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Registration Number: {{org_field_registration_no}}

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Initial Assessment and Care Planning Policy

1. Purpose

The purpose of this policy is to set out {{org_field_name}}’s arrangements for completing initial assessments, deciding whether the service can safely and lawfully meet a person’s needs, developing person-centred care and support plans, and reviewing and updating those plans in response to changing needs, risks, preferences and outcomes.

This policy is intended to support compliance with the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulation 9 (Person-centred care), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 17 (Good governance), Regulation 18 (Staffing), and Regulation 20 (Duty of candour), together with current CQC guidance and assessment expectations.

The policy also reflects responsibilities under the Mental Capacity Act 2005, the Mental Capacity Act Code of Practice, the Equality Act 2010, data protection law, and the Accessible Information Standard where applicable.

This policy ensures that:

• The individual’s needs, preferences, and aspirations are fully assessed before support begins.
• Risk factors are identified and managed effectively to protect health and well-being.
• Personalised care plans are created, implemented, and regularly reviewed.
• Consent, mental capacity, best-interest decision-making, and lawful involvement of representatives are properly considered and recorded.
• Reasonable adjustments, communication needs, and accessible information requirements are identified at the earliest stage and reflected in care planning.
• Accurate, contemporaneous and complete records support safe delivery of care, continuity, review and governance oversight.
• Changes in need, risk, presentation, outcomes or preference trigger timely reassessment and care plan review rather than waiting for the routine review date.
• Staff are trained and competent in conducting assessments and managing care planning efficiently.
• Multi-agency collaboration ensures that care is holistic and addresses all aspects of well-being.

2. Scope

This policy applies to all staff involved in the initial assessment, care planning, and ongoing review of individuals receiving support from {{org_field_name}}. It covers:

• Pre-admission assessments and suitability checks.
• How care and support plans are developed, reviewed, and adjusted.
• The involvement of individuals, families, and advocates.
• Risk assessments and safeguarding considerations.
• Coordination with healthcare and social care professionals.
• The use of technology and tools in assessment and planning.
• Assessment of capacity, consent, decision-making support, and, where relevant, best-interest processes and involvement of attorneys, deputies, advocates or other lawful representatives.
• Identification and recording of protected characteristics, cultural needs, communication needs, sensory needs, reasonable adjustments, and accessible information requirements.
• Record-keeping requirements for assessments, care plans, risk assessments, reviews, handovers and professional communications.
• Review triggers arising from incidents, safeguarding concerns, hospital admission or discharge, medication changes, deterioration, behavioural changes, significant life events, complaints or feedback.
• Information sharing, referrals, escalation and coordination with external professionals, commissioners and emergency services where required for safe care.

3. Principles of Initial Assessment and Care Planning

At {{org_field_name}}, we are committed to delivering high-quality, person-centred care. Our approach follows these key principles:

Equality, Reasonable Adjustments and Accessible Information

{{org_field_name}} will identify and record, at the earliest opportunity, any communication needs, sensory needs, cognitive needs, cultural needs, religious needs, gender-related preferences, and other needs requiring reasonable adjustment.

Information about assessment, care planning, risk, consent, complaints and reviews must be provided in a format the person can understand, such as easy read, large print, audio, translated material, braille, pictorial support, digital format or interpreter-supported communication, where required.

The service will record and flag the person’s information and communication needs and the adjustments required so that staff can respond consistently and safely.

Pre-Admission and Suitability Assessment

Before an individual is accepted into our service:

• A pre-admission assessment is conducted to ensure that our service can meet the individual’s needs effectively.
• The individual (or their representative) is invited for an initial discussion to gather relevant medical, personal, and social information.
• If the person has complex needs, a multi-disciplinary team meeting is arranged with relevant healthcare professionals to discuss appropriate support strategies.
• Suitability is assessed based on:
  • The person’s care and support needs.
  • Our staff expertise and service capacity.
  • Environmental factors and accessibility.

Suitability decisions must also take account of:

• whether the person has capacity to make the relevant decisions at the time they are made, and what support is required to maximise that capacity;
• whether any lawful representative, advocate, attorney or deputy needs to be involved;
• whether the service can make the reasonable adjustments required to meet the person’s disability, sensory, communication or cognitive needs;
• whether staffing numbers, competence, training and skill mix are sufficient to meet the person’s assessed needs safely at all times;
• whether there are known risks relating to self-neglect, self-harm, falls, choking, mobility, skin integrity, epilepsy, mental ill health, substance use, financial abuse, exploitation, behaviours that challenge, absconding, environmental safety, medication, or risks to and from others;
• whether there are any restrictions, court orders, licence conditions, safeguarding plans, tenancy-related considerations or professional recommendations that affect the service’s ability to deliver lawful and safe support; and
• whether admission can be managed without creating avoidable risk to the person or to others using the service.

If {{org_field_name}} is unable to meet the individual’s needs safely, lawfully and in a person-centred way, the service will not accept the placement. The reasons for this decision will be recorded, communicated to the referrer and/or relevant person, and, where appropriate, alternative options or further assessment recommendations will be provided.

Comprehensive Initial Assessment

Before support begins, and following any pre-admission decision to proceed, a full holistic assessment must be completed and recorded. The assessment must be proportionate to the person’s needs, reflect current information, involve the person as fully as possible, and draw on available information from the individual, family or carers, advocates, commissioners, existing care records, risk information, hospital discharge documentation and relevant professionals.

The comprehensive initial assessment must include, where relevant:

• physical health, long-term conditions, acute health needs, allergies, pain, mobility, moving and handling needs, falls risk, skin integrity, continence, oral health, sleep and fatigue;
• mental health, emotional well-being, psychological needs, trauma history where known and relevant, and any current community mental health involvement;
• communication needs, including the person’s preferred methods of communication, need for interpreters, sensory impairment support, literacy needs, communication passports, assistive communication tools, and accessible information requirements;
• capacity and consent in relation to the proposed care and support arrangements, including any specific decisions requiring a capacity assessment, and the involvement of attorneys, deputies, advocates or other lawful representatives where relevant;
• personal care preferences, including gender preferences for support where possible, privacy, dignity, routines, and what matters most to the individual;
• nutritional, hydration and swallowing needs, including cultural or religious dietary requirements, allergies, specialist diets, weight concerns and choking risks;
• medicines support needs, allergies, side effects, risks associated with medicines, and arrangements for prescribing, supply, administration, storage, monitoring and review where the service provides medicines support;
• daily living skills, strengths, independence goals, domestic tasks, budgeting, shopping, travel training, employment, education, volunteering and community participation;
• social history, family and friendship networks, relationships important to the person, and who the person wants involved in assessment, care planning and review;
• religious, spiritual, cultural, sexuality and identity-related needs and preferences;
• risks to the person and to others, including self-neglect, exploitation, abuse, falls, choking, epilepsy, diabetes, infection, absconding, behaviours that challenge, substance misuse, mental health crisis, fire safety and environmental hazards;
• safeguarding history, current safeguarding concerns, and any existing safeguarding plans or multi-agency arrangements;
• positive behaviour support needs and known triggers, de-escalation strategies, protective factors and lawful restrictive practice arrangements where applicable;
• legal status and restrictions, including tenancy considerations, court orders, probation/licence conditions, community treatment arrangements, or other legal frameworks relevant to support planning;
• assistive technology, equipment, telecare or environmental adaptations required to support safety, communication or independence;
• emergency, contingency and continuity arrangements, including what to do in the event of deterioration, hospital admission, missed visits, staff shortage, severe weather, utility failure or other disruption; and
• outcomes identified by the person, including what a good day looks like, what is important to and for them, and how progress will be measured.

A named worker or lead professional will coordinate completion of the assessment and care plan; however, responsibility for the quality, completeness and legal compliance of the assessment remains with the registered provider and registered manager.

Record Keeping and Documentation Standards

All assessments, care plans, risk assessments, capacity assessments, best-interest decisions, reviews, professional communications and significant changes must be recorded clearly, accurately, contemporaneously and in sufficient detail to support safe and person-centred care.

Records must identify who completed the entry, when it was completed, the source of information relied upon, the rationale for significant decisions, any actions required, who is responsible for those actions, and when follow-up or review is due.

Outdated versions of care plans must be archived in line with record retention requirements, and the current version must be clearly identifiable to staff.

Learning Disability and Autism

Where a person has a learning disability, is autistic, or both, assessments and care plans must reflect the person’s communication style, sensory profile, routines, distress indicators, known triggers, strengths, preferred environments, reasonable adjustments and strategies for reducing anxiety and avoiding unnecessary restriction.

Staff involved in assessment, planning and delivery of support must receive learning disability and autism training appropriate to their role, and the service will take account of current statutory and national guidance when planning support.

Developing a Personalised Care and Support Plan

Following assessment, a detailed, person-centred and outcome-focused care and support plan must be developed before, or as soon as safely possible at the start of, service delivery. The plan must be created with the individual and, where the person wishes or where lawful and appropriate, their family, advocate, attorney, deputy, commissioner and relevant professionals.

Care plans must be written in clear, practical language, reflect the person’s own views and goals, and be available in a format the person can understand. The care plan must clearly state what support is required, when it is required, how it is to be delivered, what the person can and wants to do for themselves, what choices they have made, what risks have been discussed and agreed, and when the plan will next be reviewed.

Each care and support plan must include, where relevant:

• the person’s desired outcomes, strengths, preferences, protected characteristics and reasonable adjustments;
• evidence of the person’s involvement in planning, their consent to the proposed arrangements, and any support given to help them understand and decide;
• guidance for staff on how to communicate effectively with the person and how to provide information in an accessible format;
• specific support instructions for personal care, medicines, nutrition and hydration, mobility, emotional support, daily living, appointments, finances, community access and maintaining relationships;
• details of risks identified, the agreed risk management approach, how the least restrictive option will be used, and when risks should be escalated;
• clear directions on what staff must do if the person declines support, becomes unwell, presents differently from baseline, is missing, experiences an incident, or requires emergency assistance;
• arrangements for working jointly with external professionals and for following professional guidance;
• contingency plans, hospital admission and discharge arrangements, and continuity plans for service disruption;
• review date, version control, date created, date amended, and the name and role of the person who completed or amended the plan.

Consent, Mental Capacity and Decision-Making

Care and treatment must only be provided with the consent of the relevant person, unless another lawful basis applies. During assessment and care planning, staff must presume that the person has capacity unless it is established otherwise, and must take all practicable steps to support the person to make their own decisions.

Where there is reason to doubt capacity for a specific decision, a decision-specific and time-specific mental capacity assessment must be completed and recorded in line with the Mental Capacity Act 2005 and its Code of Practice.

Where a person is assessed as lacking capacity for a specific decision, any decision made on their behalf must be made in their best interests, recorded clearly, and involve those who are lawfully entitled or appropriate to consult, such as attorneys, deputies, family members, advocates or relevant professionals.

Care plans must clearly record consent arrangements, any decisions the person is able to make independently, any areas where support is needed to make decisions, any best-interest decisions made, and any lawful representatives involved.

Staff must also record when consent is refused or withdrawn, what information was provided to the person, what alternatives were discussed, what risks were explained, and what action was taken in response.

Risk Management and Safeguarding in Care Planning

Risk assessments must be completed alongside the initial assessment and reflected in the care plan. Risk management must be person-centred, proportionate, evidence-based and focused on enabling the person to live as independently as possible while reducing avoidable harm.

Risk assessments must identify:

• the nature of the risk;
• who may be affected;
• early warning signs or triggers;
• the person’s own view of the risk and the outcome they want;
• current controls and additional actions required;
• the least restrictive approach to managing the risk;
• escalation arrangements, including when to seek urgent clinical advice, emergency services input, or safeguarding intervention; and
• review dates and events that would trigger immediate reassessment.

Where behaviour may place the person or others at risk, the assessment and care plan must include known triggers, preventative strategies, preferred approaches, de-escalation techniques, post-incident support and any lawful restrictive practice arrangements. Restrictive practices must never be used as a routine response, for staff convenience, or in a way that is inconsistent with the person’s rights, dignity and lawful safeguards.

Where responsibility for care is shared with relatives, commissioners or health professionals, the provider must work with them to ensure risk information is current, clear and acted upon.

Risk management strategies are documented in the care plan, with clear actions for mitigation.

If abuse, neglect, self-neglect, exploitation or improper treatment is suspected or identified at any stage of assessment, care planning or review, staff must take immediate action to protect the person, report concerns in line with safeguarding procedures, and make referrals to the local authority or other agencies as required by law and local protocol.

Multi-Agency Collaboration

To ensure holistic, integrated care, we work with:

• GPs and primary healthcare providers to manage medical conditions.
• Community mental health teams for individuals with mental health needs.
• Physiotherapists and occupational therapists to improve mobility and independence.
• Social workers and local authority teams for coordinated care planning.
• Advocates and legal representatives for individuals who require additional support in decision-making.

Where care is shared with other providers or transferred between services, {{org_field_name}} will ensure that relevant assessment information, risk information, medicines information, communication needs, consent arrangements, and contingency plans are shared promptly, securely and accurately with those involved in the person’s care, in line with confidentiality and information-sharing requirements.

Review and Ongoing Assessment

Care plans and risk assessments must be reviewed regularly and whenever there is a change in the person’s needs, presentation, wishes, capacity, risks, health status, medicines, living arrangements or outcomes.

A formal review must take place at least every six months, unless the person’s contract, commissioning arrangement or level of risk requires more frequent review. In addition, an immediate or early review must be undertaken following, or in response to:

• an incident, accident, near miss or safeguarding concern;
• a hospital admission or discharge;
• a significant deterioration or improvement in health or functioning;
• a change in mental state, distress, behaviours of concern or risk profile;
• a change in medicines or treatment;
• concerns raised by the person, relatives, advocates, staff, commissioners or professionals;
• a complaint, compliment, audit finding or lesson learned indicating that the plan is no longer accurate or effective.

Every review must be recorded, dated and signed or otherwise authenticated, and must clearly show what changed, what remained the same, who was involved, whether the person agreed with the updated plan, and when the next review is due.

Use of Technology in Assessments and Care Planning

Where electronic systems are used for assessment, care planning, review and risk management, records must be accurate, contemporaneous, secure, accessible to authorised staff, and protected against unauthorised access, loss or alteration.

Electronic systems must support version control, audit trails, timely updating, handover of key information and governance oversight.

Information must be shared lawfully, proportionately and securely, and records must reflect the person’s preferences about sharing information wherever this is lawful and appropriate.

4. Roles and Responsibilities

• Registered Manager: Has overall responsibility for ensuring that assessment, care planning and review systems are effective, legally compliant and consistently implemented. This includes oversight of quality, timeliness, accuracy, audit findings, staff competence, lessons learned, and action taken where assessments or care plans are incomplete, outdated or ineffective.
• Care Coordinators / Assessors / Senior Support Staff: Are responsible for completing assessments and reviews within required timescales, involving the person and relevant others, recording consent and capacity matters appropriately, escalating concerns promptly, and ensuring care plans and risk assessments remain accurate and current.
• Support Staff: Must read, understand and follow current care plans and risk assessments, record care delivered and concerns observed, seek guidance when plans are unclear or no longer appropriate, and report changes, incidents or safeguarding concerns without delay.
• Safeguarding Lead: Provides advice and oversight where abuse, neglect, exploitation, self-neglect or improper treatment is suspected; ensures timely referral and coordination with safeguarding partners; and monitors themes and learning.
• Health and Safety Lead / Clinical Leads or Other Designated Leads: Where applicable, provide specialist oversight on moving and handling, infection prevention and control, medicines, environmental safety, fire safety, or other high-risk areas relevant to care planning.
• All Staff: Must complete training and demonstrate competence relevant to their role, including person-centred care, consent, mental capacity, safeguarding, risk management, record-keeping, communication, equality and diversity, and any specialist needs relevant to the people they support.

5. Related Policies

This policy should be read in conjunction with:

• SL07 – Person-Centred Care Policy
• SL08 – Dignity and Respect Policy
• SL09 – Consent to Care Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• SL16 – Health and Safety at Work Policy
• SL21 – Medication Management and Administration Policy
• SL42 – Communication and Engagement with Service Users and Families Policy

6. Policy Review

This policy will be reviewed at least annually and sooner where there are changes in legislation, statutory guidance, CQC guidance, the assessment framework, case law, safeguarding requirements, organisational learning, or service delivery arrangements. Interim amendments may be issued where urgent updates are required. Updates will be communicated to all staff to ensure best practices are followed in assessment and care planning.

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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}}
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