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CH36-Initial Assessment and Care Planning Policy

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Initial Assessment and Care Planning Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} conducts comprehensive initial assessments and develops person-centred care plans for every individual receiving care. This ensures that care is tailored to each person’s needs, preferences, and health conditions, promoting dignity, independence, and well-being.

We will maintain assessment and care-planning documentation in a way that provides clear evidence against CQC’s assessment framework (Safe, Effective, Caring, Responsive and Well-led) and relevant quality statements, including safe systems and transitions, involving people to manage risks, and safeguarding. Care plans and reviews will explicitly record the person’s outcomes, choices, equality needs and human-rights considerations.

A structured assessment and care planning process is essential to identify risks, establish goals, and provide safe, effective, and compassionate care. This policy ensures that our initial assessment and care planning process is systematic, thorough, and in line with CQC regulations.

By implementing this policy, {{org_field_name}} ensures that every person we support:

This policy applies to all staff involved in assessments, care planning, and service delivery.

2. Scope

This policy applies to:

It covers the full process of initial assessment, risk assessment, care planning, ongoing reviews, and person-centred decision-making.

3. Legal and Regulatory Framework

This policy complies with:

By following these regulations, {{org_field_name}} ensures that care is legally compliant, safe, and tailored to individual needs.

This policy must be read alongside Regulation 11 (Need for consent). All assessment, care planning and review activity will be undertaken with the person’s informed consent wherever they have capacity to consent. Where there is doubt about capacity for a specific decision, we will complete and record a decision-specific Mental Capacity Assessment and, where required, a documented Best Interests decision in line with the Mental Capacity Act 2005.

Where restrictions may amount to a deprivation of liberty, we will ensure the correct lawful authority is in place (currently the Deprivation of Liberty Safeguards (DoLS) process). We will keep national changes under review, including the Government’s stated intention to consult further on implementation of Liberty Protection Safeguards (LPS).

4. Initial Assessment Process

4.1 Purpose of Initial Assessment

The initial assessment is the foundation of high-quality care planning. It ensures that:

Every assessment is conducted before admission or within 24 hours of arrival at {{org_field_name}} to ensure safe, well-planned care delivery.

4.2 Key Components of the Initial Assessment

The assessment is holistic, covering:

Each assessment is documented electronically and in written records, ensuring accessibility for all care staff.

We will make and record reasonable adjustments to ensure the person can participate fully, including accessible information (easy read/large print), interpreters, communication aids, and involving specialist professionals where required.

5. Care Planning Process

Consent, Capacity and Best Interests (Regulation 11 / MCA / DoLS)
Care plans and agreed outcomes will be developed and reviewed with the person’s informed consent wherever they have capacity to consent. Where capacity is in doubt for a specific decision, staff will complete and record a decision-specific capacity assessment and, where required, a documented Best Interests decision, in line with the Mental Capacity Act 2005. Where restrictions may amount to a deprivation of liberty, we will ensure the appropriate lawful authority is in place (currently DoLS) and keep national changes (including LPS) under review.

5.1 Developing a Person-Centred Care Plan

Following the initial assessment, a detailed care plan is created to ensure that care is:

Care plans clearly outline:

Each person is given a named keyworker responsible for coordinating their care and ensuring their needs are met.

5.2 Involvement of Individuals and Families

People we support and their families play a central role in care planning decisions.

6. Risk Assessment and Safeguarding

Risk assessments are an integral part of care planning, ensuring that:

Each risk assessment includes:

Risk assessments are reviewed monthly or sooner if circumstances change.

7. Ongoing Monitoring and Care Plan Reviews

7.1 Regular Reviews

Care plans are dynamic documents, reviewed:

7.2 Staff Responsibilities in Monitoring

All care staff are trained to:

Managers conduct quality audits to ensure care plans are accurate, person-centred, and legally compliant.

Staff completing assessments and care plans will be supported to maintain role-appropriate competencies, including training relevant to the needs of people using the service (for example learning disability and autism training where applicable).

7.3 Transfers and Transitions (Admissions, Hospital Transfers, Discharge and Respite)

We will ensure continuity and safety when a person moves between services. This includes providing an up-to-date summary of needs, risks, medicines, escalation plans, and communication requirements; confirming consent/lawful basis for sharing; and updating the care plan promptly following discharge, readmission or significant events.

8. Communication and Information Sharing

To ensure continuity of care:

9. Policy Review

This policy is reviewed annually or sooner if CQC regulations, best practices, or organisational needs change.

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.

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