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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. It supports compliance with Regulation 9 (Person-Centred Care), Regulation 12 (Safe Care and Treatment), and Regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 and relieving pain in line with best practice and NICE guidelines.

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

4. 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.

5. 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)
  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.

6. 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.

7. 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. Staff monitor the effectiveness and side effects of pain relief and escalate concerns such as insufficient control, drowsiness, constipation, or confusion. Controlled drugs are handled with additional safeguards and recorded in the controlled drugs register where required.

8. Monitoring and Evaluation of Pain Relief

Once pain relief has been administered or a non-pharmacological strategy applied, the individual’s response is reviewed within an appropriate timeframe (typically within 30–60 minutes). 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.

9. Multidisciplinary and Specialist Input

Where pain is complex, persistent, or poorly controlled, we liaise with external professionals including GPs, district nurses, physiotherapists, occupational therapists, and 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).

10. 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.

11. 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. Pain management is an integral part of our CH38 – End of Life and Palliative Care Policy.

12. 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.

13. Staff Training and Competency

All staff receive mandatory training in recognising, assessing, and managing pain as part of their induction and ongoing development. Training includes pain in dementia, pain in non-verbal individuals, medication safety, and communication skills. Competency assessments are carried out regularly and refreshed annually. Supervision sessions provide an opportunity to reflect on pain management practices and share learning.

14. Documentation and Governance

Pain assessments, interventions, outcomes, and reviews are fully documented in the individual’s care record. 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.

15. Policy Review

This policy will be reviewed annually or earlier in response to changes in legislation, clinical guidance, or as part of post-incident learning. 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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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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