Dementia Assessment and Review in Adult Social Care: Building a Safe, Repeatable Process for Changing Needs
Dementia is not static. People can present very differently week to week, and “small” changes (sleep, pain, appetite, continence, confidence, mood) can quickly become major risks if they are missed or normalised. Strong providers treat assessment and review as an operational control: a repeatable way to spot change early, adjust support safely, and evidence that the service remains effective. This article sits within Assessment, Review & Changing Needs and links to Service Models & Care Pathways because the review process must fit the model of care (homecare, residential, supported living) and the pathway around it.
Why “review” is a safety process, not an admin task
In dementia services, reviews protect people from three common failure modes: (1) gradual drift (risks increase slowly and become “the new normal”); (2) single-event collapse (a fall, infection or safeguarding incident exposes a weak support plan); and (3) system mismatch (care delivery does not keep pace with a changing level of need). A robust review process makes change visible, creates a structured decision trail, and ensures that staff do not rely on memory or informal handovers.
Set clear triggers for review (and document them)
Reviews should happen routinely (e.g., monthly in early placement or after a major change, then 8–12 weekly depending on stability) and also when triggers occur. The best operational practice is to publish “trigger prompts” in the care plan and daily notes template so that all staff can spot change consistently.
Examples of high-value triggers
- Repeated falls, new bruising, “near falls” or fear of mobilising
- Sleep reversal, night-time wandering, increased calling out or agitation
- Weight loss, dehydration, reduced appetite, swallowing concerns
- Medication changes, missed doses, increased PRN use or side effects
- New refusal of care, increased distress, or escalation in restrictive practice
- Carer breakdown, family concerns, safeguarding alerts or police involvement
- Hospital admission, A&E attendance, new diagnosis or new equipment
Each trigger should lead to a defined action: who is notified, what is recorded, and the timescale for review. This prevents “we’ll keep an eye on it” becoming the default response.
Roles and responsibilities: make the review owned, not hoped for
Assessment and review works when roles are explicit. A practical model is:
- Key worker: collates day-to-day evidence, updates “what good looks like” outcomes, and checks that routines remain realistic.
- Senior/carer lead: validates triggers, ensures immediate risk controls, and initiates escalation where needed.
- Registered Manager (or service manager): chairs complex reviews, ensures safeguarding and MCA decision trails, and signs off restrictive practice changes.
- Clinical liaison (where applicable): interfaces with GP, community nursing, memory service, SALT, OT, falls team.
Operationally, the key is to schedule protected time for review activity and set minimum documentation standards (so reviews don’t slip when staffing is tight).
Operational example 1: Domiciliary care review after “soft” deterioration
Context: A person living alone with moderate dementia begins missing meals and answering the door late. No single incident occurs, but the pattern shifts over two weeks.
Support approach: The provider triggers an early review using the “nutrition/hydration + safety at home” prompts. The care coordinator requests a 7-day evidence bundle: visit notes, meal intake prompts, missed call log, and family feedback.
Day-to-day delivery detail: Calls are re-timed to align with appetite peaks; staff introduce a consistent “first 5 minutes” orientation script; a simplified meal-prep routine is added (one hot option, one cold option). A welfare-check contingency is activated: if no answer within 5 minutes, staff ring the on-call and follow a documented welfare pathway.
How change is evidenced: The provider tracks “meals taken”, “hydration prompts completed”, and “answered door within expected time” for 14 days. A short outcome statement is updated: “eats two meals daily with prompts” and “accepts support without distress.” Evidence is reviewed in supervision and the plan is re-signed with the family’s input.
Operational example 2: Care home review following distress and increased PRN use
Context: In a residential dementia unit, a person begins pacing and shouting mid-afternoon. PRN medication use increases and staff report “nothing works.”
Support approach: The review focuses on function and meaning: what is the distress communicating? The manager initiates an ABC (antecedent–behaviour–consequence) style observation for five days and checks for pain, constipation, infection, and environmental triggers.
Day-to-day delivery detail: Staff adjust the afternoon routine: quieter space, reduced demands at personal care time, purposeful walking route with a named staff member, and a snack/hydration prompt before peak pacing. The activity plan is made more specific (two “go-to” tasks linked to life story). Handover includes a brief “what worked today” line to prevent drift.
How change is evidenced: PRN use is monitored weekly; incidents are themed; staff confidence is checked in supervision. The provider documents a restrictive practice review if any enhanced supervision or door-monitoring is proposed, ensuring proportionality and time-limited controls.
Operational example 3: Supported living review where capacity and risk have shifted
Context: A person in supported living with early dementia begins leaving the property at night and becomes disoriented. The previous plan assumed independent community access.
Support approach: The provider completes an urgent risk review alongside a mental capacity review for night-time decision-making. The aim is not to remove independence by default, but to ensure safety through the least restrictive option.
Day-to-day delivery detail: Staff introduce a night-time “check and reassure” routine; environmental cues are improved (clear signage, night lights). The plan adds a “positive risk-taking” framework: daytime independence remains, but night-time support is increased with clear triggers for calling on-call and family.
How change is evidenced: Night-time incidents reduce; sleep improves; the provider documents best-interests decisions where needed, and sets a review date to prevent restrictions becoming permanent.
Commissioner expectation: review cadence and auditable change control
Commissioner expectation: Commissioners typically expect a defined review cycle, trigger-based reviews, and clear evidence that the provider can manage deterioration without crisis escalation. In practice this means: signed care plan reviews, documented escalation pathways, and measurable outcomes that show whether changes to support are working (not just that a review “took place”).
Regulator / Inspector expectation: MCA, safeguarding and least restrictive practice
Regulator / Inspector expectation (CQC): Inspectors will look for robust decision trails when needs change: capacity assessments where relevant, best-interests decisions that are specific and time-limited, and evidence that restrictive practices are used proportionately and reviewed. They will also test whether staff understand the person’s “baseline” and can describe how they recognise and respond to deterioration.
Governance: how to prove your review process is working
To make assessment and review defensible, build governance around it:
- Monthly audit of review timeliness (routine and trigger-based) with exceptions escalated.
- Thematic learning from incidents (falls, safeguarding, medication, night-time events) linked to care plan updates.
- Supervision checks that staff can describe baseline, triggers and the current plan.
- Quality dashboard including: falls rate, PRN use, safeguarding alerts, unplanned hospital use, and outcomes progress.
The goal is simple: when needs change, the provider can show what was noticed, what was decided, what changed in day-to-day practice, and whether it worked.