Reviewing and Adapting Person-Centred Plans as Older People’s Needs Change
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Person-centred planning for older people is not a one-off activity. As health, cognition, mobility and social circumstances change, plans must adapt while preserving identity, choice and continuity. Poorly managed reviews can lead to confusion, distress and over-restriction, while effective reviews support ageing well.
This article focuses on dynamic, responsive planning in older people’s services, building on planning fundamentals (Person-Centred Planning) and outcome-led delivery (Outcomes-Focused & Goal-Led Support).
When person-centred plans should be reviewed
Reviews should be triggered by:
- Changes in health, mobility or cognition
- Falls, hospital admissions or safeguarding concerns
- Changes in family involvement or living arrangements
- The person expressing new preferences or goals
Routine reviews should be supplemented by responsive updates, not delayed until annual cycles.
Maintaining identity through change
As needs increase, there is a risk that plans become task-driven. Maintaining identity involves:
- Retaining personal history, routines and preferences
- Adjusting how support is delivered, not what matters
- Recording continuity explicitly within plans
Operational examples
Example 1: Increasing support without removing choice
Context: An older person required more assistance with personal care following illness.
Support approach: The plan was reviewed collaboratively, focusing on preserving privacy and routine.
Day-to-day delivery detail: Staff guidance specifies timing, preferred approaches and consent checks, avoiding rushed or standardised delivery.
Evidence of effectiveness: Reduced distress and consistent staff practice.
Example 2: Cognitive change and planning adaptation
Context: Gradual cognitive decline affected decision-making.
Support approach: Capacity was assessed decision-by-decision, with advance preferences embedded into plans.
Day-to-day delivery detail: Plans distinguish between choices the person can still make and areas requiring best-interests decisions.
Evidence of effectiveness: Clear audit trail supports lawful, respectful practice.
Example 3: Responding to family concern without overreaction
Context: Family raised concerns following a minor incident.
Support approach: A review balanced family input with the person’s wishes and proportional risk management.
Day-to-day delivery detail: Plans document agreed changes and reassure staff about what has not changed.
Evidence of effectiveness: Maintained independence and reduced unnecessary restrictions.
Commissioner and regulator expectations
Commissioner expectation: Commissioners expect plans to be living documents, reviewed promptly and proportionately in response to change.
Regulator / Inspector expectation (CQC): Inspectors will test whether plans reflect current needs and whether staff understand recent changes.
Governance and assurance mechanisms
- Review timeliness audits
- Change-trigger checklists
- Supervision discussions focused on adapting support
Responsive, person-centred reviews protect older people from both neglect and unnecessary restriction, ensuring services remain lawful, compassionate and effective.
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