What is a care plan? | An example of a care plan at a care home

Many wonder why is a care plan needed when moving into a care home and this article explains what’s included in a care home care plan and gives an example of a care plan.

What is a care plan?

A care home always assesses your needs before you move into a care home to help create a personal care plan for you.

The care home’s care plan sets out the level of care and support you will need as a care home resident, as well as details of your medication, diet, social interests and end-of-life preferences.

If you have health and social care needs and do not currently receive support, request a care needs assessment from your local authority (or trust if in Northern Ireland).

If you do not, you may receive care that is insufficient for your needs or care that is too intense, resulting in you paying for more care than you need.

Why are care plans important?

• A care plan is crucial to ensure you consistently receive the right level of care long term and that your personal requirements are known by care workers and the people around you.
• An effective care plan helps you to understand your condition and live as independently as possible. 
• By being involved in your own care planning, you ensure you will be looked after the way you want and that you can keep doing the things you enjoy, such as pursuing hobbies.
• A care plan is important because it helps your family and other loved ones to understand your wishes and how they can support you as well.

Care home provider Colten Care says it is important to get the input of both the resident and their family when drawing up a care plan.

A Colten Care spokesperson said: “We don’t accept anyone into our care whose needs we can’t meet. That judgement is made irrespective of how they are funded. Individual nursing assessments are done in an open, transparent way. 

“We devised and built our own internal scoring system that determines the care category, for example, nursing, assisted care or residential. It is used with enquiries across all our homes and provides a consistency of approach and rationale.”

Making a care plan: What does a care plan involve?

Every care home provider needs to get to know each person as an individual.

They must conduct a needs assessment so they can plan how they will deliver the person’s care.

They write this in a care plan, which any care workers delivering the person’s care will read and follow.

If you need support, a care plan is a document that specifies your assessed unique individual needs.

A care plan outlines what type of support you should get, how the support will be given and who should provide it.

A care plan is given in line with your wishes and preferences. The care home’s needs assessment is a discussion about what a person wants to achieve by receiving care in the care home.

Care plan assessment aims to identify what you need support with, who you are as a person and your preferences and goals.

. Although each care plan is unique, they all serve the same purposes, including:

• Helping identify and manage your care needs.
• Giving you the same care regardless of which care worker is on duty.
• Recording the care you receive.

Care plans are flexible so that if your care needs change, the plan will be reviewed and adjusted to make sure it to continues meet your needs and preferences.

Care home providers recommend that the person seeking care has a family member or person they trust with them for the care assessment. This is particularly important if you cannot fully answer questions, for example, due to dementia, a stroke or other medical reason.

What is included in a care plan?

You should always be involved in the care and support planning process to make your wishes known.

Depending on what support you need, your care plan could include everything related to your needs, such as visits to see family outside of care home.

Regardless of what your preferences are, your care plan should include:

• What your assessed care needs are.
• The type of support you should receive.
• The type of mobility equipment you need.
• Your desired outcomes.
• Who should provide your care.
• When care should be provided.
• Medication.
• Your cultural and ethnic background, gender, sexuality and any disabilities.
• Your dietary needs.
• Emotional and social needs.
• Records of care provided.
• Your wishes and personal preferences.
• Your end-of-life preferences.

Types of care plans

While all care home care plans are tailored to the needs of the individual, there are a few key types of care plan.

These are:   

• Nursing care plan 
• Dementia care plan
• Advance care plan

Where does the assessment for the care plan take place?  

Care assessments can take place in a person’s own home, hospital, care home or another location specified by the person seeking care. 

At care homes run by Royal Star & Garter potential residents receive a face-to-face visit by one of the nursing team.

Pauline Shaw, its director of care says: “We visit in the person’s home or hospital. Occasionally, someone will want to combine their assessment with a tour of the care home.

 “I feel there’s a big benefit from doing the assessment in the applicant’s home – the assessor gets so much contextualised information from their visit.

“They can discuss family photos, look at well-loved objects in their home. It allows a bond to develop and build – you have seen their home which is a privilege, you have that intimacy.” 

Who carries out a care plan in the care home? 

A care professional carries out a care plan. A care home’s member of staff can carry out a care assessment and this is largely done by a nurse.

Nurses in the care home are responsible for collecting and maintaining this data. Certified nursing assistants may be required to collect vital signs, such as pulse rate, respiration rate and blood pressure.

A spokesman for Colten Care said: “Assessments are only ever done by nurses. It’s a robust process that provides reassurance across the board.”

It is the same at Royal Star & Garter, with Pauline Shaw, its director of care saying: “Not every care provider does this, but we aim to send an experienced registered nurse.

“The assessor will invariably follow that person’s journey if the application is successful, they will be more involved. And that applicant will be delighted when they come into the care home and see a familiar face.” 

What questions are asked for care home assessment?

Here are some questions that may be asked by the care home:

• Do you have a preferred name, and how should we (your care team) address you? (A person’s preferred name might be different to their legal name).
• How do you like to be referred to? He/Him / She/Her They/Them? 
• What elements of your personality should we consider? 
• Does your ethnicity, religion or culture affect your care needs?
• What medication do you take?
• Do you have a history of falls?
• Do you have any memory problems?
• Are there any elements of your life that are particularly important? 
• Tell me about your job history before you retired.
• What are the essential routines you like to follow?  
• What are your hobbies and interests?
• Do you smoke? 
• What is your daily alcohol intake?
• Do you have any specific dietary requirements/needs? E.g. vegan, vegetarian, lactose intolerant?   
• Who are the important people in your life? 
• How involved are your family members? 

Who is contacted as part of the care home assessment? 

Care homes may, if necessary, contact your GP and other health professionals to better understand your care needs. 

During the assessments, you should be told if the care home needs to contact your GP, pharmacist or hospital consultant. When these health professionals are contacted, this will be in the applicant’s best interests for a specific reason. 

How long does a care home’s assessment take? 

Care homes will conduct an assessment at the care seeker’s pace and therefore there is no set time period. 

Royal Star & Garter’s Pauline Shaw says: “We don’t have a set time for the assessment. They last as long as they last. It could take an hour, it could take two hours, it could take more. We go at the person’s pace, just as we do when they move into our homes.”

What is an example of a care plan?

A care home care plan details the support a resident needs in a care home. It covers their medical, emotional, and personal care requirements

Here is an example of a fictional care plan for a resident in a care home.

Example Care Plan

Care Home: Everglade Yellow Care Home

Date of Admission: 01/08/2025.

Room Number: 27.

Personal Details

Full Name: Mrs Rose Walker

Date of Birth: 04/06/1943.

Preferred Name: Rosie

Gender: Female

Next of Kin/Emergency contact: Samantha Walker (daughter). [Telephone number here]

Marital status: Widow.

Religion: Roman Catholic.

Primary Language: English.

Ethnicity: White British.  

GP: Dr. Patel, Clearmont Surgery.

1. Medical Needs

Diagnosis:

Vascular dementia.

Osteoarthritis (knees and hands).

Medication (administered by staff):

Paracetamol (for pain management) – 500 mg, up to 4 times per day

Donepezil (for dementia) – 5 mg daily

Allergies: None

Medical Appointments:

GP appointment: 26th September 2025

Physiotherapy: Weekly sessions

Monitoring:

Blood pressure check once a week.

Pain score check twice a day.

Observe for signs of confusion or distress, particularly in evenings (sundowning).

2. Mobility & Safety

Assessment:

Mobilises with a walking frame.

Requires supervision when walking.

High falls risk – history of three falls in the last four months.

Interventions:

Call bell within reach at all times.

Encouraged to wear well-fitting non-slip footwear.

Floor sensor mat used at night.

Staff to assist with transfers using the stand aid.

3. Nutrition & Hydration

Diet:

Rosie prefers a soft diet due to difficulty chewing.

Requires assistance with meals, especially cutting food and ensuring adequate fluid intake.

Fluid Intake:

Staff to encourage fluids regularly (target 1.5L per day).

Record intake on hydration chart.

Likes: Jam on toast, tea with milk. 

Dislikes: Fish.

4. Personal Care & Hygiene

Needs:

Full assistance with washing, dressing, and grooming.

Prefers showers four times per week.

Incontinent of urine – wears pads, changed regularly.

Skin care:

Cream applied to lower legs once a day to treat dry skin.

Pressure area care – reposition every two hours, if Rosie is in bed.

5. Cognition & Communication

Cognitive Function:

Moderate dementia – Rosie’s short-term memory is affected.

She may become confused in unfamiliar situations.

Communication:

She responds well to visual prompts and reassurance.

Can express needs but may need time and patience.

6. Emotional & Social Needs

Social needs

• Rosie enjoys listening to jazz and singing.
• Loves talking about her late husband and friends.  
• Would benefit from more one-to-one time, e.g. short walks with staff member.
• Daughter visits once a week on Saturdays. Staff to remind Rosie of visits in advance.
• Video calls with grandson every Sunday around 11am.

Emotional needs

She prefers quiet spaces and gets anxious in noisy environments.

Occasionally feels anxious, particularly in the evenings (‘sundowning’).

7. Goals and Outcomes

Short-term goals:

• Support Rosie to maintain independence with mobility and personal care where possible.
• Ensure she receives adequate hydration and nutrition, helping with meals and snacks as needed.

Long-term goals:

• Encourage participation in social activities to combat feelings of isolation.

8. Daily Routine

Morning:

• 7:30 AM: Wake-up and personal care (assisted bathing, dressing)
• 8:00 AM: Breakfast (assisted with food)
• 8:30 AM: Medication administration
• 9:00 AM: Morning activity (group exercise)

Afternoon:

• 12:00 PM: Lunch (assisted, soft diet)
• 1:00 PM: Rest time (quiet time in her room or a short walk with staff)
• 2:00 PM: Afternoon activity (memory games, or music therapy)
• 3:30 PM: Tea (light snack or drink)

Evening:

• 5:00 PM: Dinner (assisted)
• 6:00 PM: Evening relaxation (reminiscing, watching TV)
• 7:00 PM: Medication (if required)
• 8:00 PM: Bedtime routine (toileting, preparing for sleep)

9. Risks and Management Strategies

Risk of falls:

• Monitor for any signs of imbalance or difficulty with mobility. Encourage use of walking aid. Staff supervision when moving.

Pressure ulcers risk:

• Regular repositioning every two hours in bed.
• Use of pressure-relieving mattress.

Risk of social isolation:

• Encourage daily participation in group activities.

Dehydration risk:

• Ensure fluid intake is monitored throughout the day, especially if Joan forgets to drink.

10. Staff Involvement

Nurse: Katie Norris.

Support Staff: Gemma Wilkins (Healthcare Assistant), Sarah Green (Activities Coordinator).

11. End of Life & Advance Care Planning

• DNACPR: In place, signed by GP and family.
• Advanced Wishes: Rosie wishes to remain in the care home for all care.
• Comfort care only if health deteriorates significantly.

Samantha Walker – Rosie’s daughter is Power of Attorney for health and welfare.

12. Care plan review schedule

Last review date: 01/08/25.

Next review date: 01/11/25.

Reviewed by: Nurse Katie Norris & care home manager Emma Robinson.

What happens if care plan is not effective?

• An assessment reviewing the care plan will indicate how well a care home resident’s condition responded to the nursing interventions and if identified goals were met or not. 
• If specific goals were not achieved, the nursing care staff will revise the care plan with their families and make adjustments to the care plan where necessary.

How often is a care plan reviewed? 

A spokesman for care provider Colten Care said: “Assessments are done before and on admission [to a care home] and then at regular intervals and in line with an individual’s changing needs.”