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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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New Service User Onboarding Policy

1. Purpose

The purpose of this policy is to ensure that the admission and onboarding of every new person to {{org_field_name}} is safe, person-centred, dignified, lawful and effective. The onboarding process must establish the person’s assessed needs, preferences, wishes, communication requirements, risks, consent and mental capacity arrangements and provide staff with sufficient information to deliver safe and appropriate care from the point of admission.

{{org_field_name}} will ensure that care and treatment provided following admission is based on an assessment of the person’s individual needs and preferences, is provided with valid consent or other lawful authority, and is planned and delivered in a way that protects the person’s health, safety, welfare, dignity, rights and independence.

This policy supports compliance with the Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including:

• Regulation 9 – Person-centred care;
• Regulation 9A – Visiting and accompanying in care homes, hospitals and hospices;
• 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 14 – Meeting nutritional and hydration needs;
• Regulation 16 – Receiving and acting on complaints; and
• Regulation 17 – Good governance.

The policy must also be implemented in accordance with the Mental Capacity Act 2005 and associated statutory safeguards wherever a person may lack capacity to make a particular decision.

2. Scope

This policy applies to all individuals referred to or choosing to receive care and support from {{org_field_name}}, including self-funded, local authority-funded, and NHS-referred people. It applies to all staff responsible for assessments, care planning, administration, and delivery of care. This policy covers initial contact, assessment, consent, care planning, service agreement, introduction to staff, and the start of care delivery. It also includes processes for people transitioning from hospital or other services.

3. Related Policies

This policy should be read in conjunction with:

• CH06 – Compliance with the Care Act 2014 Policy
• CH07 – Person-Centred Care Policy
• CH09 – Consent to Care Policy
• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH36 – Initial Assessment and Care Planning Policy
• CH42 – Communication and Engagement with Service Users and Families Policy

4. Initial Contact and Referral

The onboarding process begins with a referral or enquiry. This may come from the individual, a family member, a healthcare professional, a local authority, or an advocacy organisation. A dedicated onboarding officer or care coordinator responds promptly, providing clear information about our services, values, and expectations. At this stage, we record initial details, understand the reason for the enquiry, and assess the urgency of the required support. We ensure that communication is accessible, inclusive, and adapted to meet the individual’s needs, including those with communication or cognitive difficulties.

5. Needs Assessment and Risk Assessment

Before admission, or as soon as reasonably practicable where an emergency admission makes a complete pre-admission assessment impossible, {{org_field_name}} will undertake a comprehensive assessment of the person’s needs and preferences. The assessment must be completed by a person who has the appropriate competence, skills, knowledge and experience for the person’s needs and circumstances.

The assessment must be sufficiently detailed to determine whether {{org_field_name}} can safely and appropriately meet the person’s needs and must include, where relevant:

• physical health and diagnosed medical conditions;
• mental health and emotional wellbeing;
• cognition and mental capacity;
• communication needs and any reasonable adjustments required;
• mobility, transfers, falls risk and moving and handling requirements;
• personal care and continence needs;
• skin integrity and pressure-area care;
• nutritional and hydration requirements;
• allergies and intolerances;
• eating, drinking and swallowing needs, including any risk of choking or aspiration;
• medicines, including current prescriptions, administration requirements and known medicines risks;
• sensory needs;
• infection risks and infection prevention and control requirements;
• behaviours or circumstances that may create a risk to the person or others;
• safeguarding risks and any current safeguarding arrangements;
• cultural, religious and spiritual needs;
• relationships and social needs;
• visiting preferences and community access;
• sleep and daily routines;
• emergency healthcare requirements;
• resuscitation or other advance care documentation where this lawfully exists and is relevant;
• personal emergency evacuation requirements and other fire-safety considerations; and
• any other matter that could materially affect the person’s safe care, treatment, wellbeing or quality of life.

Individual risk assessments must identify the nature and level of each relevant risk and record the measures required to eliminate or reduce that risk so far as reasonably practicable. Risk management must be person-centred and proportionate and must not impose unnecessary restrictions on the person’s rights, choices or independence.

The person must be involved in their assessment so far as practicable. Where appropriate and lawful, those involved in the person’s care, a person lawfully authorised to act for them, family members, carers, advocates and relevant health and social care professionals must also be involved.

Where responsibility for the person’s care is being transferred or shared with a hospital, NHS service, local authority, another care provider or another professional, {{org_field_name}} must work with the person and relevant organisations to obtain and share the information necessary for safe and timely care planning and continuity of care. Any gaps, discrepancies or immediate risks identified during transfer or admission must be escalated and addressed without avoidable delay.

No planned admission will proceed unless the Registered Manager, or an appropriately authorised competent person, is satisfied that the service can safely meet the person’s assessed needs with the staffing, skills, equipment and other resources available.

Assessments and risk assessments must be reviewed whenever the person’s needs, circumstances or risks change and at planned intervals appropriate to the person’s needs.

6. Consent and Legal Considerations

Care and treatment must only be provided with the consent of the relevant person or under another lawful basis permitted by applicable legislation.

Consent must be voluntary and informed. Before seeking consent, {{org_field_name}} will provide the person with information about the proposed care or treatment, including its purpose, material risks, expected benefits and any reasonable alternatives, in a form and manner that the person can understand. Appropriate communication support and reasonable adjustments must be provided where necessary.

Consent is an ongoing process and must not be treated solely as the completion or signature of a form. A person who has capacity may consent to or refuse care and may withdraw or change their consent at any time. Relevant consent discussions, decisions and changes must be accurately documented.

In accordance with the Mental Capacity Act 2005:

• every person aged 16 or over must be presumed to have capacity unless it is established that they lack capacity in relation to the particular decision;
• a person must not be treated as unable to make a decision unless all practicable steps to support them to make that decision have been taken without success;
• a person must not be treated as lacking capacity merely because they make a decision that others consider unwise;
• any act done or decision made on behalf of a person who lacks capacity must be in that person’s best interests; and
• before an act is done or decision is made, consideration must be given to whether its purpose can be achieved in a way that is less restrictive of the person’s rights and freedom of action.

Where there is reason to doubt a person’s capacity to make a particular decision, an appropriate decision-specific capacity assessment must be undertaken and recorded. Capacity must not be assumed to be absent solely because of a diagnosis, disability, age, appearance, behaviour, communication difficulty or because the person requires care and support.

Where a person lacks capacity to make the relevant decision, any decision made or action taken on their behalf must comply with the Mental Capacity Act 2005 and must be based on the person’s best interests unless another specific legal framework applies. The person’s past and present wishes and feelings, beliefs and values and other factors they would be likely to consider must be taken into account as required by law.

Family members, relatives, next of kin and advocates do not acquire authority to consent to care or treatment merely because of their relationship with the person. They must nevertheless be consulted where required or appropriate as part of the best-interests process.

Where another person claims authority to make a decision on behalf of the person, {{org_field_name}} must establish and record the nature, scope and validity of that authority before relying on it. This includes checking, where applicable, a registered health and welfare Lasting Power of Attorney, a deputyship order made by the Court of Protection or another relevant court order. The decision must fall within the scope of the person’s lawful authority.

Where the statutory criteria for instruction of an Independent Mental Capacity Advocate apply, the appropriate referral must be made and the advocate must be involved in accordance with the Mental Capacity Act 2005.

Any advance decision to refuse treatment, advance statement, Lasting Power of Attorney, deputyship order, Court of Protection order or other legally relevant document identified during onboarding must be recorded, verified where appropriate and made available to staff who need the information to provide lawful care.

Where care arrangements involve restrictions on a person’s freedom, the restrictions must be individually assessed, necessary, proportionate and the least restrictive practicable option.

Where a person may be deprived of their liberty, {{org_field_name}} must consider the person’s individual circumstances and the current legal test for deprivation of liberty. Where an authorisation may be required, the Registered Manager or other authorised person must take the necessary action under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards, including making an application to the relevant supervisory body where applicable. Any urgent authorisation, standard authorisation, conditions, expiry dates, representatives and review requirements must be accurately recorded and monitored.

The existence of a deprivation of liberty authorisation does not remove the requirement to comply separately with the wider principles of the Mental Capacity Act 2005, including decision-specific capacity assessment, best-interests decision-making and the use of the least restrictive option.

Where Part 4 or Part 4A of the Mental Health Act 1983 applies to a person’s treatment, the applicable provisions of that Act must be followed.

All assessments, consent decisions, capacity assessments, best-interests decisions, legal authorities and associated consultations must be accurately, completely and contemporaneously documented.

7. Person-Centred Care Planning

Following assessment and before care is delivered, except where an emergency makes this impracticable, a clear and person-centred care plan must be prepared which reflects the person’s assessed needs, preferences, wishes, goals, strengths, abilities and desired outcomes.

The person must be involved in developing and reviewing their care plan as far as reasonably practicable. Information and communication support must be provided in a format appropriate to the person’s needs. Where appropriate and lawful, the care-planning process must also involve a person lawfully authorised to act on the person’s behalf, family members, carers, advocates and relevant health and social care professionals.

The care plan must include, where relevant:

• the person’s preferred daily routines and lifestyle;
• communication needs and methods;
• cultural, religious and spiritual preferences;
• personal history, relationships, interests, likes and dislikes;
• personal care and continence support;
• mobility, moving and handling and falls prevention;
• nutrition, hydration and any eating, drinking or swallowing support;
• skin integrity and pressure-area care;
• medicines support;
• physical and mental healthcare needs;
• infection prevention and control measures relevant to the person;
• identified risks and the measures agreed to manage or mitigate those risks;
• safeguarding arrangements;
• the person’s capacity and consent in relation to relevant care decisions;
• any best-interests decisions or lawful authority relied upon;
• any restrictions on the person’s freedom and the legal basis for those restrictions;
• any applicable Deprivation of Liberty Safeguards authorisation and conditions;
• visiting preferences, important relationships and arrangements for maintaining contact with family, friends and other people important to the person;
• preferences and support requirements for leaving the care home and accessing the community;
• advance care planning and legally relevant advance decisions or other documents where applicable;
• emergency contacts and emergency healthcare arrangements; and
• the person’s goals and outcomes.

Any restriction included in the care plan must be necessary, proportionate, individually assessed and supported by an appropriate legal basis. Blanket restrictions must not be applied to groups of residents simply because they live in the care home.

The care plan must identify how assessed risks will be mitigated and must provide staff with clear instructions necessary to deliver safe and appropriate care.

The care plan must be available to staff and other authorised persons who require the information to provide the person’s care. Staff responsible for providing care must be informed promptly of relevant changes.

A review date appropriate to the person’s needs must be recorded. The care plan must also be reviewed promptly whenever the person’s needs, preferences, risks, capacity, circumstances or treatment change, following significant incidents or where the existing plan is no longer effective.

8. Service Agreement and Financial Clarity

Before care begins, a Service User Agreement is completed. This includes the agreed care package, financial terms (if applicable), cancellation procedures, and contact details for the Registered Manager and key support staff. We ensure the person understands all aspects of the agreement. Clear, written information is provided in accessible formats. For individuals funded by a third party, we liaise with commissioners to confirm authorisation and agreed rates. The person is provided with a copy of their agreement and a summary of key rights, including how to make a complaint.

9. Visiting, Community Access and Maintaining Relationships

{{org_field_name}} recognises the right of people living in the care home to maintain relationships and contact with family members, friends, advocates and other people they wish to see.

Unless exceptional circumstances apply, residents must be facilitated to receive in-person visits at the care home. Visiting arrangements must, so far as reasonably practicable, reflect the individual resident’s needs, wishes and preferences and must not be subject to unnecessary or unreasonable restrictions.

Residents must not be discouraged from leaving the care home to visit family members, friends or other people, participate in community activities or otherwise spend time away from the care home.

Visiting and community-access preferences must be discussed during onboarding and incorporated into the person’s care plan where relevant.

Where there is an identified risk associated with a visit or with the resident leaving the care home, {{org_field_name}} must consider reasonable and proportionate precautions that would enable the visit or outing to proceed safely before considering a restriction.

Any decision to restrict a visit or a resident’s ability to leave the care home must:

• be based on the individual circumstances of the resident;
• be necessary and proportionate;
• be supported by a clear assessment of the relevant risk;
• take account of the resident’s care and treatment plan;
• involve the resident and other relevant persons as required;
• comply with the Mental Capacity Act 2005 where the resident lacks capacity in relation to the relevant decision;
• use the least restrictive practicable option;
• be accurately recorded, including the reasons for the decision; and
• be reviewed regularly and whenever circumstances change.

Blanket visiting restrictions must not be imposed unless there is a lawful basis and exceptional circumstances capable of justifying them.

A resident is not required to receive a visitor or leave the care home against their wishes. Where the resident has capacity, their decision must be respected. Where the resident lacks capacity to make the particular decision, any decision must be made in accordance with the Mental Capacity Act 2005 and the person’s best interests.

Any visiting restriction or arrangement must also comply with any applicable court or tribunal order or other lawful restriction.

10. Introduction to Care Staff

We introduce the person to their designated care team before the first care visit, either in person or virtually. Where possible, we match staff to the individual’s preferences, including gender, language, cultural background, or communication style. We ensure that staff are briefed on the care plan, known risks, and preferred routines. Where the individual has anxieties or complex needs, initial visits may be staggered or phased in gradually to build trust. The onboarding officer follows up after the first visit to check satisfaction and resolve any issues promptly.

11. First Week of Care

During the first week, the care plan is closely monitored by the care coordinator or team leader. Daily feedback is collected from care staff, and a review call or visit is conducted with the person to gather their impressions. Any concerns or changes are addressed without delay. This period is considered crucial for rapport building and service validation. If needed, a mini-review is scheduled within seven days to adjust the plan. Feedback is documented and used for service improvement.

12. Documentation and Record Keeping

All records created or received as part of onboarding and admission must be accurate, complete, legible and contemporaneous and must be maintained securely.

The person’s records must include, as applicable:

• referral and pre-admission information;
• needs assessments;
• risk assessments and risk-management measures;
• care plans and reviews;
• medicines information;
• consent records;
• mental capacity assessments;
• best-interests decisions and associated consultations;
• evidence of any person’s legal authority to act on behalf of the resident;
• Deprivation of Liberty Safeguards applications, authorisations, conditions, reviews and related correspondence;
• safeguarding information;
• visiting or community-access restrictions and the assessments and decisions supporting them;
• service agreements;
• information received from hospitals, commissioners and other health and social care services;
• significant communications and decisions relating to admission and care; and
• feedback and actions arising during the onboarding period.

Records must clearly identify significant decisions about the person’s care and treatment, the reasons for those decisions, the people involved and any action required.

Records must be reviewed and updated promptly when the person’s needs, risks, preferences, capacity, consent, care arrangements or circumstances change.

Records must be protected against unauthorised access, alteration, disclosure, loss or destruction. Access must be restricted to people who are authorised and have a legitimate need to access the information.

Information must only be disclosed to CQC, commissioners, health and social care professionals, representatives, relatives, advocates or other third parties where there is an appropriate lawful basis for the disclosure and subject to applicable confidentiality, information-governance and data-protection requirements. A person’s relative, next of kin or representative must not automatically be given access to confidential records solely because of their relationship with the person.

Records must be retained, accessed, shared and disposed of in accordance with applicable legislation, regulatory requirements, organisational retention arrangements and CH34 – Confidentiality and Data Protection Policy.

The Registered Manager must ensure that onboarding and admission records are included within the service’s audit and governance arrangements in accordance with CH17 – Good Governance Policy.

13. Equality, Diversity, and Inclusion

We ensure that onboarding processes are inclusive and respectful of each person’s background, needs, and preferences. Our onboarding team is trained in cultural competence, communication skills, and trauma-informed approaches. We ensure that language needs, accessibility, and health literacy levels are considered in every step of the onboarding process. Reasonable adjustments are made for people with disabilities, sensory impairments, or neurodivergence. No one is excluded based on age, race, religion, gender, sexuality, or social circumstances, in line with CH30 – Equality, Diversity, and Inclusion Policy.

14. Quality Assurance and Continuous Improvement

Onboarding processes are reviewed regularly through internal audits, spot checks, satisfaction surveys, and feedback from the people we support. Any complaints or concerns raised during onboarding are logged and reviewed under CH14 – Complaints Policy. Lessons learned are incorporated into future training and service adjustments. The Registered Manager monitors onboarding metrics such as timeliness, documentation accuracy, and early dropout rates, and reports outcomes as part of our governance framework.

15. Policy Review

This policy will be reviewed annually or earlier if there are changes in legislation, CQC guidance, or significant organisational developments.

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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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