Registration Number: {{org_field_registration_no}}

Initial Assessment and Care Planning Policy

1. Purpose

The purpose of this policy is to establish a structured, consistent and efficient approach to initial assessments and care planning within {{org_field_name}}. Our aim is to ensure that every person we support receives care and support that is safe, effective, person-centred and compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Fundamental Standards), the Care Act 2014 and the Care Quality Commission (CQC) Single Assessment Framework. Initial assessments and care plans will be used as core evidence that we meet key regulations including Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). Care will be planned and delivered in ways that promote people’s rights, well-being, safety, independence and choice.

2. Scope

This policy applies to:

All employees, including care workers, care coordinators, and management.
Service users and their families, ensuring their involvement in care planning.
Healthcare professionals and multi-disciplinary teams involved in care assessments.
Regulatory bodies, ensuring compliance with statutory requirements.

It covers:

The process of conducting initial assessments.
Risk assessments and mitigation planning.
Development and review of personalised care plans.
Service user involvement and consent.
Documentation and confidentiality.

3. Legal and Regulatory Framework

This policy aligns with the following up-to-date legal and regulatory standards:

Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3, as amended) – including the Fundamental Standards, in particular:
- Regulation 9: Person-centred care
- Regulation 10: Dignity and respect
- Regulation 11: Need for consent
- Regulation 12: Safe care and treatment
- Regulation 13: Safeguarding service users from abuse and improper treatment
- Regulation 16: Receiving and acting on complaints
- Regulation 17: Good governance
- Regulation 18: Staffing
- Regulation 19: Fit and proper persons employed
- Regulation 20: Duty of candour
Care Quality Commission (Registration) Regulations 2009, including requirements on statement of purpose, notifications and financial position.
Care Act 2014 – promoting wellbeing, prevention, personalised and outcome-focused care and support.
Care Quality Commission (CQC) Single Assessment Framework – including the five key questions (safe, effective, caring, responsive and well-led) and associated quality statements, which guide how CQC assesses the quality of assessment, care planning and review.
Mental Capacity Act 2005 (and current Code of Practice) – supporting and protecting people who may lack capacity to make specific decisions, including best-interest decision-making and use of independent advocacy.
Health and Care Act 2022, section 20(5ZA) and the Oliver McGowan Code of Practice on statutory learning disability and autism training – requiring CQC-registered providers to ensure that staff, including those undertaking assessments and care planning, receive learning disability and autism training appropriate to their role.
UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018 – ensuring lawful, fair and secure handling of personal and special category data.
Equality Act 2010 and Human Rights Act 1998 – ensuring that assessments and care plans promote equality, non-discrimination and respect for people’s fundamental rights.

4. Initial Assessment Process

To ensure care is tailored to individual needs, the initial assessment process follows these steps:

Referral and Pre-Assessment Review:
- Gather relevant medical and personal information.
- Liaise with family members, healthcare professionals, and social workers.
Face-to-Face Assessment:
- Conduct a detailed evaluation of physical, emotional, and social needs.
- Identify service user preferences, lifestyle, and cultural considerations.
- Discuss risks, safeguarding concerns, and any existing support networks.
- Identify how the person prefers to communicate and record any information or communication support needs (for example, accessible formats, interpreters, communication aids), ensuring reasonable adjustments are put in place so they can understand, participate in and agree to their care and support.
Risk Assessments:
- Evaluate mobility, falls risk, medication management, and environmental hazards.
- Assess risks related to personal care, nutrition, mental health, and safeguarding.
- Develop mitigation strategies for identified risks.
Capacity and Consent:
- Assess and record the person’s capacity to make each relevant decision about their care and support in line with the Mental Capacity Act 2005 and its Code of Practice. Capacity is time- and decision-specific and must not be assumed.
- Where the person has capacity, ensure that consent to assessments, information sharing and care interventions is voluntary, informed and recorded in the assessment and care plan.
- Where the person is assessed as lacking capacity for a specific decision, follow the best-interests process, involving family, friends, attorneys, deputies and/or an Independent Mental Capacity Advocate (IMCA) where required, and clearly record the rationale for the decision and how the least restrictive option has been chosen.
- Record any advance decisions, LPAs, advance care plans or expressed wishes, and ensure they are taken into account when planning care and support.
- Where care arrangements may amount to a deprivation of liberty, seek appropriate legal authorisation and advice in line with current law and guidance.
Multidisciplinary Collaboration:
- Work with healthcare professionals to ensure a holistic assessment.
- Incorporate input from district nurses, GPs, and therapists where needed.

Staff who undertake initial assessments and care planning must have received learning disability and autism training that is appropriate to their role, in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Oliver McGowan Code of Practice. {{org_field_name}}’s Training and Development Policy sets out how this requirement is met.

5. Care Planning and Personalisation

Following assessment, a person-centred care plan is developed:

Goal Setting:
- Co-produce clear, outcome-focused goals with the person (and, where appropriate, their family or advocate) that reflect what matters most to them, not just their clinical or physical needs.
- Set measurable short- and long-term outcomes that promote independence, safety, wellbeing, social connection and quality of life, and that can be reviewed and updated regularly.
- Ensure goals and planned interventions are tailored to the person’s strengths, preferences, cultural and spiritual background, communication needs and any reasonable adjustments required, in line with Regulation 9 (Person-centred care).
Care Delivery Plan:
- Set out clearly the person’s assessed needs and how these will be met day to day, including (where relevant) personal care, medication support, nutrition and hydration, mobility, skin integrity, continence, domestic tasks, social and community participation, and emotional support.
- Specify what staff must do, how often and to what standard, so that care can be provided safely and consistently in line with Regulations 9 and 12 (person-centred care and safe care and treatment).
- Record any risks and agreed risk-management strategies, including positive-risk-taking decisions that have been made jointly with the person.
- Record any restrictions on the person’s rights or freedoms (for example, use of bedrails, medication timing, financial safeguards), the legal basis for these, and how they are kept under review to ensure they remain necessary, proportionate and the least restrictive option.
- Ensure care plans are written in clear, accessible language and that the person is offered a copy in a format they can understand, with reasonable adjustments and communication support as required.
Safeguarding Measures:
- Ensure compliance with safeguarding policies to protect service users.
- Develop contingency plans for emergencies.
- Where safeguarding risks are identified during assessment or review, staff must follow {{org_field_name}}’s Safeguarding Policy and local multi-agency procedures, and ensure that the care plan reflects the actions agreed to keep the person safe.
Communication Plan:
- Define how care updates will be shared with families and healthcare professionals.
- Establish review timelines for regular care plan updates.

6. Service User Involvement and Consent

To empower service users and respect their choices:

Care assessments and plans will be co-produced with the person wherever possible, respecting their views, wishes, feelings and the outcomes they want to achieve.
With the person’s consent (or in their best interests if they lack capacity), family members, informal carers and/or advocates will be involved in assessments, reviews and decision-making.
Where the person has substantial difficulty being involved and has no appropriate person to support them, staff will request a Care Act advocate or IMCA in line with statutory requirements.
The person will be informed of their right to request changes to their care plan at any time and how to raise concerns or complaints about their assessment, care planning or the service they receive.
Consent (or best-interest decisions) will be clearly documented, regularly reviewed and revisited whenever there is a significant change in needs, wishes or circumstances.

7. Documentation and Confidentiality

All assessments, risk assessments and care plans must be completed in a timely manner, legible, factual, dated and signed, and maintained as part of the person’s care record, in line with Regulation 17 (Good governance).
Records must provide a clear audit trail of assessments, decisions (including capacity and best-interest decisions), consent, actions taken and reviews, so that another competent worker could safely continue the person’s care.
{{org_field_name}} processes personal data in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018, ensuring lawful bases for processing, data minimisation, accuracy, storage limitation and security.
Information will only be shared with other professionals and agencies on a need-to-know basis, with the person’s consent where they have capacity, or in their best interests or in line with safeguarding/legal requirements where they lack capacity.
Both electronic and paper records are stored securely with appropriate access controls, retention periods and disposal procedures, and are available for inspection by the CQC and other authorised bodies when required.

8. Review and Continuous Improvement

Care plans will be reviewed at least every three months, or sooner where there is a change in need, following hospital admission or discharge, safeguarding concerns, significant incidents, complaints or near misses.
Reviews will consider whether planned care remains safe, effective, person-centred and proportionate, and will be carried out in partnership with the person and, where appropriate, their family or advocate.
{{org_field_name}} will use information from incidents, complaints, compliments, audits, feedback and CQC findings to improve the quality of assessments and care planning, in line with Regulations 16, 17 and 20 (receiving and acting on complaints, good governance and duty of candour).
Where something goes wrong in the assessment or planning of care and the person experiences (or could have experienced) moderate or severe harm, we will follow our Duty of Candour Policy, including being open and honest with the person and/or their representative, providing an apology, and explaining what has been done to prevent recurrence.

9. Policy Review and Updates

This policy will be reviewed annually, or sooner where:

There are changes to the Health and Social Care Act 2008, the 2014 Regulated Activities Regulations, CQC guidance or the CQC Single Assessment Framework that affect initial assessment and care planning.
There are updates to the Mental Capacity Act 2005 Code of Practice or the Oliver McGowan Code of Practice on statutory learning disability and autism training that impact how assessments or care plans are carried out.
Internal audits, serious incidents, safeguarding enquiries, complaints, service-user feedback or regulatory feedback identify required improvements.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

DC36-Initial Assessment and Care Planning Policy