CH36-Initial Assessment and Care Planning Policy

Registration Number: {{org_field_registration_no}}

Initial Assessment and Care Planning Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} conducts comprehensive initial assessments and develops person-centred care plans for every individual receiving care. This ensures that care is tailored to each person’s needs, preferences, and health conditions, promoting dignity, independence, and well-being.

A structured assessment and care planning process is essential to identify risks, establish goals, and provide safe, effective, and compassionate care. This policy ensures that our initial assessment and care planning process is systematic, thorough, and in line with CQC regulations.

By implementing this policy, {{org_field_name}} ensures that every person we support:

Receives care that meets their individual needs and preferences.
Is fully involved in decisions about their care and support.
Has their health, well-being, and safety needs identified and managed appropriately.
Receives care in a way that promotes dignity, respect, and choice.

This policy applies to all staff involved in assessments, care planning, and service delivery.

2. Scope

This policy applies to:

All staff involved in care provision, including registered nurses, care staff, and managers.
People we support, their families, and advocates.
Healthcare professionals involved in the care process.
External partners, including GPs, hospitals, and social workers.

It covers the full process of initial assessment, risk assessment, care planning, ongoing reviews, and person-centred decision-making.

3. Legal and Regulatory Framework

This policy complies with:

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Regulation 9 (Person-Centred Care), which requires care providers to assess needs and plan care based on individual preferences and requirements.
Care Act 2014, which sets out a legal duty to provide needs-based, person-centred care that promotes well-being.
Mental Capacity Act 2005, ensuring that decisions about care are made in the best interests of individuals who lack capacity.
Equality Act 2010, ensuring that assessments and care plans are free from discrimination and promote inclusion.
CQC Fundamental Standards, requiring care to be safe, effective, responsive, and well-led.

By following these regulations, {{org_field_name}} ensures that care is legally compliant, safe, and tailored to individual needs.

4. Initial Assessment Process

4.1 Purpose of Initial Assessment

The initial assessment is the foundation of high-quality care planning. It ensures that:

Each person’s health, personal, emotional, and social needs are fully understood.
Risk factors are identified, and preventative measures are put in place.
Cultural, religious, and lifestyle preferences are respected.
Individuals and their families have a voice in planning their care.

Every assessment is conducted before admission or within 24 hours of arrival at {{org_field_name}} to ensure safe, well-planned care delivery.

4.2 Key Components of the Initial Assessment

The assessment is holistic, covering:

Personal Information – Name, date of birth, contact details, and medical history.
Health Conditions and Medical Needs – Diagnoses, medications, allergies, and existing treatments.
Nutritional and Hydration Needs – Special dietary requirements, risks of malnutrition or dehydration.
Mental Health and Cognitive Function – Dementia, depression, anxiety, or other cognitive conditions.
Mobility and Physical Function – Risks of falls, need for mobility aids, or physiotherapy support.
Personal Care Preferences – Bathing, dressing, toileting, and independence levels.
Communication Needs – Sensory impairments, preferred language, and assistive communication methods.
Social, Emotional, and Cultural Needs – Religious beliefs, social activities, and family involvement.
Risk Assessments – Fall risk, safeguarding concerns, infection control, and pressure ulcer risks.

Each assessment is documented electronically and in written records, ensuring accessibility for all care staff.

5. Care Planning Process

5.1 Developing a Person-Centred Care Plan

Following the initial assessment, a detailed care plan is created to ensure that care is:

Tailored to the individual’s needs.
Regularly reviewed and updated as conditions change.
Agreed upon by the person we support, their family, and healthcare professionals.

Care plans clearly outline:

Daily care routines, including personal care, meals, and medication schedules.
Support needs, identifying whether assistance is required for eating, dressing, or mobility.
Health monitoring plans, detailing vital checks, GP appointments, and medication reviews.
Emergency procedures, including response plans for seizures, falls, or critical illnesses.
Well-being and Social Activities, promoting engagement and quality of life.

Each person is given a named keyworker responsible for coordinating their care and ensuring their needs are met.

5.2 Involvement of Individuals and Families

People we support and their families play a central role in care planning decisions.

Families are encouraged to attend assessments and contribute to planning.
Individuals are empowered to express their preferences and make informed choices.
Advocacy services are offered when individuals need additional support in decision-making.

6. Risk Assessment and Safeguarding

Risk assessments are an integral part of care planning, ensuring that:

Health and safety risks are identified and minimised.
Safeguarding concerns are promptly addressed.
Appropriate precautions are taken for individuals with complex medical needs.

Each risk assessment includes:

Falls prevention strategies for those at risk of falling.
Medication management plans to prevent errors.
Infection control procedures to protect against contagious illnesses.
Behavioural support strategies for individuals who may display challenging behaviours.

Risk assessments are reviewed monthly or sooner if circumstances change.

7. Ongoing Monitoring and Care Plan Reviews

7.1 Regular Reviews

Care plans are dynamic documents, reviewed:

Monthly, to ensure they remain up to date.
After significant health changes, such as hospital admissions or new diagnoses.
At the request of the person we support or their family.

7.2 Staff Responsibilities in Monitoring

All care staff are trained to:

Observe and report changes in an individual’s condition.
Update records promptly to reflect any care plan adjustments.
Ensure care delivery aligns with each individual’s evolving needs.

Managers conduct quality audits to ensure care plans are accurate, person-centred, and legally compliant.

8. Communication and Information Sharing

To ensure continuity of care:

Care plans are shared with relevant staff, including nurses, carers, and support teams.
Multi-disciplinary team meetings are held regularly to review care plans.
Confidentiality is maintained, following GDPR and CQC Regulation 17 (Good Governance) requirements.

9. Policy Review

This policy is reviewed annually or sooner if CQC regulations, best practices, or organisational needs change.

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.