{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Pain Assessment and Management Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} identifies, assesses, responds to and monitors pain experienced by individuals receiving domiciliary support in a safe, timely and person-centred manner. Pain assessment and management must form part of the individual’s overall assessment, personal plan and care and support arrangements and must promote the individual’s safety, dignity, comfort, independence and well-being.

{{org_field_name}} will ensure that:

• pain is recognised and assessed using an approach appropriate to the individual’s needs, communication abilities and circumstances;
• information about pain and its impact is incorporated into the individual’s provider assessment and personal plan where relevant;
• care and support relating to pain is provided in accordance with the individual’s personal plan;
• appropriate healthcare advice or assistance is sought promptly where pain is new, unexplained, severe, worsening, persistent or otherwise gives cause for concern;
• medicines are supported or administered only in accordance with the individual’s personal plan, the Medication Management and Administration Policy (DCW21), the directions applying to the medicine and the limits of the staff member’s role and competence;
• staff involved in pain recognition, assessment, monitoring or pain-related interventions have the knowledge, skills, training and competence appropriate to their role;
• the individual’s views, wishes, preferences, communication needs, rights, consent and mental capacity are respected; and
• records relating to pain assessment, interventions, outcomes and escalation are accurate, contemporaneous and sufficient to inform the ongoing provision and review of care and support.

This policy must be read and implemented in accordance with:

• the Regulation and Inspection of Social Care (Wales) Act 2016;
• the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended;
• the statutory guidance issued by the Welsh Ministers for service providers and responsible individuals on meeting the service standard regulations for domiciliary support services;
• the Social Services and Well-being (Wales) Act 2014;
• the Mental Capacity Act 2005 and its Code of Practice;
• applicable medicines legislation and current national medicines guidance;
• applicable National Institute for Health and Care Excellence guidance; and
• the Health and Safety at Work etc. Act 1974, where relevant to the safety of staff and individuals receiving care and support.

2. Scope

This policy applies to all employees, agency workers, temporary workers, volunteers and other persons working for or on behalf of {{org_field_name}} whose duties involve the assessment, planning, provision, monitoring or review of care and support for individuals who experience, or may experience, pain.

It applies to individuals receiving domiciliary support from {{org_field_name}}, including individuals who have acute or chronic pain, cognitive impairment, communication difficulties, long-term conditions or palliative and end-of-life care needs.

Healthcare professionals, including GPs, community or district nurses, pharmacists, specialist pain services and palliative care professionals, are not subject to this organisational policy unless separately employed or engaged by {{org_field_name}}. Staff must, however, work collaboratively with relevant healthcare professionals in accordance with the individual’s assessed needs, personal plan and agreed professional responsibilities.

This policy covers:

• recognition and assessment of pain;
• incorporation of identified pain needs into the individual’s provider assessment and personal plan;
• pharmacological and non-pharmacological pain management within the scope of the domiciliary support service;
• consent and mental capacity;
• staff training, competence and delegated healthcare activities;
• monitoring and recording the effectiveness of agreed interventions; and
• escalation to healthcare professionals, safeguarding authorities or emergency services where required.

3. Policy Statement

{{org_field_name}} is committed to providing high-quality, compassionate, and effective pain management for all service users. Our approach focuses on:

• Early identification and accurate assessment of pain.
• Use of evidence-based pain management strategies.
• Ensuring service users’ preferences and consent are respected.
• Collaboration with healthcare professionals to optimise pain relief.
• Providing ongoing staff training and support in pain recognition and management.

4. Managing Pain Assessment and Management Efficiently

4.1. Recognising and Assessing Pain

Pain may affect an individual’s physical, psychological and emotional well-being. The expression of pain varies between individuals and may be particularly difficult to recognise where an individual has dementia, cognitive impairment, learning disability, sensory impairment, neurological impairment, communication difficulties or is unable to communicate verbally.

Staff must not assume that an individual is free from pain solely because the individual does not verbally report pain.

Indicators of Pain

Staff must remain alert to verbal and non-verbal signs that may indicate pain, including:

• verbal reports of pain, discomfort, soreness, aching or other symptoms;
• requests for pain relief or statements that usual pain relief is ineffective;
• facial expressions such as grimacing, frowning or distress;
• vocalisations such as moaning, crying or calling out;
• changes in behaviour, including agitation, restlessness, withdrawal, distress, aggression or reduced engagement;
• guarding or protecting a part of the body;
• changes in posture, movement, mobility or willingness to move;
• changes in sleep, appetite or usual activities;
• physiological or physical changes that may be associated with pain; and
• changes from the individual’s normal presentation which may indicate pain or discomfort.

Where a member of staff observes new, unexplained or significant changes, the staff member must record and report the concern in accordance with this policy and the individual’s personal plan and seek appropriate healthcare advice where required.

Pain Assessment

Pain assessment must be person-centred and appropriate to the individual’s communication abilities, cognitive function and assessed needs.

Where a formal pain assessment tool is required, an appropriate recognised tool must be used in accordance with staff training and the individual’s assessment and personal plan. This may include, where appropriate:

• a numerical rating scale for an individual who is able to understand and use it;
• an appropriate visual or pictorial pain scale for an individual who benefits from this form of communication; or
• an appropriate observational pain assessment tool for an individual who is unable to provide a reliable verbal self-report.

A pain assessment tool must support, and must not replace, communication with the individual, observation, knowledge of the individual’s usual presentation and appropriate professional assessment.

Pain-related needs identified before or during commencement of the service must be reflected in the information used to determine whether {{org_field_name}} can meet the individual’s care and support needs.

Where pain is relevant to the individual’s care and support needs:

• it must be considered when preparing the individual’s initial personal plan;
• where care and support begins urgently and a personal plan could not be prepared beforehand, the relevant information must be incorporated into the personal plan prepared within 24 hours of commencement of the service;
• it must be considered as part of the provider assessment completed within seven days of commencement of care and support;
• the outcome of the assessment must inform any necessary revision of the personal plan;
• pain-related needs, risks, agreed interventions and escalation arrangements must be recorded sufficiently clearly to direct staff providing care and support; and
• the assessment and personal plan must be reviewed and revised when required, including where there is a significant change in the individual’s pain, needs or circumstances.

The individual’s personal plan must be formally reviewed as required and at least every three months in accordance with the applicable regulatory requirements.

4.2. Pain Management Strategies

Pain management must be individualised and must reflect the individual’s assessed needs, personal outcomes, preferences, consent, personal plan and relevant healthcare instructions.

Care staff must work within the limits of their role, training and assessed competence. Staff must not diagnose the cause of pain, prescribe medication, independently alter prescribed treatment or make clinical treatment decisions that fall outside their role.

Pharmacological Pain Relief

Where {{org_field_name}} provides support with pain-relieving medicines, all such support must be provided in accordance with the Medication Management and Administration Policy (DCW21), the individual’s personal plan and the directions applicable to the medicine.

This includes prescribed medicines, medicines intended to be used when required, topical preparations and any non-prescription or over-the-counter medicine with which staff are required to provide support.

Care staff must not independently recommend, select or commence an over-the-counter analgesic for an individual as part of the care service. Where an individual requires assistance with a non-prescription or over-the-counter medicine, staff must follow the organisation’s medicines arrangements and the individual’s agreed care arrangements and must obtain advice from an appropriate healthcare professional where this is required to establish that the product is suitable for the individual.

Where staff administer, assist with or otherwise support an individual with pain-relieving medication:

• the level of support required must be identified through assessment and reflected in the individual’s personal plan;
• the individual’s consent must be obtained unless there is lawful authority to act where the individual lacks capacity for the particular decision;
• staff must have received appropriate training and have been assessed as competent for the activity they undertake;
• the medicine must be administered or supported in accordance with the prescription, dispensing label, authorised medication record, agreed instructions and the Medication Management and Administration Policy (DCW21), as applicable;
• administration or support must be recorded accurately and contemporaneously;
• any refusal, omission, error, adverse effect or concern must be managed and escalated in accordance with the Medication Management and Administration Policy (DCW21);
• where medication is prescribed to be taken when required, staff must follow the individual’s authorised instructions or protocol and record the reason for administration and the outcome where this forms part of the agreed medicines arrangements; and
• staff must not change the dose, frequency, timing or route of a prescribed medicine unless the change has been authorised by an appropriately authorised healthcare professional and incorporated into the relevant medication documentation.

Individuals who are able to manage their own medicines must be supported to retain independence and control in accordance with their assessed needs, wishes and personal plan.

Non-Pharmacological Pain Relief

Non-pharmacological interventions may be provided where they are appropriate to the individual’s assessed needs and wishes and fall within the role and competence of staff.

Examples may include:

• supporting the individual to change position or maintain an agreed comfortable position;
• supporting mobility or movement in accordance with the individual’s personal plan and any professional instructions;
• assisting the individual to use prescribed or professionally recommended equipment;
• supporting agreed relaxation or distraction techniques; and
• supporting the use of heat or cold therapy, massage or other interventions only where their use has been assessed as appropriate, any relevant risks have been considered, and staff have received the information, instruction or training required to provide the intervention safely.

Where an intervention constitutes a delegated healthcare activity, it must only be undertaken where it has been appropriately delegated by a registered healthcare professional and where roles, responsibilities, instructions, competence, monitoring and escalation arrangements are clear.

Staff must record pain-related interventions and the individual’s response where required by the personal plan or relevant care records. Persistent pain, deterioration or an ineffective intervention must be escalated in accordance with Section 4.4.

4.3. Collaboration with Healthcare Professionals

{{org_field_name}} must work collaboratively with relevant healthcare professionals where this is necessary to ensure the individual’s pain-related care and support needs are met safely.

Staff must seek or facilitate timely healthcare advice or assistance where:

• pain is severe, sudden, new or unexplained;
• pain has significantly increased or changed;
• pain persists despite the agreed interventions;
• the individual reports that their prescribed or agreed pain relief is ineffective;
• there are signs or symptoms suggesting an adverse effect or reaction to medication;
• the individual repeatedly refuses pain medication or another agreed intervention and there is concern about their well-being;
• pain is associated with a fall, injury or significant deterioration in the individual’s condition;
• the individual’s needs appear to have changed beyond what can safely be met under the existing personal plan; or
• staff have any other concern requiring professional assessment.

Depending upon the circumstances and the arrangements recorded in the individual’s personal plan, staff may contact or facilitate contact with the individual’s GP, community or district nurse, pharmacist, specialist pain service, palliative care team, NHS 111 Wales, emergency services or another appropriate healthcare professional.

Care staff must provide relevant factual information, including observations, pain assessment findings, interventions already provided, medication records where appropriate and any changes from the individual’s usual presentation.

Any decision to prescribe, discontinue, increase, reduce or otherwise clinically alter a medicine must be made by an appropriately authorised healthcare professional. Care staff must not make such changes independently.

Advice or instructions received from healthcare professionals must be recorded and communicated to relevant staff. Where the advice results in a change to the individual’s assessed care and support needs, the provider assessment and personal plan must be reviewed and revised as necessary.

4.4. Monitoring, Reviewing and Escalating Pain Concerns

Pain management must be monitored to establish whether the individual’s agreed care and support remains safe, appropriate and effective.

Where pain monitoring is identified as part of the individual’s care and support arrangements, staff must assess or observe the individual’s pain during care visits to the extent required by the individual’s personal plan and circumstances. Staff must not rely solely on a numerical pain score where the individual’s presentation, communication needs or condition requires a broader assessment.

Records must include relevant information about:

• the individual’s report or observed signs of pain;
• the pain assessment method or tool used, where applicable;
• the location, nature or severity of pain where the individual can provide this information;
• agreed interventions provided;
• pain-relieving medication administered or supported, where applicable;
• the individual’s response to the intervention;
• refusals or inability to provide an agreed intervention;
• any deterioration, adverse effect or other concern;
• advice sought or received from a healthcare professional; and
• action taken and any required follow-up.

Staff must monitor the apparent effectiveness of prescribed or agreed pain-relieving medication but must not independently adjust medication. Concerns about effectiveness, adverse effects or the need for a medication review must be referred to an appropriate healthcare professional.

The individual must be involved in monitoring and reviewing their pain management as far as practicable. A family member, carer or representative may be involved where the individual wishes this, where the person has lawful authority to act for the individual, or where such involvement is otherwise lawful and appropriate. Information must not be routinely disclosed to family members without regard to the individual’s consent, confidentiality, mental capacity and legal rights.

Staff must escalate concerns promptly where:

• pain becomes severe or suddenly worsens;
• pain persists despite agreed treatment or intervention;
• there is new or unexplained pain;
• the individual experiences a suspected adverse medication reaction;
• there is a significant change in the individual’s mobility, behaviour, consciousness or general condition associated with pain;
• the individual’s pain-related needs can no longer be safely met under the existing personal plan; or
• urgent medical assessment appears necessary.

Emergency assistance must be sought without delay where the individual’s symptoms or condition indicate a medical emergency.

Where new, unexplained or inadequately managed pain gives rise to a reasonable concern that the individual may have experienced abuse, neglect or improper treatment, staff must take immediate action to protect the individual and follow the Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13) and the applicable Wales Safeguarding Procedures.

A significant or continuing change in pain must trigger a review of the individual’s assessment and personal plan as necessary.

4.5. Staff Training and Competency in Pain Management

Staff must have the knowledge, skills, training and competence necessary for the pain-related duties they are required to undertake.

Relevant staff must:

• receive training appropriate to their role in recognising and responding to pain;
• understand verbal and non-verbal indicators of pain and the importance of recognising changes from an individual’s normal presentation;
• be able to use any pain assessment tool that they are required to use for an individual;
• understand the limits of their role and know when healthcare advice or emergency assistance must be sought;
• understand and follow the individual’s personal plan and relevant risk assessments;
• where involved in medicines support or administration, complete the training and competency requirements specified in the Medication Management and Administration Policy (DCW21) before undertaking those duties;
• understand the requirement to obtain consent and the action required where there is doubt about an individual’s capacity to make a particular decision;
• understand safeguarding responsibilities where pain may indicate abuse, neglect or improper treatment;
• maintain accurate and contemporaneous records; and
• report changes, concerns, errors or incidents promptly through the appropriate organisational procedures.

Where a pain-related intervention is a delegated healthcare activity, staff must not undertake the activity unless:

• the delegation has been made by an appropriately registered healthcare professional;
• the activity is appropriate for delegation;
• clear instructions, responsibilities, limits and escalation arrangements have been established;
• the staff member has received the required training;
• the staff member has been assessed as competent to undertake the activity; and
• appropriate supervision, review and reassessment of competence are in place.

Pain-management competence must be monitored through supervision, observation, competency assessment and the organisation’s training and development arrangements. Where {{org_field_name}} requires annual refresher training, staff must complete this within the timescale set by the organisation and additional training or reassessment must be provided sooner where concerns, changes in practice or individual needs indicate that this is necessary.

No staff member may undertake a pain-related activity that is outside their role, training or assessed competence.

4.6. Person-Centred Approach, Consent and Mental Capacity

Pain assessment and management must be person-centred and must respect the individual’s dignity, privacy, autonomy, communication needs, culture, religion, beliefs, preferences and personal outcomes.

The individual must be involved as fully as possible in decisions concerning pain assessment and management and must receive information in a form and manner they can understand.

Where an individual has capacity to make the particular decision concerned, their informed decision must be respected. This includes a capacitous decision to refuse medication, assessment or another intervention, even where staff or others consider a different decision would be preferable.

Staff must not assume that an individual lacks mental capacity because of age, disability, diagnosis, dementia, communication difficulty or because the individual makes a decision that others consider unwise.

Where there is reason to doubt the individual’s capacity to make a particular decision about pain assessment, medication or treatment, the Mental Capacity Act 2005 must be followed. Capacity is decision-specific and time-specific and all practicable steps must be taken to support the individual to make the decision before concluding that they are unable to do so.

Where an individual lacks capacity to make the particular decision:

• staff must establish whether another person has lawful authority to make the decision, such as an attorney acting within the scope of a valid Lasting Power of Attorney or a deputy appointed by the Court of Protection;
• where no authorised decision-maker applies, any act or decision undertaken on behalf of the individual must comply with the Mental Capacity Act 2005 and its best-interests requirements;
• the individual’s past and present wishes, feelings, values and beliefs must be considered;
• the individual must be involved in the decision as far as reasonably practicable;
• relevant persons must be consulted where required and appropriate;
• the least restrictive available option must be considered; and
• the assessment, decision, consultation and reasons for the decision must be recorded appropriately.

A family member or next of kin does not automatically have legal authority to consent to treatment or medication on behalf of an adult who lacks capacity.

Covert administration of medication must not take place merely because an individual refuses medication. Any covert administration must be separately authorised and managed in accordance with the Mental Capacity Act 2005, applicable professional guidance and the Medication Management and Administration Policy (DCW21).

Any restriction associated with pain management must be lawful, necessary and proportionate. Staff must follow the organisation’s Mental Capacity Act and restrictive-practice arrangements where care or treatment could restrict the individual’s freedom or liberty.

The individual’s personal plan must clearly record relevant preferences, consent arrangements, capacity or best-interests decisions where applicable, agreed pain-management interventions and the action staff must take when the individual refuses an intervention or when their condition changes.

5. Related Policies

This policy aligns with:

• Medication Management and Administration Policy (DCW21) – Covering safe medication handling.
• Palliative and End-of-Life Care Policy (DCW38) – Covering pain relief for terminal conditions.
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13) – Ensuring pain is not overlooked.
• Person-Centred Care Policy (DCW07) – Ensuring individual needs are prioritised.
• Staff Supervision, Training, and Development Policy (DCW27) – Ensuring staff competency in pain management.

6. Policy Review

This policy will be reviewed annually or sooner if required due to:

• Changes in CIW regulations or NICE guidelines.
• New pain management research or treatment options.
• Feedback from staff, service users, or healthcare professionals.

---

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.