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Pain Assessment and Management Policy

1. Purpose

The purpose of this policy is to ensure that all people supported by {{org_field_name}} receive timely, person-centred, and evidence-based assessment and management of pain. Uncontrolled or unrecognised pain can have a significant negative impact on a person’s quality of life, mental health, mobility, nutrition, sleep, and social engagement. This policy provides a clear framework for assessing, monitoring, documenting, and managing pain in a home care setting. This policy supports compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 9 (Person-centred care), 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 17 (Good governance), Regulation 18 (Staffing), and Regulation 20 (Duty of candour). It also supports CQC’s current assessment framework by promoting safe, effective, caring, responsive and well-led pain assessment and management.

2. Scope

This policy applies to all staff at {{org_field_name}} involved in the planning or delivery of care, including registered nurses, care assistants, and support workers. It covers both acute and chronic pain, including physical, emotional, and psychological pain. It applies to all individuals receiving care and support regardless of age, medical diagnosis, or communication ability.

This policy ensures a consistent, sensitive and proactive approach to identifying, assessing, relieving, monitoring and reviewing pain within a care home setting, including residential care, nursing care where provided, respite care, end-of-life care and support for people who may have dementia, a learning disability, autism, sensory impairment, communication difficulties or fluctuating capacity.

This policy applies to all pain-related care and support delivered by staff, including observation, reporting, care planning, support with prescribed medicines, PRN medicines, non-medicine approaches, escalation to healthcare professionals, communication with families or representatives, documentation and audit. Where the care home provides nursing care, registered nurses must work within their professional scope of practice and relevant clinical guidance. Where the care home does not provide nursing care, staff must not make clinical decisions outside their role and must escalate concerns promptly to the GP, NHS 111, district nursing service, specialist palliative care team or emergency services as appropriate.

3. Related Policies

This policy should be read in conjunction with the following:

• CH07 – Person-Centred Care Policy
• CH11 – Safe Care and Treatment Policy
• CH21 – Medication Management and Administration Policy
• CH36 – Initial Assessment and Care Planning Policy
• CH42 – Communication and Engagement with Service Users and Families Policy
• CH44 – Supporting Individuals with Dementia Policy
• CH38 – End of Life and Palliative Care Policy

• Safeguarding Adults from Abuse and Improper Treatment Policy
• Good Governance Policy
• Complaints, Concerns and Compliments Policy
• Duty of Candour Policy
• Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Policy
• Consent to Care and Treatment Policy
• Equality, Diversity and Human Rights Policy
• Record Keeping and Confidentiality Policy
• Incident Reporting and Investigation Policy
• Falls Prevention and Management Policy
• Moving and Handling Policy
• Skin Integrity and Pressure Ulcer Prevention Policy
• Nutrition and Hydration Policy
• Infection Prevention and Control Policy
• Learning Disability and Autism Support Policy
• Homely Remedies Policy, where used by the service
• Controlled Drugs Policy, where controlled drugs are stored, administered or recorded by the service

4. Legal and Regulatory Framework

{{org_field_name}} will assess and manage pain in line with current legislation, CQC requirements and recognised best practice. This includes the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Mental Capacity Act 2005, the Equality Act 2010, the Care Act 2014, the Human Rights Act 1998, medicines legislation including the Misuse of Drugs Act 1971 where controlled drugs are used, and relevant NICE guidance.

The service will use this policy to support compliance with the CQC fundamental standards, including person-centred care, dignity and respect, consent, safe care and treatment, safeguarding, good governance, staffing and duty of candour. The service will also use CQC quality statements to evidence that pain management is safe, effective, caring, responsive and well-led.

5. Recognising and Reporting Pain

All staff are trained to recognise signs of pain, both verbal and non-verbal. These may include facial grimacing, vocal complaints, guarding behaviour, restlessness, aggression, reduced appetite, withdrawal, or sleep disturbances. Staff are required to document and report any suspected or confirmed pain immediately to the relevant senior staff member or healthcare professional. Prompt recognition is particularly important for individuals with cognitive impairment, dementia, or limited verbal communication. Any change in behaviour should be considered a possible sign of pain until proven otherwise.

Staff must treat new, unexplained, severe, worsening or persistent pain as a potential sign of deterioration, injury, infection, pressure damage, fracture, constipation, urinary retention, medication side effects, safeguarding concern or other significant health need. Staff must report concerns immediately to the nurse in charge, senior care staff member or Registered Manager, depending on the staffing structure of the home. Where urgent clinical advice is required, staff must contact the GP, NHS 111, district nurse, specialist palliative care team or emergency services without delay.

Staff must escalate immediately if the person has chest pain, suspected stroke symptoms, suspected fracture, severe abdominal pain, sudden severe headache, breathlessness, reduced consciousness, signs of sepsis, uncontrolled pain despite prescribed treatment, pain following a fall, or pain associated with suspected abuse or neglect.

6. Pain Assessment Tools and Methods

Pain must be assessed using an appropriate validated tool based on the person’s communication ability, cognitive function, and preferences. These tools may include:

• Numerical rating scale (0-10)
• Verbal descriptor scale (mild, moderate, severe)
• Wong-Baker FACES pain scale
• Abbey Pain Scale (for people with advanced dementia)
• PAINAD (Pain Assessment in Advanced Dementia)

Staff must use the pain assessment tool that is most appropriate for the person and must use it consistently wherever possible so that changes can be identified over time. The assessment must include the person’s usual presentation, baseline comfort level, preferred communication method, known pain indicators, pain history, diagnosis, current medicines, allergies, contraindications, and any previous adverse response to pain relief.

Where appropriate, staff should use a structured assessment approach such as PQRST or SOCRATES to record:

• Provoking or relieving factors;
• Quality or nature of the pain;
• Region and whether the pain radiates;
• Severity or intensity;
• Timing, duration and pattern;
• impact on sleep, mobility, appetite, mood, continence, personal care and social engagement;
• action taken and outcome.

The assessment includes the site, intensity, nature, duration, frequency, triggers, and relieving factors of pain. Pain is assessed on admission, during each care review, after any intervention, and whenever pain is suspected. Documentation is maintained in the individual’s care records and monitored for patterns or changes.

Pain assessment must not rely solely on verbal reporting. Staff must consider non-verbal indicators, behaviour changes, body language, facial expression, vocalisation, posture, mobility, sleep, appetite, personal care tolerance and interaction with others. For people with dementia, learning disability, autism, acquired brain injury, sensory impairment or communication difficulties, staff must seek information from people who know the person well and must record the person’s individual signs of pain in the care plan.

7. Mental Capacity, Consent and Best Interests

Staff must seek the person’s consent before carrying out pain assessment, physical observation, repositioning, use of equipment, non-medicine interventions or support with pain-relieving medicines. Consent must be informed, voluntary and specific to the proposed care or treatment.

Where there is reason to believe that the person may lack capacity to make a specific decision about pain assessment or pain management, staff must follow the Mental Capacity Act 2005. Capacity must be assessed for the specific decision at the specific time. Where the person lacks capacity, any decision must be made in their best interests, must consider the least restrictive option, and must involve the person, family members, representatives, attorneys, deputies or advocates where appropriate.

Staff must not assume that a person lacks capacity because they have dementia, a learning disability, autism, mental health needs, communication difficulties, fluctuating presentation or because they refuse pain relief. Refusal of pain assessment or pain relief must be explored, documented and escalated where refusal places the person at risk of avoidable harm.

8. Person-Centred Pain Management Planning

Each individual has a person-centred pain management plan that reflects their clinical needs, preferences, history, cultural beliefs, and personal goals. Plans are developed in consultation with the individual, their family or advocate, and relevant professionals such as GPs, pharmacists, or pain specialists. The plan may include medication, physiotherapy, massage, heat or cold therapy, psychological support, relaxation techniques, or environmental adjustments. The care plan clearly identifies who is responsible for each intervention and includes safety considerations such as allergies, medication interactions, and previous adverse responses.

Each care plan must include, where relevant:

• the person’s own description of pain and preferred terminology;
• known causes or likely causes of pain;
• individual signs that may indicate pain;
• the agreed pain assessment tool;
• prescribed regular and PRN pain relief;
• non-medicine approaches that are safe and acceptable to the person;
• contraindications, allergies and previous adverse reactions;
• safe positioning, moving and handling requirements;
• impact on nutrition, hydration, continence, sleep, mood, mobility and skin integrity;
• when staff must re-assess pain after an intervention;
• when staff must escalate concerns;
• family, advocate or representative involvement, where appropriate;
• review date and named person responsible for review.

9. Safe Administration of Pain Medication

All pain-relieving medications are administered in accordance with CH21 – Medication Management and Administration Policy. Staff are trained in safe medication practices and understand the different classes of pain relief, including non-opioid analgesics, opioids, adjuvant medications, and topical treatments. PRN (as needed) medications for pain are only given in line with a documented care plan and must be recorded immediately after administration.

Each PRN pain medicine must have a person-centred PRN protocol. The protocol must include the name of the medicine, strength, route, dose, minimum time between doses, maximum dose in 24 hours, what the medicine is prescribed for, signs or symptoms that indicate it may be needed, when it should not be given, possible side effects, expected response, review arrangements, and when staff must seek clinical advice. Staff must record the reason for giving PRN pain relief, the dose given, the time given, the outcome and any side effects or concerns.

Staff monitor the effectiveness and side effects of pain relief and escalate concerns such as insufficient control, drowsiness, constipation, or confusion. Controlled drugs must be stored, administered, recorded, checked, audited, returned and disposed of in line with legal requirements, the service’s medicines policy, the controlled drugs policy, local pharmacy arrangements and CQC guidance. Controlled drug records must be accurate, contemporaneous and signed by appropriately trained staff. Any discrepancy must be reported, investigated and escalated without delay.

Opioid medicines and other strong analgesics must be monitored closely because they may cause side effects including sedation, constipation, nausea, confusion, respiratory depression, falls risk and reduced oral intake. Staff must report side effects, lack of effectiveness, repeated PRN use, refusal of pain relief, missed doses, medication errors, discrepancies or concerns about over-sedation immediately to the nurse in charge, senior staff member, GP, pharmacist or relevant healthcare professional.

The care home must not crush tablets, open capsules, alter formulations, apply patches, remove patches, use covert administration, or administer medicines outside the prescriber’s directions unless this is authorised and documented in line with the medicines policy, Mental Capacity Act requirements and professional guidance.

10. Monitoring and Evaluation of Pain Relief

Once pain relief has been administered or a non-medicine strategy applied, the person’s response must be reviewed and recorded within a clinically appropriate timeframe based on the intervention, route of medicine, prescribed directions and the person’s condition. As a guide, staff should normally reassess within 30–60 minutes after oral pain relief, sooner where the person is distressed or deteriorating, and in line with clinical instructions for injections, patches, anticipatory medicines or specialist palliative care medicines. Staff document the effectiveness of the intervention and note any further actions required. If pain persists or worsens, this must be escalated to the GP or other appropriate health professionals. Regular care reviews assess the long-term effectiveness of pain management strategies and adjust them where necessary. Audit of pain records is carried out by senior staff or the Registered Manager to ensure high standards and regulatory compliance.

Repeated PRN use, increasing pain scores, reduced effectiveness of usual pain relief, night-time pain, pain affecting eating or drinking, pain during personal care, pain on movement, new pain after a fall, or pain associated with pressure damage must trigger a review of the care plan and escalation to an appropriate healthcare professional.

11. Multidisciplinary and Specialist Input

Where pain is new, complex, persistent, poorly controlled, recurrent, associated with deterioration, or affecting the person’s quality of life, we liaise promptly with relevant external professionals, including GPs, district nurses, community nurses, pharmacists, physiotherapists, occupational therapists, tissue viability nurses, falls services, mental health professionals, dementia specialists, learning disability teams, pain specialists and specialist palliative care teams. Referrals to pain clinics or mental health services may also be made where emotional or psychological pain is identified. Teamwork and timely communication ensure a holistic approach to care and align with Regulation 9 (Person-Centred Care) and Regulation 12 (Safe Care and Treatment).

12. Communication with People We Support and Families

We involve the person being supported and their family or advocate in all aspects of pain assessment and management. Care staff are encouraged to use empathetic, clear communication and provide reassurance throughout the process. Where a person lacks capacity, we follow the Mental Capacity Act 2005 and make best interest decisions with involvement from their representatives. We ensure that individuals feel heard, believed, and empowered in their pain management.

Information about pain, pain relief options, possible side effects and review arrangements will be provided in a way the person can understand. Staff must make reasonable adjustments where a person has communication needs, sensory impairment, dementia, a learning disability, autism, mental health needs or limited English. This may include easy-read information, visual pain scales, communication aids, interpreters, involvement of people who know the person well, or additional time and reassurance.

13. Cultural, Emotional, and End-of-Life Considerations

We recognise that the expression and perception of pain can vary significantly based on cultural, emotional, or religious factors. Staff are trained to respect and explore these dimensions sensitively. For individuals nearing the end of life, we adopt anticipatory pain management practices and work closely with palliative care professionals to ensure comfort and dignity. For people who are approaching the end of life, the service will work with GPs, community nursing teams and specialist palliative care professionals to ensure that pain and other distressing symptoms are anticipated, assessed and managed promptly. Where anticipatory medicines are prescribed, the care plan and medicines records must clearly state the indication for use, dose, route, frequency, maximum dose, monitoring requirements, expected effect, side effects and when staff must seek further clinical advice. Pain management is an integral part of our CH38 – End of Life and Palliative Care Policy.

14. Safeguarding and Pain Neglect

Unrelieved or unreported pain may constitute a safeguarding concern. Staff must be alert to the possibility of pain being ignored, underestimated, or dismissed, especially in vulnerable adults. Any suspicion of deliberate neglect or failure to treat pain must be escalated under CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy. Pain is treated as a safeguarding and dignity issue as much as a clinical concern.

Concerns may include repeated failure to assess pain, failure to administer prescribed pain relief, unexplained delays in escalation, dismissing a person’s report of pain, failure to recognise pain in people who cannot communicate verbally, inappropriate withholding of pain relief, inappropriate use of medication to sedate rather than relieve pain, or poor moving and handling practice that causes avoidable pain. Such concerns must be reported in line with safeguarding procedures, incident reporting procedures and whistleblowing arrangements.

15. Staff Training and Competency

All staff involved in care delivery must receive training appropriate to their role in recognising, reporting, assessing, recording and responding to pain. Training must include pain in older people, pain in dementia, pain in people who do not communicate verbally, pain in people with a learning disability or autism, end-of-life pain, medicines safety, PRN medicines, controlled drugs where relevant, consent, Mental Capacity Act requirements, safeguarding, escalation and accurate record keeping.

Staff must receive learning disability and autism training appropriate to their role in line with the statutory requirement for CQC-registered providers and the Oliver McGowan Code of Practice. The Registered Manager must ensure that training needs are assessed, training is recorded, and staff competence is reviewed through supervision, observation, spot checks, medicines competency assessments where applicable, audits and learning from incidents.

Staff must not undertake pain-related tasks, including administration or support with medicines, unless they have been trained, assessed as competent and authorised to do so. Any staff member who is unsure about pain management, medicines, capacity, consent or escalation must seek advice from a senior staff member or appropriate healthcare professional without delay.

16. Documentation and Governance

Pain assessments, interventions, outcomes, and reviews are fully documented in the individual’s care record. Records must be clear, accurate, complete, contemporaneous and stored securely. Pain-related documentation must include the assessment tool used, pain score or observed indicators, location and nature of pain, action taken, medicines or non-medicine intervention used, consent or best-interest decision where relevant, outcome of intervention, escalation, advice received, family or representative involvement where appropriate, and any changes made to the care plan. These records are reviewed as part of internal audits, case reviews, and quality assurance processes. The Registered Manager is responsible for monitoring pain management across the service and reporting any trends, gaps, or risks. Learning from complaints, feedback, or incidents relating to pain is captured and used to improve service quality in line with CH17 – Good Governance Policy.

The Registered Manager or delegated senior staff member will complete regular audits of pain management practice. Audits should include, where relevant:

• completion and quality of pain assessments;
• use of appropriate pain assessment tools;
• PRN protocols and PRN outcome recording;
• regular and PRN analgesia records;
• controlled drug records and balance checks;
• timeliness of escalation;
• care plan reviews following changes in pain;
• end-of-life and anticipatory medicines records;
• evidence of consent, capacity or best-interest decisions;
• safeguarding concerns linked to unmanaged pain;
• complaints, incidents, medication errors and duty of candour records;
• staff training and competency records.

Findings from audits, incidents, complaints, safeguarding concerns and feedback must be used to improve practice. Actions must be recorded, allocated to named staff, monitored to completion and reviewed for effectiveness.

17. Duty of Candour, Incidents and Notifications

Where a pain-related incident causes, or has the potential to cause, harm, staff must report it in line with the incident reporting policy. This may include medication errors, missed doses, delayed escalation, uncontrolled pain, injury during care, poor moving and handling, failure to follow a pain management plan, or avoidable distress.

Where a notifiable safety incident has occurred, the service will follow the duty of candour requirements. This includes acting in an open and transparent way, informing the person and/or relevant representative, providing a truthful account of what is known, offering an apology, explaining what further enquiries or actions will take place, keeping written records, and providing reasonable support.

The Registered Manager will ensure that CQC notifications are submitted where required under the Care Quality Commission (Registration) Regulations 2009, including where an incident results in serious injury, abuse or allegations of abuse, death, or other notifiable events.

18. Equality, Human Rights and Reasonable Adjustments

Pain must be assessed and managed without discrimination. Staff must recognise that people may experience, express or report pain differently because of age, disability, dementia, learning disability, autism, mental health needs, trauma history, culture, religion, language, gender, sensory impairment or previous experiences of healthcare. Staff must not make assumptions that pain is “normal for age”, “behavioural”, “attention-seeking” or “part of dementia” without proper assessment and escalation.

The service will make reasonable adjustments to ensure that people can communicate pain and participate in decisions about pain management. Pain management must uphold dignity, privacy, autonomy, comfort and the person’s human rights.

19. Policy Review

This policy will be reviewed at least annually, or sooner following changes to legislation, CQC guidance, NICE guidance, safeguarding requirements, medicines guidance, local health system procedures, learning from incidents, complaints, audits, safeguarding enquiries or feedback from people using the service and their representatives.

The review will be led by the Registered Manager in collaboration with senior care staff and, where appropriate, external clinical advisors. Feedback from people we support and their families will also inform improvements to this policy.

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