Care home care plans: how families can be involved

By · Published 2026-09-22 · Last reviewed 2026-09-22

Care home residents paint pictures together at a table helped by a young volunteer.
Photo: Pictures by Ann, CC BY 2.0

Families can and should help shape a care home care plan, but the resident stays at the centre. If your relative can make their own decisions, you take part with their agreement. If they cannot, the law in England and Wales requires staff to consult carers, family and any attorney about their best interests, and Scotland, Wales and Northern Ireland all expect representatives to be involved in writing and reviewing the plan.

A care plan is the working document that tells staff how to look after your relative, from how they take their tablets to what helps when they are frightened at night. Families can help write it, and usually make it far better, but it remains the resident's plan. Your role depends on whether your relative can make their own decisions, whether you hold a power of attorney, and which UK nation the home is in.

What is a care home care plan?

Every registered care home must keep a written plan for each resident. Different nations call it different things: England and Northern Ireland say care plan, Scotland and Wales say personal plan. Whatever the name, it should set out:

Do not confuse the home's plan with two other documents. In England, if the council arranged the place there is also a council care and support plan under the Care Act 2014, and if the NHS pays through continuing healthcare the NHS has its own plan. The home's plan is the one used every day, and it is the one this article is about.

Do families have a right to be involved?

Broadly yes, but the route depends on where the home is and whether your relative can decide things for themselves.

England

Care homes in England must meet the fundamental standards enforced by the Care Quality Commission (CQC). Regulation 9, person-centred care, says the home must assess needs and preferences collaboratively with the resident, design care to achieve their preferences, and enable them to make, or take part in making, decisions about their care. The regulation is built around the resident, so a resident who can make their own decisions chooses how much family are involved. If your mother wants you at every meeting, the home should welcome you; if she would rather keep some things private, the home must respect that.

Where a resident cannot make a particular decision, the Mental Capacity Act 2005 applies. Anyone deciding what is in the person's best interests must consider their past and present wishes, and section 4 of the Act says they must, where practicable, consult anyone caring for the person or interested in their welfare, anyone the person named, and any attorney or deputy. Staff should be asking you what your relative would have wanted, not just telling you what they have decided.

A health and welfare lasting power of attorney (LPA) goes further: the attorney can decide about daily routine, medical care, moving into a care home and life-sustaining treatment, but only once the donor cannot decide themselves. Give the home a copy of the registered LPA and ask them to record who holds it.

Scotland

Scottish regulations are more specific. Under regulation 5 of the 2011 requirements for care services, the provider must prepare a written personal plan within 28 days of the person first receiving the service, must consult the resident and, where appropriate, their representative when preparing and revising it, and must review it when the resident or representative asks, when needs change significantly, and at least once every six months. The Health and Social Care Standards add that a person should be fully involved in developing and reviewing their personal plan, which should always be available to them, and that if they cannot decide, the views of those who know their wishes, such as a carer or representative, are sought. A welfare power of attorney takes effect once the granter has lost capacity and it is registered with the Office of the Public Guardian (Scotland).

Wales

In Wales, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 require the personal plan to be reviewed as and when needed and at least every three months. The review must involve the individual, the placing authority where there is one, and any representative, unless the adult declines their involvement or including them would be against the person's well-being. Care Inspectorate Wales inspects against these rules. The Mental Capacity Act 2005 and LPAs apply in Wales as in England.

Northern Ireland

Care homes are inspected by the Regulation and Quality Improvement Authority (RQIA) against Department of Health care standards. Those standards distinguish between relatives, meaning anyone with an interest in the resident's care, and a representative, meaning the person responsible for decisions for a resident who lacks capacity, and expect care plans to be agreed and reviewed with them. One important difference: an enduring power of attorney in Northern Ireland covers financial matters only, so there is no equivalent of a health and welfare LPA. Ask the home and the health and social care trust who they will consult if your relative cannot decide.

How do we get involved from the start?

The best time to shape the plan is before and during the move, while staff are still learning who your relative is.

  1. Attend the pre-admission assessment. Most homes assess a person before offering a place. Ask to be there and correct anything out of date.
  2. Write a life story. Where they grew up, their work, family names, faith, what frightens them, how they take their tea. Alzheimer's Society's free This is me leaflet, endorsed by the Royal College of Nursing since 2010, is designed for exactly this and suits anyone with dementia, delirium or communication difficulties.
  3. Describe a normal day. Waking time, breakfast, naps, bath or shower, television, bedtime. Staff cannot copy a routine they have never seen.
  4. List what works and what does not. Which phrases calm them, whether they hide pain, how they show they need the toilet.
  5. Say what you want to be told about. Falls, GP visits, new medicines, weight changes, refusing food. Put it in the plan so the night shift knows too.
  6. Agree a way to communicate. Who the key worker is, how often you will get an update, and who to speak to when the manager is away.

Can we read the care plan?

The plan belongs to the resident. It contains their health information, so the home needs their agreement to show it to you, or a proper reason to share it if they cannot agree, such as your role as attorney or your part in a best-interests decision. In Scotland the standards say the plan should always be available to the person, and Welsh regulations make representatives part of reviews. Homes often ask residents at admission who may see their records, so raise it then. If you are refused, ask for the reason in writing; a home that involves families properly will usually find a way, for example by going through the plan with you in the resident's presence.

How often should the plan be reviewed?

Making a review worthwhile

Reviews are often quick and paper-heavy. Keep a dated note of changes you have noticed, ask for a time you can attend in person or by phone, go through the plan section by section rather than asking whether everything is fine, and ask for the date of the next review and a copy of what was changed.

Should the plan record future wishes?

Yes, and this is where families are most valuable, because you often know what your relative said when they were well.

Advance statements and advance decisions

The NHS explains that an advance statement is a written record of a person's preferences, wishes, beliefs and values for future care. It is not legally binding, but anyone making decisions must take it into account. An advance decision, sometimes called a living will, is different: it refuses specific treatments in advance and is legally binding in England and Wales if it meets the legal requirements. Ask the home to keep copies of both in the plan and to tell the GP.

Resuscitation decisions

A do not attempt cardiopulmonary resuscitation (DNACPR) decision is made by a doctor, but the person must be consulted and told, unless the doctor believes telling them would cause physical or psychological harm. If the person lacks capacity, the NHS says the doctor must ask the people important to them about their wishes, and should involve an independent mental capacity advocate if there is nobody suitable. If a DNACPR form appears in the file and nobody spoke to your relative or to you, ask the home to arrange a conversation with the GP. Scotland and Northern Ireland have their own arrangements; the GP can explain what applies locally.

What if the plan is not being followed?

A good plan is worthless if the care does not match it. If the plan says two staff for transfers and you see one, or it says a pressure cushion and there is none:

  1. Tell the senior carer or nurse on duty the same day. Most gaps are fixed at this level.
  2. If it happens again, ask the manager in writing how the home will check the plan is followed.
  3. Use the complaints procedure if you are not satisfied, and tell the social worker or NHS coordinator if they arranged the place.
  4. Raise it with the regulator: the CQC in England, the Care Inspectorate in Scotland, Care Inspectorate Wales, or the RQIA in Northern Ireland.
  5. If you think your relative is being harmed or neglected, contact the council's adult safeguarding team (the health and social care trust in Northern Ireland).

When the family and the home disagree

Disagreements about risk, such as whether someone may walk unaided or eat food they might choke on, are common. In England and Wales, ask for a best-interests meeting with the home, the GP and anyone else involved. Staff must weigh safety against the person's wishes and freedom, not simply choose the safest option. If agreement is impossible, an independent advocate can help, and the Court of Protection can decide serious disputes.

This article is general information. Decisions about capacity, treatment and legal authority depend on your relative's circumstances, so for a specific problem speak to the manager and GP first and get advice from Age UK, Citizens Advice, a solicitor or the regulator.

Frequently asked questions

My father has capacity but the home talks to me instead of him. Is that right?

No. If your father can make his own decisions, the plan is his and the home should discuss it with him, involving you as much as he wishes. Gently steer conversations back to him and ask staff to record in the plan how he wants you involved.

Do I need power of attorney to be consulted?

In England and Wales, no. The Mental Capacity Act requires decision-makers to consult carers and anyone interested in the person's welfare when someone cannot decide for themselves. An attorney has more authority, because they can make certain decisions rather than only being consulted. In Scotland a welfare power of attorney gives similar decision-making authority; in Northern Ireland there is no health and welfare power of attorney.

Should the plan include end-of-life wishes even if my mother is well?

Yes. Recording preferences early, while your mother can express them, means they are known if she later becomes seriously ill. An advance statement, any advance decision and a note of who to involve should all sit in the plan.

Key takeaways