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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Pain Assessment and Management Policy

1. Purpose

The purpose of this policy is to ensure that all individuals receiving care at {{org_field_name}} have their pain effectively recognised, assessed, managed, and monitored in a timely and person-centred manner. Unrelieved pain can significantly affect an individual’s physical, emotional, and psychological wellbeing. In accordance with the Regulation and Inspection of Social Care (Wales) Act 2016, this policy ensures our procedures meet CIW regulatory expectations and promote the best possible quality of life for those in our care. This policy also reflects the principles outlined in the Social Services and Well-being (Wales) Act 2014, upholding individual rights to dignity, autonomy, and high-quality care.

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 individuals have the right to have their pain acknowledged and treated. We take a holistic approach to pain management that considers physical, emotional, psychological, spiritual, and social dimensions of pain. Pain is assessed regularly and whenever a change in condition is observed or reported. Care plans reflect each individual’s unique experience and expression of pain, including non-verbal cues, behaviours, and preferences. We work in close collaboration with individuals, families, advocates, GPs, pharmacists, and other healthcare professionals to ensure safe and effective pain relief.

4.2 Pain Assessment Tools and Frequency
Pain assessment is carried out using validated tools appropriate to the individual’s needs and cognitive ability. These may include:

• Numeric Rating Scale (0–10) for individuals able to self-report
• Abbey Pain Scale or Pain Assessment in Advanced Dementia (PAINAD) for individuals with cognitive impairment
• Verbal Descriptor Scale or Faces Pain Scale for those with communication difficulties

All individuals are assessed on admission and at regular intervals thereafter, including during care plan reviews, after incidents, and following interventions or surgeries. Staff are trained to identify both verbal and non-verbal indicators of pain, such as facial expressions, vocalisations, restlessness, withdrawal, appetite changes, and changes in usual behaviour.

4.3 Recording and Monitoring
Pain scores and observations are documented in the individual’s care record and evaluated daily, or more frequently where pain is acute or fluctuating. Staff must clearly record:

• The individual’s self-report of pain or observed behaviour
• The location, nature, intensity, and duration of the pain
• The impact on function, mood, and sleep
• Interventions provided and their outcomes

All documentation is reviewed by the senior on duty or nurse to ensure follow-up action is taken, including appropriate referrals or medication reviews.

4.4 Prompt Pain Relief and Access to Medication
We are committed to providing timely and appropriate pain relief. This includes:

• Administering prescribed analgesia as per the MAR (Medication Administration Record) chart
• Escalating to GPs or the out-of-hours service if pain is not controlled or increasing
• Providing non-pharmacological strategies such as repositioning, massage, warm compresses, distraction, and emotional reassurance

Our Medication Management Policy (CHW21) ensures that analgesics, including opioids, NSAIDs, and adjuvant medications, are stored, administered, and monitored in accordance with national guidance and pharmacy protocols. The effectiveness of medication is routinely reviewed and documented.

4.5 Pain Management at End of Life
Pain relief is prioritised during palliative and end-of-life care. Anticipatory medications are requested and administered in line with advance care plans and the Gold Standards Framework. We work closely with palliative care nurses and hospices to ensure comfort, dignity, and peace. Staff receive enhanced training in end-of-life symptom control and emotional support. Individuals and families are consulted and supported at every stage.

4.6 Multidisciplinary Working
The Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, ensures that staff liaise with external professionals to support complex pain management needs. This includes regular reviews with:

• GPs and prescribing clinicians
• Community nursing teams
• Physiotherapists and occupational therapists
• Palliative care and pain specialists

Where needed, referrals are made to appropriate specialists, and recommendations are incorporated into the care plan and risk assessment.

4.7 Communication and Involvement
Staff are expected to listen actively, reassure individuals reporting pain, and ensure their concerns are addressed. Family members are kept informed and involved, with consent. Any indication of unresolved pain must be raised immediately with the senior on duty. Care staff are encouraged to document observations and advocate for the individual. Our culture promotes openness, kindness, and attention to distress, in line with the CIW values of respect, dignity, and well-being.

4.8 Training and Competency
All staff receive training on:

• Recognising different types and causes of pain
• Using pain assessment tools
• Supporting individuals who cannot verbally express pain
• Safe use of medications for pain relief
• Person-centred and ethical decision-making in pain control

Competency assessments are completed during induction and reviewed annually. Staff have access to guidance, supervision, and clinical support when dealing with complex or persistent pain.

4.9 Escalation, Safeguarding and Review
Any concerns that pain is being ignored, mismanaged, or inadequately treated must be escalated without delay to the Registered Manager or the Safeguarding Lead, {{org_field_safeguarding_lead_name}}, in their role as {{org_field_safeguarding_lead_role}}. Concerns may also be referred to the GP, local safeguarding team at {{org_field_local_authority_authority_name}}, or CIW. Pain management is reviewed regularly as part of the individual’s care planning and the service’s internal quality assurance audits. Trends or recurring issues are addressed as part of our Quality of Care Review and clinical governance cycle.

5. Policy Review

This policy is reviewed annually or sooner in response to legislative changes, CIW guidance updates, feedback from service users, complaints, or incidents involving unmanaged pain. The review will be led by the Registered Manager in consultation with clinical advisors and care teams. All staff will be informed of updates through training, staff meetings, and internal communication systems.

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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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