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Registration Number: {{org_field_registration_no}}

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Initial Assessment and Care Planning Policy

1. Purpose

The purpose of this policy is to ensure that all individuals receiving care at {{org_field_name}} undergo a comprehensive initial assessment and have a person-centred care plan developed that meets their individual needs, preferences, and aspirations. This policy ensures compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended), the Social Services and Well-being (Wales) Act 2014, the Mental Capacity Act 2005, and the Welsh Government statutory guidance for providers of care home and domiciliary support services, last updated on 27 March 2024. It is intended to support compliance with Care Inspectorate Wales (CIW) requirements relating to suitability of the service, personal plans, provider assessment, review, records, and quality assurance.

2. Scope

This policy applies to all staff involved in assessing, planning, and delivering care to residents at {{org_field_name}}, including care staff, nurses, management, and multi-disciplinary professionals. It covers the entire care planning process, from the initial assessment before admission to ongoing reviews and updates of the care plan. This policy also applies to the Registered Manager, Responsible Individual, and any staff member undertaking pre-admission assessment, provider assessment, review, care planning, record keeping, or multidisciplinary coordination.

3. Initial Assessment Process

Before agreeing to provide care and support, {{org_field_name}} will determine whether the service is suitable to meet the individual’s assessed care and support needs and to support the individual to achieve their personal outcomes.

Pre-Admission Assessment:

A suitably skilled, knowledgeable and competent assessor, who has received training in undertaking assessments, will complete the pre-admission assessment.

The assessment will take into account, as available:

• the individual’s care and support plan;
• any health or other relevant professional assessments;
• the individual’s views, wishes and feelings;
• risks to the individual’s well-being;
• risks to the well-being of other individuals using the service;
• any reasonable adjustments the service could make to meet needs safely and effectively.

Where the individual does not already have a care and support plan, the service will complete an assessment of care and support needs and identify the individual’s personal outcomes before agreeing to provide the service.

The assessment will consider, as relevant, health needs, personal care, mobility, communication, cognition, emotional well-being, behaviour, continence, nutrition and hydration, medicines, cultural and religious needs, social interests, family involvement, risks, specialist equipment, and any need for nursing or specialist input.

Where the individual has complex or specialist needs, specialist advice will be sought in a timely way. Where the individual has nursing needs, assessment input will be obtained from a registered nurse with the relevant skills and competence.

Involvement of the Individual:

The individual will be involved in the assessment and decision-making process as fully as possible. Where applicable, the placing authority and any representative will also be involved.

A representative will not be involved where the individual is an adult, or a child aged 16 or over, and does not wish the representative to be involved, or where involving the representative would be inconsistent with the individual’s well-being.

Information will be provided in a format and language appropriate to the individual’s needs, including Welsh or English and other accessible formats where required.

Decision on Admission:

The care home will only accept an individual where it has determined, based on the assessment and available information, that the service can safely and effectively meet the individual’s needs and support the individual to achieve their personal outcomes, having regard to the statement of purpose.

In reaching this decision, the service will also consider compatibility with the existing resident group, the impact on other individuals using the service, staffing, environment, equipment, and access to specialist or health services as required.

Where the service cannot safely meet the individual’s needs, the decision and rationale will be recorded and communicated promptly to the individual and/or representative, and to the placing authority or commissioner where applicable.

4. Care Planning Process

An initial personal plan will be prepared before the commencement of the provision of care and support. Where the individual is in urgent need of care and support and there has been no time to prepare the plan beforehand, the initial personal plan will be prepared within 24 hours of the commencement of the service. The initial personal plan will then be reviewed and updated within the first 7 days in line with the outcome of the provider assessment.

Personalised Approach:

Personal plans will be co-produced with the individual and, where applicable, the placing authority and any representative. The plan will reflect the individual’s views, wishes, feelings, personal outcomes, preferred routines, strengths, cultural and religious needs, communication needs, and the support required to maintain or develop independence.

Comprehensive Assessment Areas:

• Physical Health: Existing medical conditions, medication management, mobility requirements, nutrition, and hydration needs.
• Mental and Emotional Well-being: Cognitive abilities, emotional health, communication preferences, and mental health considerations.
• Personal Care Needs: Assistance with hygiene, dressing, continence management, and sleep routines.
• Social and Recreational Interests: Hobbies, family visits, and social engagement opportunities.
• Risk Assessment and Safeguarding: Identifying potential risks and ensuring appropriate measures are in place for resident safety.

The personal plan will clearly set out:

• how day-to-day care and support needs will be met;
• how the individual will be supported to achieve personal outcomes;
• the steps to mitigate identified risks to the individual’s well-being;
• the steps to support positive risk-taking and independence where appropriate;
• the individual’s preferences, wishes, aspirations and beliefs;
• actions required from staff and other professionals;
• any monitoring, escalation, review dates, and specialist referrals required.

Consent, Capacity and Documentation:

The service will seek and record the individual’s consent to assessment, care planning, information sharing, and delivery of care wherever the individual has capacity to make the relevant decision.

Where there is reason to doubt an individual’s capacity to make a specific decision, capacity will be assessed in line with the Mental Capacity Act 2005. If the individual lacks capacity for the relevant decision, a best-interests decision will be made and recorded, appropriate parties will be consulted, and any restrictions on liberty or movement will only be used where there is lawful authority.

The policy does not require a signature in every case. Where an individual is unable or unwilling to sign, the service will record how involvement, wishes, consent, refusal, best-interests decision-making, or other lawful authority has been evidenced.

Any representative signing or agreeing on behalf of the individual must have appropriate legal authority or the individual’s consent to act on their behalf.

All assessments, provider assessments, personal plans, reviews, mental capacity assessments, best-interests decisions, and associated records will be accurate, up to date, stored securely, and managed in accordance with data protection law and the service’s records-management procedures.

Provider Assessment within the First 7 Days

Within 7 days of the commencement of care and support, {{org_field_name}} will complete a provider assessment.

The provider assessment will:

• assess how the individual’s care and support needs can best be met;
• assess how the individual can best be supported to achieve personal outcomes;
• ascertain the individual’s views, wishes and feelings;
• assess any risks to the individual’s well-being; and
• assess any risks to the well-being of other individuals using the service.

The provider assessment will build on the pre-admission assessment, any care and support plan, and any health or other relevant assessments. It will be proportionate to the individual’s circumstances and will identify any areas requiring more in-depth or specialist assessment.

The provider assessment will be carried out by a person who has the skills, knowledge and competence to do so and who has received training in carrying out assessments. Where the individual has complex or specialist needs, the assessor will seek relevant specialist advice. Where the individual has nursing needs, the assessment will be undertaken with input from a registered nurse with the relevant skills.

Following completion of the provider assessment, the personal plan will be reviewed and revised as necessary. A record of the provider assessment will be kept and a copy will be given to the individual and, where appropriate, any representative.

5. Reviewing and Updating Care Plans

Care plans are dynamic documents that are regularly reviewed to reflect changes in the individual’s health, preferences, or circumstances.

Regular Reviews:

• Formal reviews of the personal plan will be carried out as and when required, but at least every three months, and sooner if there is any change in needs, risks, preferences, health status, behaviour, outcomes, or circumstances.

Each review will include consideration of the extent to which the individual has been able to achieve their personal outcomes and whether the personal plan remains accurate, proportionate, and effective.

• The individual will be involved in reviews as fully as possible and, where appropriate, any representative and the placing authority will also be involved. A representative will not be involved where the individual is an adult, or a child aged 16 or over, and does not wish that involvement, or where involvement would be inconsistent with the individual’s well-being.

Triggers for Review:

• Change in medical condition or medication.
• Change in mobility, cognition, or mental health.
• Feedback from residents, families, or healthcare professionals.
• Significant incidents, such as falls or hospital admissions.
• Failure of the current plan to support the individual to achieve their personal outcomes.
• New or changed risks, including safeguarding concerns.
• Use of control, restraint or restrictive practice.
• Specialist professional advice or hospital discharge recommendations.
• A change indicating the service may no longer be able to meet the individual’s assessed needs.

A record will be kept of each review, the outcome of the review, and any revisions made. A copy of the current personal plan, and any revised plan, will be made available to the individual in a format and language appropriate to their needs. Where a copy is not provided, the reason will be recorded.

6. Multi-Disciplinary Collaboration

Effective care planning involves input from various professionals to ensure holistic care.

Team-Based Approach:

• Regular meetings with healthcare professionals such as GPs, nurses, social workers, and therapists to discuss care needs.
• Collaboration with external agencies for specialist support (e.g., speech therapy, dietitians, dementia services).

Family and Advocate Involvement:

• Residents’ families and representatives are invited to care planning meetings to provide input and raise concerns.
• We respect and support residents who do not have family involvement by ensuring independent advocates are available when needed.

Where individuals have complex, specialist, behavioural, communication, or nursing needs, the service will seek timely advice from relevant professionals and ensure that responsibilities for assessment, review, intervention and monitoring are clear between all agencies involved. Recommendations from multidisciplinary professionals will be reflected in the personal plan and review process.

7. Emergency and Contingency Planning

We ensure that care plans include contingency arrangements for emergencies.

Advance Care Planning:

Where appropriate, the service will discuss and record the individual’s wishes and preferences in relation to future care, deterioration, end of life care, cultural or spiritual needs, and who should be involved in decisions.

The personal plan will reflect any advance statement, advance decision to refuse treatment (ADRT), decisions relating to cardiopulmonary resuscitation, and any valid legal authority such as a Health and Welfare Lasting Power of Attorney or deputyship, where applicable.

Crisis Management:

• Protocols for responding to sudden health deterioration, falls, or medical emergencies.
• Contact details for next of kin and emergency services readily available.

Where emergency admission or urgent commencement of care occurs, the service will ensure an initial personal plan is in place within 24 hours and will complete the provider assessment and full review/update within the first 7 days.

8. Compliance and Monitoring

Ensuring high-quality care planning requires regular audits and compliance monitoring.

Care Plan Audits:

• Regular internal audits ensure care plans are up-to-date, detailed, and person-centred.
• Audit findings inform continuous improvements in care planning.

CIW Inspections and Assurance:

We will maintain evidence-based records to demonstrate compliance with Regulations 14 to 18 and related duties concerning records, capacity, safeguarding, restrictive practices, and quality assurance.

Audit activity will specifically check:

• suitability decisions made before admission;
• completion of the initial personal plan before commencement, or within 24 hours in urgent cases;
• completion of the provider assessment within 7 days;
• three-monthly review compliance;
• evidence of the individual’s involvement and personal outcomes;
• accessible copies of plans and reviews;
• lawful consent, capacity assessment, best-interests decisions, and any relevant deprivation-of-liberty documentation;
• evidence that specialist advice has been obtained where required.

We will also keep this policy and practice under review in line with CIW’s current inspection framework and published ratings requirements for care homes.

9. Access to Personal Plans and Record Keeping

{{org_field_name}} will keep accurate, up-to-date and secure records relating to pre-admission assessment, provider assessment, personal plans, reviews, risk assessments, multidisciplinary input, mental capacity assessments, best-interests decisions, advance care planning, and any restrictive practice or safeguarding concerns linked to care planning.

The individual will be informed how to access their records and will be given a copy of the personal plan and any revised plan in a format and language appropriate to their needs, unless there is a documented reason why this is not appropriate.

Records will be stored securely, with arrangements in place for confidentiality, controlled access, business continuity, and secure retention in accordance with legal and organisational requirements.

10. Related Policies

This policy should be read in conjunction with:

• CHW07 – Person-Centred Care Policy
• CHW11 – Safe Care and Treatment Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW36 – Moving and Handling Policy
• CHW38 – End of Life and Palliative Care Policy

11. Policy Review

This policy will be reviewed annually or sooner if there are changes in legislation, regulatory requirements, or organisational needs. Any updates will be communicated to all staff through training sessions and policy briefings. This policy will also be reviewed sooner following any change to Welsh legislation, statutory guidance, CIW inspection/ratings requirements, Social Care Wales practice expectations, or relevant case law affecting capacity, best interests, safeguarding, or deprivation of liberty.

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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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