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Creating care plans that actually work requires more than good intentions. Vague goals like "improve mobility" or "increase social contact" sound reasonable, but they're almost impossible to implement consistently or measure meaningfully.
That's where SMART goal-setting comes in. Originally developed for business planning in 1981 by George Doran, the SMART framework has become standard practice in health and social care because it solves a specific problem: it turns aspirations into actionable, measurable commitments.
For homecare providers, SMART goals aren't just good practice - they're essential for meeting CQC expectations around person-centred care, demonstrating outcomes, and keeping care plans responsive as client needs change.
This guide explains how to apply the SMART framework to care planning, with practical examples, documentation guidance, and a clear checklist you can use when creating or reviewing care plans.
What does SMART stand for?
S – Specific
M – Measurable
A – Achievable
R – Relevant
T – Time-bound
Each element addresses a different weakness in how care goals are typically written. Used together, they create care plans that are clear, credible, and easy to evaluate.
Why SMART goals matter in care planning
A care plan built on vague goals creates three problems:
- Carers don't know what success looks like – "Improve wellbeing" could mean anything; without clarity, carers second-guess what they should be doing
- You can't demonstrate progress – CQC inspectors and families want evidence that care is working; without measurable goals, you're relying on anecdote
- Care plans drift out of date – Without time-bound goals and review points, plans become static documents that don't reflect current needs
SMART goals solve this by making care plans specific enough to implement and structured enough to review.
How to apply SMART to care planning
S – Specific
A specific goal answers: Who, what, when, where, why, and how?
Vague goals fail because they don't tell carers what to do. A goal like "increase social activity" leaves too much open to interpretation.
A specific goal would be:
"Rejoin my Thursday afternoon book club at the community centre (1pm–3pm) by the end of March, supported by a carer walking with me to the venue and reading one chapter aloud with me twice a week."
What makes this specific:
- What: Rejoin book club
- When: Thursdays, 1–3pm, by end of March
- Where: Community centre
- Who: Client and carer
- How: Walking support to venue + twice-weekly reading practice
- Why: Reconnect with social groups and maintain enjoyment of reading
Questions to ask when writing specific goals:
- Could a new carer read this and know exactly what to do?
- Does it describe the activity clearly enough that two carers would interpret it the same way?
- Have we agreed this with the client, their family, and the care team?
How to document needs and goals
When writing goals, use the person's own language and perspective wherever possible. This makes the plan more meaningful and relatable.
Poor example:
"Mr D is unable to dress by himself."
Better example:
"Mr D likes to dress smart every morning, but has been finding it difficult to make the choice of clothing to wear."
The second version captures both the need and the person's preferences. When setting the goal, involve them directly:
"Mr D, would you like to be able to make your own choice of clothes to wear every day with the support of staff?"
This approach ensures the goal reflects what matters to the person, not just what's convenient to document.
M – Measurable
A measurable goal lets you track progress and know when it's been achieved.
If you can't measure it, you can't tell if the care plan is working — and you can't demonstrate quality at a CQC inspection.
For the book club goal, measurable elements include:
- Ability to walk to the community centre (with or without aid)
- Participation in twice-weekly reading sessions
- Attendance at book club by end of March
Setting review points:
Break longer-term goals into checkpoints. For example:
- Week 2: Walking to end of street with support
- Week 4: Reading one chapter aloud without difficulty
- Week 8: Attending first book club session
This allows you to spot barriers early and adjust support before the goal becomes unachievable.
Measurable goals also create a clear record for care reviews, family updates, and regulatory inspections.
Documenting and evaluating progress
Each time an intervention is carried out, document the outcome in the person's care notes. This serves multiple purposes:
- Keeps everyone informed about progress
- Provides evidence for CQC inspections
- Helps identify when goals need adjusting
- Allows the person and their family to see achievements
Regular evaluation isn't optional — it's what keeps care plans current and effective.
A – Achievable
An achievable goal stretches the client appropriately without being unrealistic.
This is where person-centred care planning becomes critical. A goal that's achievable for one person may be completely inappropriate for another, even if they have similar care needs on paper.
Checklist for achievable goals:
- Has the goal been agreed with the person, their family, and their care team?
- Is it genuinely important to the person (not just something that sounds good on paper)?
- Do we have the resources, skills, and time to support it?
- Does the goal stretch the client's abilities without being extreme or discouraging?
- Can progress be made within the agreed timeframe?
Assign clear responsibilities:
Be specific about who will support each step. Document whether it's:
- The care worker on duty
- A specific team member
- The client themselves (with support)
- A family member
When everyone knows their role, goals are far more likely to be achieved.
If a client hasn't walked independently in six months, "walk unaided to the shops within two weeks" is probably not achievable. A better starting point might be "stand and take five supported steps twice daily within two weeks."
Achievable goals respect where someone is now while creating a realistic path forward.
R – Relevant
A relevant goal supports what actually matters to the client.
Care plans sometimes include goals that look good on paper but don't align with what the person wants from their life. A goal might be specific, measurable, and achievable — but if it's not relevant to the client's priorities, it won't feel meaningful.
Questions to test relevance:
- Does this goal support the client's broader care outcomes?
- Is this the right time to focus on this goal?
- Does it align with other things we're working on, or does it conflict?
- Is this goal important to the client, or just to someone else?
For example, a goal to "attend a weekly exercise class" might seem beneficial, but if the client's priority is reconnecting with old friends, a goal focused on social re-engagement (like the book club example) would be more relevant.
Relevant goals keep care plans focused on what the client values, not what's easiest to tick off a list.
T – Time-bound
A time-bound goal includes a clear deadline or timeframe.
Without a deadline, goals drift. "Improve mobility" could mean next week or next year — and without that clarity, there's no urgency and no point at which you evaluate whether the approach is working.
Time-bound goals answer:
- When will this goal be achieved?
- What can we do this week to move toward it?
- When will we review progress?
For the book club example, the time-bound element is "by the end of March." That creates a clear target and implies intermediate checkpoints along the way (e.g., weekly walking practice, fortnightly reading sessions).
Time-bound goals also align with regulatory requirements. CQC expects care plans to be reviewed regularly — typically every 90–180 days depending on risk and complexity. Setting time-bound goals makes those reviews more structured and evidence-based.
Putting it all together: a SMART care plan example
Weak goal (not SMART):
"Increase social activity."
SMART goal:
"Rejoin my Thursday afternoon book club at the community centre (1pm–3pm) by the end of March. To achieve this, I will be supported by my carer to walk to the venue each week and to read one chapter of my current book aloud together twice a week. Progress will be reviewed every two weeks."
Why this works:
- Specific: Clear activity, location, timing, and support needed
- Measurable: Walking ability, reading participation, attendance by end of March
- Achievable: Appropriate level of support; realistic timeframe
- Relevant: Aligns with client's wish to reconnect socially and maintain enjoyment of reading
- Time-bound: Target date of end of March; fortnightly reviews
Who should be involved in care planning?
SMART goals must be agreed with the person, their family, and the care team. This collaborative approach ensures:
- Goals reflect what matters to the person
- Family members understand and can support the plan
- Carers know exactly what's expected
- Everyone is working toward the same outcome
Getting sign-off:
Where possible, ask the person to sign their care plan. This reinforces their involvement and consent.
What if someone can't sign?
If a person is unable to sign or agree to their care plan — perhaps due to communication difficulties or cognitive challenges — make a clear note in the care documentation explaining why. This maintains transparency and helps everyone understand the situation.
When should care plans be reviewed?
Care plans aren't static documents. They should be reviewed:
- At scheduled intervals – Monthly, quarterly, or as agreed with your organisation's policy
- After any significant change – In the person's health, circumstances, or preferences
- Whenever interventions are carried out – Document progress each time
During reviews, involve the person, their family, and the care team to discuss:
- What's working well
- What needs adjusting
- Whether goals are still relevant
- Any changes in needs or preferences
Regular reviews keep care plans current and demonstrate your commitment to responsive, person-centred care.
How SMART goals support outcome-focused care
SMART goals align naturally with outcome-focused care planning - an approach increasingly expected by the CQC and central to demonstrating quality.
When you set SMART goals, you're not just documenting tasks. You're creating a clear line of sight between:
- What the client wants to achieve (outcomes)
- What activities will help them get there (goals)
- What carers need to do to support those activities (tasks)
Digital care planning tools make this easier by connecting assessments, goals, and tasks in one place. For example, Birdie's care planning software allows you to map tasks directly to client outcomes, track progress in real time, and prompt reviews at the right intervals — so SMART goals stay current and actionable.
Learn more about outcome-focused care planning
SMART care planning checklist
Use this checklist when creating or reviewing care plans:
Specific:
- Does the goal clearly state what will be achieved?
- Is it clear who will be involved and what support is needed?
- Could a new carer read this and know what to do?
- Have we used the person's own language and perspective?
Measurable:
- Can we track progress toward this goal?
- Are there clear milestones or review points?
- Will we know when the goal has been achieved?
- Have we documented how progress will be measured?
Achievable:
- Has this goal been agreed with the client, their family, and the care team?
- Do we have the resources and skills to support it?
- Is the goal realistic within the timeframe?
- Have we assigned clear responsibilities for who does what?
Relevant:
- Does this goal align with the client's priorities and outcomes?
- Is this the right time to focus on this goal?
- Does it support their broader care plan?
- Is it important to the person, not just convenient to document?
Time-bound:
- Is there a clear deadline or target date?
- Have we set interim review points?
- Does the timeframe align with regulatory review requirements?
- Do we know when the next evaluation will happen?
Documentation:
- Have we recorded the goal in the person's own words where possible?
- Is it clear who is responsible for each part of the plan?
- Have we noted if the person was unable to sign, and why?
- Have we scheduled the next review date?
Final thoughts
SMART goal-setting isn't about adding bureaucracy to care planning. It's about replacing vagueness with clarity — so carers know what to do, clients know what to expect, and you can demonstrate that care is working.
When care plans are built on SMART goals, they become easier to implement, simpler to review, and far more credible at inspection.
If you're looking to improve how your team approaches care planning, explore how digital care planning tools can help you create, track, and review SMART goals more efficiently — or book a demo to see outcome-focused care planning in action.
Published date:
February 21, 2022
Author:
Emma-Lee Curtis
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