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Initial Assessment and Care Planning Policy

1. Introduction

Our Home Care business is committed to ensuring that all service users receive a comprehensive, person-centred, and outcome-focused initial assessment and care plan, in line with Care Inspectorate Wales (CIW) regulations, the Social Services and Well-being (Wales) Act 2014, and the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA). Our approach ensures that individuals receive care that is tailored to their specific needs, preferences, and aspirations, while promoting dignity, independence, and well-being. This policy applies to all employees, including Care Coordinators, Registered Managers, Senior Carers, and Care Assistants, and provides clear guidance for CIW inspectors on how we ensure compliance with regulatory requirements.

This policy also reflects the requirements of The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended) and the Welsh Government statutory guidance for care home and domiciliary support service providers (last updated 27 March 2024), and is aligned to CIW’s inspection lines of enquiry on service suitability (Reg 14) and development/review of the personal plan (Regs 15–18).

2. Key Principles of Initial Assessment and Care Planning

• Person-Centred Approach: Each service user is actively involved in designing their own care plan.
• Holistic Needs Assessment: Care planning considers physical, emotional, social, and cultural needs.
• Risk Management and Safety: Individual Risk Assessments (RA) are conducted to minimise potential risks.
• Outcome-Focused Planning: Care plans are designed to promote independence, choice, and control.
• Regular Review and Adaptability: The individual’s personal plan is reviewed as and when required but at least every three months, and sooner where there is a change in needs, risks, or outcomes, and in line with any reviews undertaken by the placing authority (where applicable).
• Compliance with Regulatory Standards: Care planning adheres to CIW’s Quality Standards for Home Care.

3. How We Manage Initial Assessments and Care Planning Efficiently

A. The Initial Assessment Process

Every new service user undergoes a comprehensive initial assessment before care delivery begins.

For Staff:

• Step 1: Receive a referral from the Local Authority, NHS, private client, or family member.
• Step 2: Arrange an Initial Assessment Meeting (IAM) at the service user’s home.
• Step 3: Gather information on medical history, mobility, dietary needs, mental capacity, communication preferences, personal care needs, medication requirements, and lifestyle preferences.
• Step 4: Complete a Holistic Needs Assessment (HNA) to capture all aspects of well-being.
• Step 5: Conduct a Risk Assessment (RA) for falls, home safety, and safeguarding risks.

For CIW Inspectors: Initial assessment records confirm a comprehensive and person-centred approach. Risk assessments demonstrate that potential hazards are identified and managed.

B. Developing the Personalised Care Plan (PCP)

Each individual will have a personal plan that sets out how, on a day-to-day basis, their care and support needs will be met and how they will be supported to achieve their personal outcomes, including risk management and positive risk-taking where appropriate.

For Staff:

• Step 1: Create a Person-Centred Care Plan (PCCP) based on the assessment findings.

Timing requirement: An initial personal plan is prepared before the commencement of care and support. Where the individual is in urgent need and there has been no time to prepare the plan in advance, the personal plan will be in place within 24 hours of the service commencing.

• Step 2: Include information on personal preferences, religious or cultural needs, and social interests.
• Step 3: Set SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals to promote well-being.
• Step 4: Document all care routines in the Care Management System (CMS) for digital access.
• Step 5: Obtain written consent from the service user or their representative before care begins.

Access, copies, and communication needs (Regulation 17): We keep an accurate record of the personal plan, any revised versions, and the outcome of each review. We will provide the individual with a copy of the personal plan and any revised plan in a format and language appropriate to their needs (for example, Welsh/English, large print, easy-read, or alternative formats) and we will explain how the individual (and, where applicable, their representative and placing authority) can access the plan.

Mental capacity and best-interest decision-making: Where there is reason to doubt capacity, we will assess decision-specific capacity in line with the Mental Capacity Act 2005. If the individual lacks capacity for a relevant decision, we will make and record a best-interest decision, involve appropriate parties, and ensure there is lawful authority for any restrictions. Where arrangements may amount to a deprivation of liberty, we will act in accordance with the Deprivation of Liberty Safeguards where applicable and keep the required records.

For CIW Inspectors: Care plans demonstrate clear, achievable goals and service user involvement. Consent forms confirm that individuals understand and agree to their care plans.

C. Risk Assessments and Safeguarding Considerations

A key part of care planning is risk identification and management.

For Staff:

• Complete Risk Assessments (RA) covering:
  • Falls Prevention (home environment, mobility aids)
  • Medication Management (self-administration, assistance required)
  • Nutritional Risks (swallowing difficulties, meal preferences)
  • Safeguarding and Abuse Prevention (vulnerable adults, financial exploitation)
• Implement Risk Reduction Strategies (RRS) based on findings.

For CIW Inspectors: Documentation confirms that risks are assessed and managed proactively. Care plans include mitigation strategies for identified risks.

D. Outcome-Focused Care Planning

We design care plans that focus on achieving meaningful outcomes for service users.

For Staff:

• Set individual goals, such as improving mobility, increasing social engagement, or regaining independence.
• Encourage active participation in decision-making.
• Regularly assess progress towards goals and adjust plans accordingly.

For CIW Inspectors: Service user feedback confirms that care plans are personalised and empowering. Outcome reviews demonstrate that care is achieving measurable benefits.

E. Involving Families and Multi-Disciplinary Teams

Collaboration with families, healthcare professionals, and social workers is key to effective care planning.

For Staff:

• Engage family members and next of kin in care planning, if appropriate.
• Coordinate with GPs, district nurses, and occupational therapists to ensure holistic care.
• Use the Multi-Disciplinary Team (MDT) approach for complex cases.

For CIW Inspectors: Care plans show clear records of MDT involvement and professional recommendations. Communication logs demonstrate family involvement and regular updates.

F. Reviewing and Updating Care Plans

Care plans must be reviewed and updated regularly to reflect changing needs.

For Staff:

• Conduct a Formal Care Review (FCR) at least every 3 months (and sooner if required).
• Reviews must include a review of the extent to which the individual has been able to achieve their personal outcomes, and the personal plan must be revised where necessary.
• Update care plans immediately if a service user’s condition changes.
• Ensure service users and families are consulted during reviews.
• Each review includes a review of progress toward personal outcomes and whether the plan remains accurate and up to date.
• Reviews involve the individual and, where applicable, the placing authority and any representative (subject to the individual’s wishes/well-being).
• Following review, we will consider whether the personal plan should be revised and revise it as necessary, recording the outcome and sharing the updated plan as required.

For CIW Inspectors: Care plans include dated review logs to confirm compliance with regulations. Changes in care delivery are well-documented with service user consent.

G. Suitability of the Service (Pre-Commencement Decision – Regulation 14)

We must not provide care and support for an individual unless we have determined the service is suitable to meet their care and support needs and support them to achieve their personal outcomes.

Before accepting a package of care, we will:

• consider all available information, including the individual’s care and support plan (if available), health/professional assessments, and the person’s views, wishes and feelings;
• assess and document risks to the individual’s well-being and (where relevant) risks to the well-being of other individuals receiving care and support;
• consider and document any reasonable adjustments we could make to meet needs safely;
• involve the individual and, where applicable, the placing authority and any representative, unless involving a representative would be inconsistent with the individual’s well-being or the individual (aged 16+) does not wish them to be involved;
• ensure the assessment is completed by a person with the skills, knowledge and competence to carry it out and who has received training in undertaking assessments.

Where we cannot safely meet needs/outcomes, we will record the rationale and communicate this promptly to the referrer/commissioner and the individual (and representative where appropriate).

H. Provider Assessment (within the first 7 days – Regulation 18)

Within 7 days of commencement of care and support, we will complete a provider assessment (building on referral information and any existing care and support plan). The assessment will:

• identify and confirm the individual’s personal outcomes;
• confirm the care and support needed to achieve outcomes and the individual’s preferences (including cultural/religious needs);
• identify risks to the individual’s well-being (and, where relevant, others) and how these will be mitigated;
• identify any areas requiring more in-depth or specialist assessment.

The provider assessment will be undertaken by a trained, competent assessor and will be co-produced with the individual and, where applicable, the placing authority and any representative (subject to the individual’s wishes and well-being).

Following completion, we will review and update the personal plan in line with the assessment outcome and keep a record of the assessment and share a copy with the individual and, where appropriate, their representative.

4. Governance and Continuous Improvement

We ensure high standards of assessment and care planning through regular audits, staff training, and quality monitoring.

What We Do:

• Conduct Quarterly Care Plan Audits (QCPA) to review care plan effectiveness.
• Hold Annual Service User Feedback Sessions (ASFUS) to improve assessment processes.
• Train staff in Person-Centred Planning (PCP) and Risk Assessment (RA) best practices.

For CIW Inspectors: Audit records confirm regular reviews and quality monitoring. Training logs demonstrate staff competency in care planning.

5. Compliance Monitoring and Audit Procedures

• Internal Audits: Conducted quarterly to assess assessment and care planning compliance.
• Annual Reviews: Full compliance check against CIW regulations and Social Care Wales standards.
• Staff Supervisions & Appraisals: Used to ensure staff maintain care planning competency.

6. Conclusion

We are committed to delivering comprehensive, person-centred, and outcome-focused care planning in compliance with CIW regulations, RISCA, and the Social Services and Well-being (Wales) Act 2014. This policy ensures that service users receive care that is tailored, safe, and continuously reviewed to meet their evolving needs.

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