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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 establish a structured and efficient approach to initial assessments and care planning within {{org_field_name}}. By ensuring a thorough and person-centred assessment process, we aim to deliver care that is safe, effective, responsive, and compliant with Care Quality Commission (CQC) Fundamental Standards and the Care Act 2014. This policy outlines our commitment to identifying service users’ needs, preferences, and risks while ensuring their well-being and dignity are upheld.

2. Scope

This policy applies to:

• All employees, including care workers, care coordinators, and management.
• Service users and their families, ensuring their involvement in care planning.
• Healthcare professionals and multi-disciplinary teams involved in care assessments.
• Regulatory bodies, ensuring compliance with statutory requirements.

It covers:

• The process of conducting initial assessments.
• Risk assessments and mitigation planning.
• Development and review of personalised care plans.
• Service user involvement and consent.
• Documentation and confidentiality.

3. Legal and Regulatory Framework

This policy aligns with the following legal and regulatory standards:

• Care Act 2014 – Promoting personalised and outcome-focused care.
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Ensuring safety and quality in care planning.
• Care Quality Commission (CQC) Fundamental Standards – Governing safe, person-centred care.
• Mental Capacity Act 2005 – Supporting decision-making for individuals lacking capacity.
• General Data Protection Regulation (GDPR) 2018 – Ensuring confidentiality and secure handling of personal data.

4. Initial Assessment Process

To ensure care is tailored to individual needs, the initial assessment process follows these steps:

• Referral and Pre-Assessment Review:
  • Gather relevant medical and personal information.
  • Liaise with family members, healthcare professionals, and social workers.
• Face-to-Face Assessment:
  • Conduct a detailed evaluation of physical, emotional, and social needs.
  • Identify service user preferences, lifestyle, and cultural considerations.
  • Discuss risks, safeguarding concerns, and any existing support networks.
• Risk Assessments:
  • Evaluate mobility, falls risk, medication management, and environmental hazards.
  • Assess risks related to personal care, nutrition, mental health, and safeguarding.
  • Develop mitigation strategies for identified risks.
• Capacity and Consent:
  • Assess the service user’s capacity to make decisions under the Mental Capacity Act 2005.
  • Obtain informed consent for care interventions and service provision.
• Multidisciplinary Collaboration:
  • Work with healthcare professionals to ensure a holistic assessment.
  • Incorporate input from district nurses, GPs, and therapists where needed.

5. Care Planning and Personalisation

Following assessment, a person-centred care plan is developed:

• Goal Setting:
  • Establish short- and long-term objectives based on service user preferences.
  • Promote independence and enhance quality of life.
• Care Delivery Plan:
  • Outline support needs, including personal care, medication, meal preparation, and social activities.
  • Assign key workers and establish care schedules.
• Safeguarding Measures:
  • Ensure compliance with safeguarding policies to protect service users.
  • Develop contingency plans for emergencies.
• Communication Plan:
  • Define how care updates will be shared with families and healthcare professionals.
  • Establish review timelines for regular care plan updates.

6. Service User Involvement and Consent

To empower service users and respect their choices:

• Care plans are developed in collaboration with the service user and their representatives.
• Regular feedback sessions ensure that care remains aligned with individual needs.
• Service users are informed of their rights to request care modifications.

7. Documentation and Confidentiality

All assessments and care plans are documented in compliance with:

• GDPR and Data Protection Act 2018 – Ensuring secure storage and controlled access.
• CQC record-keeping guidelines – Maintaining accuracy, accessibility, and confidentiality.
• Electronic and paper-based systems – Used for efficient documentation and audits.

8. Review and Continuous Improvement

To maintain high-quality care, all care plans undergo:

• Quarterly reviews to assess effectiveness and adapt to changing needs.
• Emergency reviews following hospital admissions, safeguarding concerns, or changes in condition.
• Annual audits to evaluate compliance and service user satisfaction.

9. Policy Review and Updates

This policy is reviewed annually or sooner if:

• Legislative updates require modifications.
• Regulatory feedback suggests improvements.

Service user feedback identifies the need for changes.

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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.