Care and Support Planning 

1. Introduction

A care and support plan, which has been drawn up with the adult, their family / representative and involved professionals, needs regularly reviewing to ensure that it is up to date and reflects the adult’s care and support needs and their wishes and preferences (see Care and Support Planning).

Ensuring that everyone with a care and support plan has the opportunity to reflect on what is working, what is not working and what might need to change is an important part of the planning process.

The review process should be:

  • person centred;
  • outcome focused;
  • accessible;
  • proportionate to the needs being met.

The process involves the adult, a family member or representative and other involved professionals.

The intended outcomes detailed in the plan should be reviewed and revisions made, if needed.

Where a plan is for an adult with mental health needs this chapter should be read in conjunction with Mental Health Act 1983 Code of Practice. Where a plan is for an adult who lacks mental capacity, see Mental Capacity.

2. Reviewing the Plan

Without regular reviews, plans can become out of date, resulting in people not getting the right care and support necessary to meet their needs. Regular reviews ensure the plan remains relevant to their goals and aspirations.

The process should be straightforward and cover the following elements, of which the adult should be informed before the review begins.

  • Has the adult’s circumstances and / or 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 adult have new outcomes they want to meet?
  • Could improvements be made to achieve better outcomes?
  • Are there any changes in the adult’s informal and community support networks that might impact negatively or positively on the plan?
  • Have there been any changes in their needs or circumstances that might mean they are at risk of abuse or neglect?
  • Is the adult, family and / or representative satisfied with the plan?

There are different routes to reviewing a plan including:

  • a planned review, the date for which is set with the adult during the planning process or through general monitoring;
  • an unplanned review that results from a change in needs or circumstances, for example, a fall or hospital admission;
  • a requested review, when the adult with the plan, or their carer, family member, advocate or other interested party makes a request that a review is conducted. This may also be as the result of a change in needs or circumstances.

3. Planned Reviews

During the planning process, the adult, a family member / representative, social worker or other professional will have discussed when it might be useful to review the plan and will have agreed to record this date in the plan. The adult may have had a view about the timescale within which the review should occur. Even when there are anticipated review dates, plans are kept under review generally (see above).

3.1 First planned review

The first planned review should be an initial review six to eight weeks after the plan is first completed. This is an opportunity for all parties to check that the plan is working as intended and helps to identify any teething problems.

4. Unplanned Reviews

If there is any information or evidence that suggests that circumstances have changed in a way that may affect the efficacy, appropriateness or content of the plan, a review should be undertaken immediately to ascertain whether the plan requires revision. This could be where:

During the review process, the adult – or the person acting on their behalf – should be kept fully involved and informed about what is happening, the timescale involved and any likely consequences. This can help to alleviate anxiety at a time when things in the adult’s life may have changed substantially.

5. Requesting a Review of the Plan

If a request for a review is made by the adult or someone acting on their behalf, a review should take place. This applies not just to the adult receiving the care, but to others supporting them or interested in their wellbeing.

6. Revision of the Plan

When revising the plan the adult, their carer and anyone else they may want involved, and their representative, where they have one, should be included.

The assessment process following a review does not start from the beginning of the process, but picks up from what is already known about the adult. In some cases a complete change of the plan may be required, whereas in others only minor adjustments may be needed. In either case, the following aspects of planning should be included:

  • the adult’s wishes and feelings are identified as far as possible and they are supported to be involved;
  • the revision is proportionate to the needs to be met;
  • where the plan was produced in combination with other plans, this is considered at the revision stage;
  • the development of the revised plan is made with the involvement of the adult and anyone else they ask to be involved;
  • any additional elements incorporated in the original plan should be replicated in the revised plan, if appropriate and agreed by all parties.

Particular attention should be paid if the revisions to the plan that are proposed increase restraints or restrictions on an adult who does not have the capacity to agree to them. This may become a deprivation of liberty, which requires appropriate safeguards to be put in place (see Mental Capacity and Deprivation of Liberty Safeguards).