What Is a Care Plan? What It Includes, How Often to Review It and What CQC Expects
A plain definition of a care plan, what it should contain, when it must be reviewed and how inspectors judge care records.
A care plan is a written record of a person’s care needs, preferences and goals and how staff will meet them. CQC does not set a fixed review interval, but Regulation 9 guidance says assessments should be reviewed regularly and whenever needed, including when the person moves between services, and Regulation 17 requires an accurate, complete and contemporaneous record for each person.
Care plans are the backbone of care records and one of the first things inspectors sample. This guide explains what a care plan is, what to include, how often to review it and what “good” looks like. It does not cover clinical care pathways, which depend on your service. CQCLogic does not produce care plans: it is a compliance platform, so you should keep your care planning system for that.
Key takeaways
- A care plan records needs, preferences, goals, risks and how staff will support the person.
- It must be based on an assessment done with the person and reviewed regularly and whenever needs change.
- Regulation 17 requires an accurate, complete and contemporaneous record for each person.
- There is no fixed review period, so set one by risk and record it.
- Inspectors compare the plan with what they observe and what staff and people tell them.
In this guide
What a Care Plan Is
A care plan turns an assessment into action. Regulation 9 requires an assessment of needs and preferences carried out collaboratively with the person, care designed to meet those needs and reflect those preferences, and regular review (CQC: Regulation 9). The plan is the record of that process. In home care it is often called a support plan or care and support plan.
What to Include
| Section | Content |
|---|---|
| About me | Life story, routines, likes and dislikes, what matters to the person |
| Needs and outcomes | Health, personal care, emotional, social, cultural, religious and spiritual needs, and goals |
| How we support | Specific actions, who does them, when and how the person prefers it |
| Risks | Linked risk assessments and how risks are managed. See risk assessments |
| Capacity and consent | How capacity was assessed, decisions made and who acts for the person. See MCA and DoLS |
| Health and medicines | Conditions, medicines, allergies, professionals involved |
| Review record | Date, who took part, what changed |
How Often Should a Care Plan Be Reviewed?
CQC does not set a number. Its guidance says assessments should be reviewed “regularly and whenever needed” and specifically when people transfer between services, use respite care or are re-admitted or discharged. Reviews should confirm that goals or plans are being met and are still relevant. Many services review monthly for people at higher risk and at least every few months otherwise, plus after any incident, hospital stay or change in needs. Choose a schedule by risk, write it in your policy and follow it. In home care, NICE recommends a review of home care plan outcomes within 6 weeks of starting the service (NICE quality standard on home care for older people).
What CQC Expects From Records
Regulation 17 requires providers to maintain “an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided and of decisions taken”. Guidance says records must be complete, legible, accurate and up to date, and include consent and decisions made under the Mental Capacity Act (CQC: Regulation 17). Both paper and electronic records are acceptable if held securely and in line with data protection law.
Auditing Care Plans
- Sample plans for different needs and shifts.
- Check the plan matches the assessment, and daily notes show it being followed.
- Check reviews are dated and involve the person.
- Compare what the plan says with what you see and what staff can tell you.
See how to carry out an audit and what person-centred care means.
Check your records against what inspectors look for
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Frequently Asked Questions
What is a care plan?
A written record of a person’s needs, preferences and goals and how staff will meet them, based on an assessment done with the person and reviewed regularly.
What should a care plan include?
Personal history and preferences, assessed needs and outcomes, how support will be given, linked risk assessments, capacity and consent, health and medicines information and a review record.
How often should a care plan be reviewed?
CQC gives no fixed period. Guidance says assessments should be reviewed regularly and whenever needed, including on transfer between services. Set a schedule by risk and follow it.
Who should be involved in writing a care plan?
The person, and anyone lawfully acting for them or that they want involved, with staff who have the right skills and knowledge for the assessment.
What does CQC look for in care records?
Records that are accurate, complete, up to date and secure, that reflect the person’s preferences and decisions, and that match what inspectors see and hear.
What is the difference between a care plan and a risk assessment?
A care plan describes the person’s needs and how they will be met. A risk assessment identifies specific risks and how they will be managed. They should link to each other.
Sources: CQC: Regulation 9, Person-centred care · CQC: Regulation 17, Good governance