Login

CHW162-Pain Assessment and Management Policy

{{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 all individuals receiving care and support at {{org_field_name}} have pain recognised, assessed, managed, monitored and reviewed promptly, safely and in a person-centred manner.

Unrelieved or inadequately managed pain may adversely affect an individual’s physical, psychological, emotional and social well-being, functional ability, sleep, nutrition, mobility, communication and quality of life. Staff must therefore respond appropriately to any report, indication or observation of pain and must not assume that pain is an inevitable consequence of age, disability, dementia, illness or frailty.

This policy supports compliance with:

In accordance with Regulation 21, care and support relating to pain must be provided in a way that protects, promotes and maintains the individual’s safety and well-being and must be provided in accordance with the individual’s personal plan.

Where an individual requires assessment, treatment, advice or other input from a healthcare professional in relation to pain, {{org_field_name}} will support the individual to obtain such healthcare input as necessary and in a timely manner.

2. Scope

This policy applies to all staff at {{org_field_name}}, including care workers, nurses, team leaders, managers, domestic and kitchen staff, and any external professionals involved in the care and support of individuals who may be experiencing pain. It is relevant to anyone using our service, regardless of age, cognitive ability, communication needs, or diagnosis.

3. Related Policies

This policy should be read in conjunction with:
CHW07 – Person-Centred Care Policy
CHW08 – Dignity and Respect Policy
CHW11 – Safe Care and Treatment Policy
CHW17 – Infection Prevention and Control Policy
CHW21 – Medication Management and Administration Policy
CHW24 – Management of Accidents, Incidents, and Near Misses Policy
CHW27 – Staff Supervision, Training, and Development Policy
CHW38 – End of Life and Palliative Care Policy
CHW40 – Assisting with Personal Care Policy

4. Policy Statement and Procedures

4.1 Person-Centred and Holistic Approach

At {{org_field_name}}, we recognise that pain is subjective and that an individual’s description or expression of pain must be taken seriously. Individuals have the right to be listened to, treated with dignity and respect, and involved as fully as possible in decisions about the assessment and management of their pain.

Pain assessment and management will take account of the individual’s:

Reasonable steps will be taken to meet the individual’s language and communication needs. Appropriate communication aids, accessible information, interpreters or other communication support will be used where required. Where Welsh is the individual’s language of need or choice, this will be recognised and supported in accordance with the service’s Welsh-language arrangements.

Where an individual has difficulty communicating verbally, staff must not assume that the absence of a verbal report means that pain is absent. Staff must consider behavioural, physiological and other non-verbal indicators and use an appropriate recognised pain assessment approach where required.

Where there is reason to doubt an adult’s capacity to make a particular decision concerning pain assessment, treatment or care, staff must follow the Mental Capacity Act 2005. Capacity must be considered in relation to the specific decision at the relevant time. Where the individual lacks capacity for that decision, any decision made on their behalf must be made in their best interests and by a person with lawful authority to make or implement that decision.

Pain-related needs, risks, preferences, agreed interventions and monitoring arrangements must be reflected in the individual’s personal plan where they are relevant to the person’s day-to-day care and support. The personal plan and relevant assessments must be reviewed and revised when there is a significant change in pain, health status, treatment, risks or care and support needs.

Staff will work with the individual and, where appropriate, their representative, GP, pharmacist, registered nurse, specialist clinician, palliative care team and other relevant healthcare professionals to achieve safe and effective pain management.

4.2 Pain Assessment and Reassessment

Pain must be assessed whenever an individual reports pain or where staff observe signs, behaviours or changes that may indicate pain. Pain assessment must also form part of relevant health and care assessments where pain is known, suspected or reasonably foreseeable.

Assessment must be appropriate to the individual’s needs, communication ability and cognitive function. Where appropriate, recognised pain assessment tools may include:

The individual’s own description of their pain should be used wherever they are able to communicate this reliably. An observational pain tool must not replace the individual’s own report where the individual is able to describe their pain.

Staff must consider, where relevant:

For individuals who are unable to describe their pain reliably, staff must know the individual’s usual presentation and be alert to changes including facial expression, guarding, vocalisation, agitation, withdrawal, altered mobility, reduced appetite, disturbed sleep or changes in behaviour.

Pain must be reassessed:

Any significant change in the individual’s pain or associated care and support needs must prompt review of the relevant assessment and personal plan and referral to an appropriate healthcare professional where necessary.

4.3 Recording and Monitoring

All pain assessments, observations, interventions, referrals and outcomes must be recorded accurately, contemporaneously and in sufficient detail to provide continuity of care and demonstrate the actions taken in response to the individual’s needs.

Records must include, where relevant:

The frequency of monitoring must be proportionate to the individual’s needs, the nature and severity of the pain, the intervention provided and any advice received from a healthcare professional.

Acute, severe, unstable or unexplained pain must be monitored more frequently and escalated promptly.

Where healthcare advice or treatment is obtained, a record of the consultation and, where available, relevant correspondence and resulting actions must be retained as part of the individual’s care record.

Senior staff or the registered nurse, where the service provides nursing care, must ensure that identified actions and referrals are followed through and that unresolved or worsening pain is escalated appropriately.

4.4 Pain Relief, Medicines and Access to Healthcare

Individuals experiencing pain must receive appropriate and timely support. Staff must not leave significant, worsening, unexplained or uncontrolled pain without appropriate action.

Pain management may include prescribed medicines, appropriate non-pharmacological interventions and referral to healthcare professionals.

Where analgesia is prescribed, staff who are authorised to administer medicines must:

Only staff who have received appropriate medicines training and have been assessed as competent may manage, administer or support an individual with medicines within the scope of their role.

Medicines used for pain management must be ordered, received, stored, administered, recorded and disposed of in accordance with the service’s Medication Management and Administration Policy and the requirements applicable to medicines management.

Where pain is persistent, worsening, severe, unexplained or insufficiently controlled, or where staff have concerns about the individual’s condition, advice must be sought promptly from an appropriate healthcare professional. Depending upon the circumstances, this may include the GP, registered nurse, pharmacist, out-of-hours service, NHS 111 Wales, specialist palliative care team or emergency services.

Non-pharmacological interventions may be used where appropriate to the individual and their condition. These must be safe, agreed with the individual where possible, consistent with the individual’s personal plan and must not delay necessary clinical assessment or treatment.

Where more than one healthcare professional or service is involved in managing the individual’s pain, the relevant responsibilities, recommendations and escalation arrangements must be clear and recorded.

4.5 Pain Management during Palliative and End-of-Life Care

Pain relief and symptom control are integral to safe, dignified and person-centred palliative and end-of-life care.

Where appropriate, the individual’s wishes and preferences regarding end-of-life care must be identified and reflected in their personal plan. Relevant advance statements, valid and applicable advance decisions to refuse treatment and details of any person holding lawful authority, including a health and welfare Lasting Power of Attorney where applicable, must be taken into account.

Staff must work collaboratively with the individual’s GP, community nursing team, specialist palliative care services, pharmacy and other relevant healthcare professionals to ensure that pain and other symptoms are assessed and managed appropriately.

Anticipatory medicines may only be administered where they have been lawfully prescribed and in accordance with the prescription, MAR documentation, authorised directions and the service’s Medication Management and Administration Policy.

Staff must:

Where the individual lacks capacity to make a relevant decision, decisions must be made in accordance with the Mental Capacity Act 2005.

4.6 Access to Healthcare and Multidisciplinary Working

{{org_field_name}} will ensure that individuals are supported to access treatment, advice and other services from healthcare professionals as necessary in relation to the assessment and management of pain.

The Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, will ensure that appropriate arrangements are in place for staff to seek professional advice and make referrals in a timely manner.

Relevant healthcare professionals may include:

Where an individual’s needs are complex or pain remains unresolved, appropriate specialist assessment or advice must be sought.

Where several professionals or agencies are involved, responsibilities for treatment, monitoring, referral, review and escalation must be clearly established and recorded so that the individual and staff understand who is responsible for each aspect of care.

Recommendations and clinical instructions relevant to day-to-day care must be incorporated into the individual’s personal plan and other relevant care documentation without unnecessary delay.

Records of professional consultations, recommendations and resulting actions must be maintained in the individual’s care record.

4.7 Communication, Consent and Individual Involvement

Individuals must be involved as fully as possible in decisions concerning the assessment and management of their pain.

Staff must:

Representatives and family members may be involved where the individual wishes this, where the individual has given appropriate consent, or where the person has lawful authority to act on the individual’s behalf.

Information must not be disclosed to relatives or other persons solely because they are related to the individual. Confidentiality and lawful information-sharing requirements must be respected.

Where an adult may lack capacity to make a particular decision concerning pain management, staff must follow the Mental Capacity Act 2005 and the service’s Mental Capacity and Consent Policy.

Where appropriate, individuals must be supported to access advocacy to assist them to express their views, understand information or participate in decisions affecting their care.

4.8 Training and Competence

Staff must receive training, instruction, supervision and support appropriate to their role and to the needs of individuals using the service.

Relevant staff training must include, as appropriate:

Staff who manage, administer or support individuals with medication must receive medicines training appropriate to their role and must be assessed as competent before undertaking those duties.

Competence must be reviewed where required by the service’s medicines procedures, following identified concerns, following significant changes in practice or where supervision, audit or incident review indicates that reassessment is necessary.

Training and competence requirements must be reviewed against the needs of individuals using the service and the service’s statement of purpose. Records of relevant staff training and competence assessment must be maintained.

4.9 Escalation, Safeguarding, Incidents and Regulatory Notification

Any individual experiencing new, severe, persistent, worsening, unexplained or uncontrolled pain must be appropriately assessed and the concern escalated without unnecessary delay.

Staff must seek urgent or emergency healthcare assistance where the individual’s symptoms or condition indicate that this is necessary.

Where staff have concerns that an individual’s pain is being ignored, inadequately assessed, deliberately left untreated, repeatedly mismanaged or otherwise associated with possible abuse, neglect or improper treatment, the concern must be reported immediately in accordance with the service’s Safeguarding Policy and the Wales Safeguarding Procedures.

The Registered Manager or Safeguarding Lead, {{org_field_safeguarding_lead_name}}, in their role as {{org_field_safeguarding_lead_role}}, must ensure that:

Safeguarding referral to the local authority and notification to Care Inspectorate Wales are separate processes. A safeguarding referral must not be treated as replacing a required notification to CIW, and a CIW notification must not replace a required safeguarding referral.

The service provider must ensure that CIW is notified of events that are notifiable under the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.

In particular, where an accident or injury requires treatment by a healthcare professional and, in the reasonable opinion of a healthcare professional, has or may have resulted in prolonged pain or another outcome meeting the statutory notification threshold, the required notification to CIW must be made without delay and in the manner required by CIW.

Where allegations of abuse, misconduct or other events involving staff, volunteers or the service meet separate notification requirements, these must also be notified in accordance with the Regulations and the service’s incident and notification procedures.

Pain-related incidents, concerns, safeguarding matters, medication errors, complaints and patterns of unresolved pain must be reviewed through the service’s governance and quality assurance arrangements. Where monitoring identifies recurring problems, appropriate corrective action must be taken and the effectiveness of that action reviewed.

5. Legislative and Regulatory Framework

This policy must be read and implemented having regard to the current versions of the following, as applicable:

Particular regard must be given to the requirements concerning:

6. Policy Governance, Monitoring and Review

This policy will be reviewed at least annually and sooner where necessary, including following:

The Registered Manager is responsible for the operational implementation of this policy and for ensuring that staff understand and follow the procedures relevant to their roles.

The Responsible Individual must ensure that suitable arrangements are in place to keep this policy and associated procedures up to date, having regard to the statement of purpose and the requirements of the Regulations.

Pain-management practice will be included within the service’s monitoring and quality assurance arrangements where relevant. Information from incidents, safeguarding matters, medication concerns, complaints, audits, care-record reviews and feedback will be considered to identify patterns, risks and opportunities for improvement.

Where deficiencies are identified, corrective action must be taken proportionately and without unnecessary delay. Any required amendments to individuals’ assessments, personal plans, staff training or service procedures must be implemented and monitored.

Staff must be informed of material changes to this policy and provided with any further instruction, training or competency assessment necessary to implement those changes safely.

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.

Leave a Reply

Your email address will not be published. Required fields are marked *