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{{org_field_name}}

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 and aligns with CIW best practices in care planning and delivery.

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.

3. Initial Assessment Process

Before a resident moves into {{org_field_name}}, an initial assessment is conducted to ensure the service can meet their needs.

• Pre-Admission Assessment:
  • A senior staff member, in collaboration with healthcare professionals and family members (where applicable), will carry out a pre-admission assessment.
  • The assessment will cover health conditions, mobility, personal preferences, social interests, medication needs, dietary requirements, and any risks.
  • Where necessary, specialist input (such as physiotherapists, occupational therapists, or dementia specialists) will be sought to enhance accuracy.
• Involvement of the Individual:
  • The resident, their family, and/or their advocate will be actively involved in the assessment process.
  • The assessment process will ensure the individual’s rights, dignity, and choices are respected in line with the Social Services and Well-being (Wales) Act 2014.
• Decision on Admission:
  • The care home will only accept residents if it is deemed that their needs can be met safely and effectively within our setting.
  • A written agreement outlining the services provided, responsibilities, and terms of residence will be given to the individual and their representative before admission.

4. Care Planning Process

Once an individual moves into {{org_field_name}}, a detailed, person-centred care plan is developed within the first 72 hours.

• Personalised Approach:
  • Care plans are developed collaboratively with the resident and relevant stakeholders.
  • The plan will reflect personal choices, cultural and religious preferences, and lifestyle needs.
• 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.
• Consent and Documentation:
  • The resident (or their legal representative) must consent to the care plan and sign to confirm their agreement.
  • All assessments and care plans are securely stored in compliance with GDPR regulations.

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 care plan reviews are conducted at least every six months or sooner if changes in health or needs occur.
  • Residents and their families are encouraged to participate in reviews to ensure the care plan remains relevant.
• 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.

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.

7. Emergency and Contingency Planning

We ensure that care plans include contingency arrangements for emergencies.

• Advance Care Planning:
  • Discussions on end-of-life care preferences (where appropriate).
  • Clear documentation of Do Not Attempt Resuscitation (DNAR) orders and power of attorney arrangements.
• Crisis Management:
  • Protocols for responding to sudden health deterioration, falls, or medical emergencies.
  • Contact details for next of kin and emergency services readily available.

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:
  • We ensure all care plans comply with CIW expectations and regulatory requirements.
  • Evidence-based records are maintained to demonstrate compliance and quality assurance.

9. 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

10. 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.

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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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.