A care plan is one of the most important documents in a care home. It should explain what support a resident needs, how that support should be given, what risks staff need to manage, what the resident prefers, and what should happen if their needs change.
For families, the care plan can be the difference between vague reassurance and real accountability. It should show whether the care home understands your parent or relative as a person: how they like to be spoken to, what help they need with washing and dressing, what medication matters, whether they are at risk of falls, what food they enjoy, how dementia affects them, what makes them anxious, and who should be contacted if something changes.
Good care plans are not just paperwork. They guide daily care. They help new staff understand the resident. They reduce mistakes. They support dignity, safety and independence. They also help families ask better questions when something does not feel right.
This guide explains what care plans in care homes include, why they matter, what families should ask, how often they should be reviewed, how they connect to medication, falls, nutrition, dementia and safeguarding, and what to do if the care plan is not being followed.
If your relative is just moving into a care home, you may also find Moving Into a Care Home: What to Pack and How to Prepare useful. If you are still choosing a home, read How to Choose a Care Home in the UK, Care Home Visit Checklist and What Does a Good Care Home Look Like?.
1. What is a care plan in a care home?
A care plan is a written plan that explains a resident’s needs, preferences, risks and support arrangements. In a care home, it should help staff provide safe, consistent and person-centred care.
It should not be a generic document that says the same thing for every resident. A good care plan should be personal. It should describe what the resident can do independently, what they need help with, what matters to them, and what staff should do in ordinary daily situations as well as when something goes wrong.
In England, CQC Regulation 9 is about person-centred care. CQC says care and treatment should be appropriate, meet people’s needs, and reflect their preferences. CQC’s Regulation 9 guidance explains that providers must make sure care is based on assessment of needs and preferences.
A care plan may include information about:
- personal care;
- mobility and falls risk;
- medication;
- nutrition and hydration;
- continence;
- skin care and pressure sore prevention;
- communication;
- dementia support;
- mental capacity;
- behaviour or distress;
- sleep and night-time needs;
- social activities;
- religious, cultural or personal preferences;
- family contact;
- end-of-life wishes where relevant.
Some care homes use digital care plans. Others use paper files. The format matters less than whether the plan is accurate, accessible to staff, regularly reviewed and actually followed.
2. Why care plans matter for families
Families are often told, “Don’t worry, we know what Mum needs.” A care plan should show that this is true. It should turn conversations, assessments and promises into practical instructions for staff.
Care plans matter because they help answer questions such as:
- Does the home understand my relative’s needs?
- Do staff know what support should be provided?
- Has the home assessed important risks?
- Are changes in health being recorded?
- Is the home responding to falls, weight loss or confusion?
- Are family concerns being included?
- Is care personal or generic?
- Can new or agency staff understand what to do?
A care plan is also important if things go wrong. If your relative falls, loses weight, refuses medication, becomes distressed or develops a pressure sore, the care plan should show what risk was known, what support was agreed, and whether staff followed the plan.
This does not mean care plans should be used to blame staff for every problem. Older people can fall, become ill or decline even with good care. But a good care plan helps everyone understand what was expected, what changed and what should happen next.
If you are worried about safety or repeated problems, see Care Home Red Flags and Safeguarding Adults in Care Homes.
3. What should be included in a care home care plan?
A care plan should be broad enough to cover the resident’s life, not only their medical needs. It should explain daily routines, risks, preferences and the support required from staff.
Personal care
The plan should explain what help the resident needs with washing, bathing, dressing, grooming, shaving, oral care, hair care, nail care and continence support.
It should include:
- whether the person prefers a bath, shower or wash;
- what they can do independently;
- where staff should offer help;
- preferred time of day for personal care;
- privacy and dignity preferences;
- preferred toiletries;
- oral care needs, including dentures;
- whether the person may refuse care and how staff should respond.
Mobility and falls risk
The plan should explain how the resident moves safely. It should include walking aids, transfer support, whether one or two carers are needed, and what to do if the person tries to walk without help.
It should cover:
- walking ability;
- use of frame, stick or wheelchair;
- transfer support;
- hoist or stand aid use;
- falls risk;
- toileting-related falls risk;
- night-time falls risk;
- footwear;
- room layout and hazards;
- what happens after a fall.
If falls are a concern, read Falls in Care Homes: What Families Should Ask.
Medication
The care plan should explain medication needs clearly. Medication errors can happen when information is missing, unclear or not handed over properly.
NICE says good communication about medicines is important when residents transfer to or from a care home, including discharge summaries with current medicines. NICE’s quality standard on medicines management in care homes explains expectations around safe medicines processes.
The plan should cover:
- current medication;
- time-critical medication;
- pain relief;
- inhalers, creams, eye drops or patches;
- medicines taken “when required”;
- side effects to watch for;
- medication refusal;
- allergies;
- who orders repeat prescriptions;
- who reviews medication.
CQC also provides guidance on medicines care plans, including the need for clear information about conditions being treated and medicines such as time-specific or “when required” medicines. CQC’s medicines care plan guidance is useful for families asking about medication records.
Food, drink and weight
The plan should explain food preferences, support needed at meals, hydration needs, swallowing guidance, allergies and what to do if the resident stops eating or drinking well.
It should include:
- likes and dislikes;
- cultural or religious food needs;
- allergies;
- diabetes or special diets;
- swallowing difficulties;
- texture-modified meals;
- thickened fluids if prescribed;
- help needed with eating;
- weight monitoring;
- food and fluid charts if needed;
- when to involve the GP or dietitian.
For more detailed questions, read Care Home Food and Nutrition: What Families Should Ask.
Skin care and pressure sore prevention
Residents who are frail, less mobile, underweight, unwell or incontinent may be at higher risk of pressure sores. The care plan should explain how skin is checked and protected.
It may include:
- skin assessment;
- pressure sore risk level;
- repositioning plan;
- pressure-relieving mattress or cushion;
- continence care;
- nutrition and hydration support;
- skin checks;
- when nursing or tissue viability advice is needed.
Communication and emotional wellbeing
The plan should explain how the person communicates, what helps them feel safe, and what staff should do if they are anxious, upset or withdrawn.
It should include:
- preferred name;
- hearing or vision needs;
- use of glasses or hearing aids;
- speech difficulties;
- language needs;
- mental health history;
- what causes anxiety;
- what provides reassurance;
- how the person shows pain or distress;
- how family should be involved.
4. Care plans for dementia, behaviour and mental capacity
For residents with dementia, confusion, distress or changing capacity, the care plan should be especially detailed. It should not simply say “has dementia”. It should explain how dementia affects that person and what support works.
Dementia care planning
A dementia care plan should describe the resident’s routines, triggers, communication style, risks and preferences.
It may cover:
- memory problems;
- orientation needs;
- wandering or walking around;
- distress or agitation;
- personal care refusal;
- sleep disturbance;
- food and drink support;
- continence needs;
- meaningful activities;
- family involvement;
- what helps during “I want to go home” distress.
If dementia is central to your relative’s care, read Dementia Care Homes UK and Choosing a Care Home for Someone with Dementia.
Behaviour or distress
Some residents may shout, walk constantly, refuse care, become aggressive, become withdrawn or appear distressed. The care plan should try to understand why, not simply label the person as difficult.
It should ask:
- Is the person in pain?
- Are they frightened?
- Are they overstimulated?
- Are they hungry, thirsty or tired?
- Do they understand what staff are doing?
- Are staff approaching them in the right way?
- Are there known triggers?
- What helps them calm down?
The plan should give staff practical guidance. For example, “explain each step before personal care”, “offer a cup of tea before attempting a shower”, or “avoid approaching from behind because this startles her”.
For more on this, see Care Homes for People with Challenging Behaviour.
Mental capacity and consent
A care plan should reflect whether the resident can make specific decisions. Mental capacity is decision-specific. A person may be able to choose what to wear but not understand the risks of refusing essential medication or pressure sore care.
The plan may need to record:
- whether the resident can consent to care;
- what decisions they can make independently;
- whether a capacity assessment is needed;
- whether there is a health and welfare Lasting Power of Attorney;
- whether best interests decisions are needed;
- how restrictions are minimised;
- whether deprivation of liberty safeguards may be relevant.
If your parent refuses care or you are unsure who can make decisions, see What to Do If a Parent Refuses Care.
5. Care plans after hospital discharge or respite care
Care planning is especially important when someone moves into a care home after a hospital stay or for emergency respite. Needs may have changed quickly, medication may have been altered, mobility may be worse, and family may not yet know whether the placement is temporary or permanent.
The care plan should reflect:
- hospital discharge summary;
- new diagnoses;
- current medication;
- wound care;
- mobility changes;
- falls risk;
- rehabilitation goals;
- diet or swallowing advice;
- continence changes;
- follow-up appointments;
- nursing needs;
- equipment needs;
- whether the stay is temporary or long-term.
GOV.UK explains that a needs assessment can identify support such as home care, equipment, day services or care homes. GOV.UK’s needs assessment page is useful if council involvement is needed.
If the person is moving from hospital, read Choosing a Care Home After a Hospital Stay. If the placement is urgent or temporary, see Emergency Respite Care.
For respite stays, the care plan still matters. A short stay is not an excuse for vague care. The home still needs to know medication, mobility, food preferences, continence needs, dementia risks, allergies, emergency contacts and what would make the stay unsafe.
6. Who should be involved in the care plan?
A care plan should involve the resident as much as possible. It should not be written only by staff in an office. The resident’s wishes, feelings and preferences matter, even when they need significant support.
People who may be involved include:
- the resident;
- family members, if the resident agrees or lacks capacity and family involvement is appropriate;
- health and welfare attorney;
- care home manager;
- senior carer;
- registered nurse, if nursing care is provided;
- GP;
- district nurse;
- social worker;
- physiotherapist;
- occupational therapist;
- speech and language therapist;
- dietitian;
- mental health team;
- palliative care team.
Age UK explains that if someone has eligible care and support needs after a care needs assessment, they should receive a care plan explaining how those needs will be met. Age UK’s care plan guide also explains that care plans should be reviewed, and that people can challenge a plan they are unhappy with.
Families can provide information that professionals may not know, such as:
- what the person was like before illness or dementia;
- how they show pain;
- what phrases upset or reassure them;
- food they will actually eat;
- how they like personal care done;
- sleep habits;
- faith or cultural preferences;
- important relationships;
- what matters most to them.
A good care home should welcome this information. It should not treat family knowledge as interference.
7. How often should a care plan be reviewed?
A care plan should be reviewed regularly and whenever needs change. It should not sit unchanged for months while the resident’s health, mobility, cognition or risks are changing.
Care plans may need review:
- after admission;
- after the first few weeks of settling in;
- after a fall;
- after hospital admission or discharge;
- after a medication change;
- after weight loss;
- after a pressure sore develops;
- after choking or swallowing concerns;
- after increased confusion or delirium;
- after repeated care refusals;
- after changes in continence;
- after family concerns;
- when end-of-life care becomes relevant;
- when the resident’s wishes change.
Ask the care home:
- How often are care plans reviewed?
- Who reviews them?
- How are families involved?
- How are changes shared with staff?
- How quickly is the plan updated after an incident?
- How are agency staff told about changes?
- Can we request a review?
After moving in, it is reasonable to ask for an early review once staff have got to know the resident. You may find Moving Into a Care Home helpful for what families should check during the first weeks.
8. What families should ask at a care plan review
A care plan review should be practical. It should not be a rushed meeting where the family is told everything is fine. Families should leave understanding what has changed, what the risks are, what staff are doing, and what needs follow-up.
Useful questions include:
- What has changed since the last review?
- Is the care plan still accurate?
- Are staff following it?
- Has there been any weight loss?
- Has there been any fall or near miss?
- Are there medication concerns?
- Is my relative eating and drinking well?
- Are there signs of pain?
- Are there skin concerns or pressure sore risks?
- Has continence changed?
- Is sleep disturbed?
- Is dementia affecting care differently now?
- Are activities and social contact suitable?
- Does staffing still match their needs?
- Should GP, nurse, dietitian, physiotherapist or occupational therapist be involved?
If staffing is a concern, ask how the plan is realistic with current staffing levels. Read Care Home Staffing Levels: What Families Can Ask for more detailed questions.
If your relative has complex care needs, ask for the care plan to include specific instructions, not broad phrases. “Support with mobility” is less useful than “uses a walking frame, needs one carer to supervise short distances, needs two carers for transfers when tired, and should be offered toileting every two hours during the day.”
9. Red flags in care plans
A weak care plan can be a warning sign. It may suggest the home does not understand the resident, is not updating records, or is not turning risk assessments into practical care.
Red flags include:
- the care plan is generic;
- important risks are missing;
- staff cannot explain what is in the plan;
- family concerns are not recorded;
- the plan is not updated after falls or incidents;
- medication changes are not reflected;
- food, drink or weight concerns are not included;
- dementia needs are described vaguely;
- refusal of care is not planned for;
- swallowing guidance is missing;
- pressure sore risk is not addressed;
- staff do not follow the plan;
- agency staff do not know the plan;
- the home refuses to discuss the plan without a clear reason.
For example, if a resident has fallen three times but the care plan still says “mobile independently”, that is a concern. If a resident has lost weight but there is no nutrition plan, that is a concern. If a resident refuses personal care but the plan only says “assist with washing”, that is not detailed enough.
If red flags are part of a wider pattern, read Care Home Red Flags.
10. What if the care plan is not being followed?
A care plan only matters if staff know it and follow it. Families may notice that the plan says one thing but daily care looks different.
Examples include:
- the plan says drinks should be within reach, but they are not;
- the plan says two carers are needed, but one carer is helping transfers;
- the plan says dentures should be worn at meals, but they are missing;
- the plan says Parkinson’s medication is time-critical, but it is delayed;
- the plan says the resident needs help eating, but meals are left untouched;
- the plan says falls risk should be reviewed, but nothing changes after a fall;
- the plan says family should be contacted after incidents, but they are not told.
If this happens, record examples with dates and times. Then ask for a meeting with the manager or nurse.
You might say:
“The care plan says Dad needs drinks within reach and prompting because he forgets to drink. On three visits this week, his drink was across the room. Can we review how the plan is being followed and how staff are being reminded?”
Ask:
- Do all staff know the care plan?
- How are updates shared at handover?
- How are agency staff briefed?
- Who checks that care plans are followed?
- What will change after this concern?
- When will the plan be reviewed again?
If the failure creates risk of harm, such as missed medication, unsafe transfers, dehydration, neglect, pressure sores or repeated falls, escalate the concern. In England, you can tell CQC about unsafe care, although CQC does not usually resolve individual complaints directly. If you suspect neglect or abuse, contact the local authority safeguarding team.
11. Care plans, safeguarding and complaints
Poor care planning can become a safeguarding issue if it leads to harm or serious risk. Not every care plan problem is safeguarding. Some issues are complaints or quality concerns. But repeated failure to assess, plan, review or follow care can put a resident at risk.
Safeguarding may be relevant if:
- known risks are ignored;
- falls keep happening without review;
- medication is repeatedly missed;
- the resident is losing weight and no plan is made;
- swallowing advice is not followed;
- pressure sores develop without proper prevention;
- personal care is repeatedly missed;
- the resident is left unsafe because staffing does not match the plan;
- family concerns are dismissed despite evidence of risk;
- several residents appear affected by the same poor systems.
If you are worried, start with the care home manager if it is safe to do so. Ask for a care plan review and written response. If the issue continues, use the complaints process. If there is risk of harm or neglect, contact adult safeguarding. If someone is in immediate danger, call 999.
For detailed guidance, read Safeguarding Adults in Care Homes. If the problem is connected to falls, read Falls in Care Homes. If nutrition is the concern, read Care Home Food and Nutrition.
It is reasonable for families to be involved, but it is also important to be factual. Keep notes of what happened, who you spoke to and what was agreed. Specific examples are more useful than general frustration.
12. Frequently asked questions
What is a care plan in a care home?
A care plan is a written plan that explains a resident’s needs, preferences, risks and support arrangements. It guides staff on how to provide safe, person-centred care.
What should be included in a care home care plan?
It should include personal care, medication, mobility, falls risk, nutrition, hydration, continence, skin care, communication, dementia support, emotional wellbeing, mental capacity, family contact and emergency arrangements.
Who writes the care plan in a care home?
Care plans are usually written by care home staff, such as senior carers, nurses or managers, based on assessments and input from the resident, family and professionals where appropriate.
Should families be involved in care plans?
Yes, where the resident agrees or where family involvement is appropriate. Families often know important details about routines, preferences, communication, distress, food, sleep and personal history.
How often should a care plan be reviewed?
Care plans should be reviewed regularly and whenever needs change. Reviews are especially important after falls, hospital admissions, medication changes, weight loss, pressure sores, increased confusion or family concerns.
Can I ask to see my parent’s care plan?
You can ask, but access depends on consent, mental capacity, legal authority and confidentiality. If your parent has capacity, they usually decide who can see their information. If you have relevant power of attorney, explain this to the home.
What if the care plan is wrong?
Tell the manager or senior staff member and ask for it to be corrected. Give specific examples. If the error creates risk, ask for an urgent review.
What if staff are not following the care plan?
Record examples with dates and times, then raise the concern with the manager. Ask how staff are briefed, how updates are shared and what will change. Escalate if there is risk of harm.
Should medication be included in the care plan?
Yes. The care plan should include medication needs, time-critical medicines, allergies, “when required” medicines, side effects to watch for, refusal of medication and who reviews medication.
Should falls risk be included in the care plan?
Yes. The plan should explain mobility, walking aids, transfer support, falls risk, night-time risk, toileting support and what happens after a fall.
Should dementia needs be included in the care plan?
Yes. A dementia care plan should explain how dementia affects the person, including communication, distress, walking around, personal care, eating, sleep, routines, triggers and what helps.
What is a person-centred care plan?
A person-centred care plan is tailored to the individual. It reflects their needs, preferences, choices, routines, strengths, risks, relationships and what matters to them.
What should happen after a fall in a care home?
The resident should be checked for injury, medical help should be sought if needed, family should be informed where appropriate, the incident should be recorded and the falls risk assessment and care plan should be reviewed.
Can poor care planning be neglect?
It can be if known risks are ignored, care is not provided, or failure to plan and review leads to harm or serious risk. Examples include repeated falls without review, missed medication, dehydration, pressure sores or unsafe transfers.
What should I do if I am unhappy with the care plan?
Ask for a care plan review and explain your concerns clearly. If the issue is not resolved, use the complaints process. If there is risk of harm or neglect, contact the local authority adult safeguarding team.
