skipped because monthly reviews are done, so goals and history are never revisited.
- Review dates tracked in the manager's head, so overdue reviews are discovered by the inspector.
- Old versions destroyed, so the home cannot show what the plan said when a decision was made.
What good looks like on inspection day
The inspector asks how the home makes sure care plans are current. The manager shows the review dashboard: every plan with a next date, none overdue, and the completion figure for the last quarter. The inspector picks three residents. Each has monthly review notes with evidence read and changes traced to logs and correspondence. One had a fall in the spring and the plan shows a review two days later, a physiotherapy referral, a mobility change and a falls risk reassessment, with the family informed. One has a learning disability and the care plan, PCP, health action plan, PBS plan and hospital passport all have review dates within the last three months and agree with each other.
The inspector reads an annual review and finds the person's own words, her daughter present, the goals from last year revisited with progress noted, capacity confirmed, consent recorded and two changes made because of what the person said. The inspector asks the person whether she was involved and she says yes and names the key worker. The inspector asks the key worker what changed at the last review and gets the same answer.
Nothing here was assembled for the visit. The review cycle produced it, because the home treats review as the stage of care planning where the plan is tested against the person's life, and the record shows the test.
Final conclusion
How often a care plan should be reviewed comes down to a rhythm: monthly as a check, immediately on change, annually in full with the person and their people. Who signs matters less than who was involved and whether the record shows it. What a review records is what was checked, what changed and why, what did not and why, who decided, and when it will be looked at again. Build the review dates into the record, make the logs the evidence, keep the history, and the care plan stays what it should be: a current, honest account of how one person wants to live and how the home has agreed to help.
Frequently asked
How often should a care plan be reviewed in a care home?
At least monthly as a light-touch check against the daily logs, immediately after any significant change such as a fall, hospital admission, new diagnosis or safeguarding concern, and in full with the person and their family or advocate at least annually. There is no single statutory frequency, but Regulation 9 requires review with the person and the Care Act guidance expects local authority plans to be reviewed within twelve months.
Who should be involved in a care plan review?
The person first, in a format they can use, then family, friends or an advocate with the person's consent or as part of best interests, the key worker, the senior or manager, and any professionals whose area the review touches. The monthly review may be the key worker and the person; the annual review is a meeting with everyone who matters.
Who signs a care plan review?
The person signs or gives recorded agreement where they have capacity and are willing. Where they lack capacity, the record shows the capacity assessment and who was consulted in their best interests, and a person with relevant lasting power of attorney or an advocate may sign where appropriate. The reviewer signs as author and the manager signs as having checked it.
What triggers an early care plan review?
A fall, hospital admission or discharge, new diagnosis, change in weight, skin, swallowing, mobility, behaviour, mood or capacity, a medication change or error, a safeguarding concern, incident or complaint, a concern from family or a professional, a change in circumstances such as bereavement, and the start of end of life care. The review should follow within days, not wait for the monthly date.
What should a care plan review record?
What sections were checked and what evidence was read, what changed and why, what did not change and why, decisions and actions with owners and dates, who was involved and what they said including the person's own view, capacity and consent, and the next review date. A signature on an unchanged plan is not a review.
Why should care plans be updated regularly?
Because the plan is what staff follow, and a plan that describes the person as they were leads to unsafe care: the wrong mobility support, the wrong diet texture, the wrong assumptions about capacity. Regular updating also keeps preferences honest, measures progress against goals and gives inspectors evidence that the home knows the person now.
Is the local authority review the same as the care home review?
No. The local authority reviews the care and support plan under the Care Act, at least every twelve months, to check eligibility, outcomes and funding. The home reviews its own care plan to keep daily care accurate and person-centred. Each should inform the other, and the home should chase an overdue authority review in writing.
Sources
- CQC: Regulation 9 Person-centred care
- CQC: Regulation 17 Good governance
- Care Act 2014
- Department of Health and Social Care: Care and support statutory guidance, review of care and support plans
- Mental Capacity Act 2005
- NICE guideline NG86: People's experience in adult social care services
- NHS England: Annual health checks for people with a learning disability
