Reviewing and Adapting Person-Centred Plans for Older People as Needs Change
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Older people’s needs rarely remain static. Changes in health, cognition, mobility, or emotional wellbeing can occur gradually or suddenly. When person-centred plans are not actively reviewed and adapted, support becomes misaligned, risks increase, and independence can be lost unnecessarily.
This article connects person-centred planning principles (see Person-Centred Planning) with responsive service delivery (see Quality and Governance). Its focus is how services ensure plans remain live documents rather than static records.
Why plan reviews are a core quality function
Reviews are not administrative tasks. They are quality interventions that ensure support remains proportionate, lawful, and aligned with the person’s wishes. Poor review processes are a common theme in safeguarding incidents and regulatory breaches.
Triggers for reviewing person-centred plans
- Changes in mobility, falls, or physical health
- Fluctuations in cognition or capacity
- Hospital admissions or acute illness
- Changes in mood, engagement, or behaviour
Making reviews meaningful, not bureaucratic
Involve the person at every stage
Reviews should prioritise the person’s experience of their support, not just professional observations.
Use evidence from daily delivery
Daily notes, incident logs, and outcome measures should inform reviews, creating a clear link between lived experience and plan changes.
Balance stability with adaptation
While adaptation is essential, unnecessary changes can create confusion. Reviews should preserve what works while addressing emerging needs.
Operational examples
Example 1: Responding to increased falls risk
Context: A pattern of near-misses emerges. Support approach: A focused review is triggered. Day-to-day delivery detail: Mobility aids are introduced, and staff prompts are adjusted. Evidence: Falls reduce without restricting independence.
Example 2: Cognitive changes affecting routines
Context: Confusion increases during evenings. Support approach: The plan is reviewed with the person and family. Day-to-day delivery detail: Visual cues and simplified routines are added. Evidence: Reduced anxiety and improved engagement.
Example 3: Health deterioration and dignity
Context: Increased fatigue affects personal care. Support approach: Support is adapted to prioritise comfort and choice. Day-to-day delivery detail: Shorter visits with clear preferences documented. Evidence: Dignity preserved and distress reduced.
Commissioner and regulator expectations
Commissioner expectation: Providers must evidence timely reviews that respond to change and prevent avoidable escalation.
Regulator / Inspector expectation (CQC): Inspectors will look for clear links between changes in need, review decisions, and updated care delivery.
Governance and assurance
- Clear review triggers embedded in policy
- Audit trails showing why plans changed
- Supervision oversight of review quality
Effective review processes protect people, support staff, and demonstrate high-quality, responsive care in older people’s services.
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