Registration Number: {{org_field_registration_no}}

Initial Assessment and Care Planning Policy

1. Purpose

Initial Assessment and Care Planning Policy

1. Purpose

The purpose of this policy is to establish a structured, consistent and efficient approach to initial assessments and care planning within {{org_field_name}}. Our aim is to ensure that every person we support receives care and support that is safe, effective, person-centred and compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Fundamental Standards), the Care Act 2014 and the Care Quality Commission (CQC) Single Assessment Framework. Initial assessments and care plans will be used as core evidence that we meet key regulations including Regulation 9 (Person-centred care), Regulation 10 (Dignity and respect), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). Care will be planned and delivered in ways that promote people’s rights, well-being, safety, independence and choice.

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 current legal and regulatory requirements:

· Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended, including the Fundamental Standards relevant to assessment and care planning:

o Regulation 9 – Person-centred care.

o Regulation 10 – Dignity and respect.

o Regulation 11 – Need for consent.

o Regulation 12 – Safe care and treatment.

o Regulation 13 – Safeguarding service users from abuse and improper treatment.

o Regulation 16 – Receiving and acting on complaints.

o Regulation 17 – Good governance.

o Regulation 18 – Staffing.

o Regulation 19 – Fit and proper persons employed.

o Regulation 20 – Duty of Candour.

· Care Quality Commission (Registration) Regulations 2009 – including applicable requirements relating to registration, statutory notifications and the provider’s Statement of Purpose.

· Care Act 2014 and Care and Support Statutory Guidance – including the principles of wellbeing, prevention, personalisation, involvement, safeguarding and appropriate advocacy.

· CQC’s current assessment framework – including the five key questions of Safe, Effective, Caring, Responsive and Well-led and the applicable quality statements relevant to assessment, care planning, consent, risk management and governance.

· Mental Capacity Act 2005 and current Code of Practice – including the presumption of capacity, support to make decisions, decision-specific capacity assessment, best-interest decision-making, consultation, advocacy and use of the least restrictive option.

· Health and Care Act 2022, Section 181 – which introduced the statutory requirement for CQC-registered providers to ensure that staff receive learning disability and autism training appropriate to their role.

· Section 20(5ZA) and Section 21A of the Health and Social Care Act 2008, as inserted by the Health and Care Act 2022 – establishing the learning disability and autism training requirement and the statutory Code of Practice framework.

· Oliver McGowan Code of Practice on statutory learning disability and autism training – setting out the standards relevant training must meet. CQC must take the Code into account when considering compliance with applicable registration requirements.

· UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018, as amended by the Data (Use and Access) Act 2025 – governing the lawful, fair and secure processing of personal and special category data contained within assessments, risk assessments and care records.

· Equality Act 2010 – including duties relating to non-discrimination and reasonable adjustments.

· Human Rights Act 1998 – supporting respect for people’s rights, dignity, autonomy, privacy and family life.

{{org_field_name}} will ensure that assessment and care planning arrangements remain consistent with current legislation, statutory guidance and CQC requirements.

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.
- Identify how the person prefers to communicate and record any information or communication support needs (for example, accessible formats, interpreters, communication aids), ensuring reasonable adjustments are put in place so they can understand, participate in and agree to their care and support.
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 and record the person’s capacity to make each relevant decision about their care and support in line with the Mental Capacity Act 2005 and its Code of Practice. Capacity is time- and decision-specific and must not be assumed.
- Where the person has capacity, ensure that consent to assessments, information sharing and care interventions is voluntary, informed and recorded in the assessment and care plan.
- Where the person is assessed as lacking capacity for a specific decision, follow the best-interests process, involving family, friends, attorneys, deputies and/or an Independent Mental Capacity Advocate (IMCA) where required, and clearly record the rationale for the decision and how the least restrictive option has been chosen.
- Record any advance decisions, LPAs, advance care plans or expressed wishes, and ensure they are taken into account when planning care and support.
- Where care arrangements may amount to a deprivation of liberty, seek appropriate legal authorisation and advice in line with current law and guidance.
Multidisciplinary Collaboration:
- Work with healthcare professionals to ensure a holistic assessment.
- Incorporate input from district nurses, GPs, and therapists where needed.

Staff who undertake initial assessments and care planning must have received learning disability and autism training that is appropriate to their role, in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Oliver McGowan Code of Practice. {{org_field_name}}’s Training and Development Policy sets out how this requirement is met.

5. Care Planning and Personalisation

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

Goal Setting:
- Co-produce clear, outcome-focused goals with the person (and, where appropriate, their family or advocate) that reflect what matters most to them, not just their clinical or physical needs.
- Set measurable short- and long-term outcomes that promote independence, safety, wellbeing, social connection and quality of life, and that can be reviewed and updated regularly.
- Ensure goals and planned interventions are tailored to the person’s strengths, preferences, cultural and spiritual background, communication needs and any reasonable adjustments required, in line with Regulation 9 (Person-centred care).
Care Delivery Plan:
- Set out clearly the person’s assessed needs and how these will be met day to day, including (where relevant) personal care, medication support, nutrition and hydration, mobility, skin integrity, continence, domestic tasks, social and community participation, and emotional support.
- Specify what staff must do, how often and to what standard, so that care can be provided safely and consistently in line with Regulations 9 and 12 (person-centred care and safe care and treatment).
- Record any risks and agreed risk-management strategies, including positive-risk-taking decisions that have been made jointly with the person.
- Record any restrictions on the person’s rights or freedoms (for example, use of bedrails, medication timing, financial safeguards), the legal basis for these, and how they are kept under review to ensure they remain necessary, proportionate and the least restrictive option.
- Ensure care plans are written in clear, accessible language and that the person is offered a copy in a format they can understand, with reasonable adjustments and communication support as required.
Safeguarding Measures:
- Ensure compliance with safeguarding policies to protect service users.
- Develop contingency plans for emergencies.
- Where safeguarding risks are identified during assessment or review, staff must follow {{org_field_name}}’s Safeguarding Policy and local multi-agency procedures, and ensure that the care plan reflects the actions agreed to keep the person safe.
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 assessments and plans will be co-produced with the person wherever possible, respecting their views, wishes, feelings and the outcomes they want to achieve.
With the person’s consent (or in their best interests if they lack capacity), family members, informal carers and/or advocates will be involved in assessments, reviews and decision-making.
Where the person has substantial difficulty being involved and has no appropriate person to support them, staff will request a Care Act advocate or IMCA in line with statutory requirements.
The person will be informed of their right to request changes to their care plan at any time and how to raise concerns or complaints about their assessment, care planning or the service they receive.
Consent (or best-interest decisions) will be clearly documented, regularly reviewed and revisited whenever there is a significant change in needs, wishes or circumstances.

7. Documentation and Confidentiality

All assessments, risk assessments and care plans must be completed in a timely manner, legible, factual, dated and signed, and maintained as part of the person’s care record, in line with Regulation 17 (Good governance).
Records must provide a clear audit trail of assessments, decisions (including capacity and best-interest decisions), consent, actions taken and reviews, so that another competent worker could safely continue the person’s care.
{{org_field_name}} processes personal data in accordance with the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018, ensuring lawful bases for processing, data minimisation, accuracy, storage limitation and security.
Information will only be shared with other professionals and agencies on a need-to-know basis, with the person’s consent where they have capacity, or in their best interests or in line with safeguarding/legal requirements where they lack capacity.
Both electronic and paper records are stored securely with appropriate access controls, retention periods and disposal procedures, and are available for inspection by the CQC and other authorised bodies when required.

8. Review and Continuous Improvement

Care plans and assessments will be reviewed regularly to ensure that they remain accurate, relevant, safe and person-centred.

{{org_field_name}} will:

· Review care plans at least every three months, or sooner where required by the person’s needs or circumstances.

· Complete an earlier review where there is a significant change in the person’s health, abilities, risks, preferences, capacity, communication needs or support arrangements.

· Review care arrangements following hospital admission or discharge where relevant.

· Review care plans following significant incidents, safeguarding concerns, medication incidents, falls, complaints or other events that may affect how care should be provided.

· Involve the person in reviews to the maximum extent possible.

· Involve family members, representatives, attorneys, deputies, advocates and relevant professionals where appropriate and lawful.

· Reassess capacity where there is reason to believe that the person’s ability to make the relevant decision may have changed.

· Obtain and record consent to revised care arrangements where the person has capacity.

· Follow the Mental Capacity Act 2005 best-interest process where the person lacks capacity for the particular decision.

· Review risk assessments and ensure that identified controls remain proportionate and effective.

· Update staff promptly where changes affect the way care must be delivered.

Reviews will consider whether planned care remains:

· Safe.

· Effective.

· Person-centred.

· Consistent with the person’s current needs and preferences.

· Consistent with valid consent or applicable best-interest decisions.

· Necessary and proportionate.

· The least restrictive option where restrictions are involved.

· Consistent with applicable professional, legal and regulatory requirements.

{{org_field_name}} will use information from:

· Incidents and near misses.

· Safeguarding concerns.

· Complaints and compliments.

· Service-user and representative feedback.

· Staff feedback.

· Care-plan audits.

· Risk-assessment audits.

· Medication audits where relevant.

· CQC inspection or assessment findings.

· Other quality and governance information.

· to identify improvements required in assessment and care planning.

Duty of Candour

Where something goes wrong during the assessment, planning or delivery of care, {{org_field_name}} will act openly and transparently with the person and/or their representative in accordance with Regulation 20 – Duty of Candour.

Where the incident meets the statutory definition of a notifiable safety incident applicable to {{org_field_name}}, the organisation will follow the formal Duty of Candour procedure.

For a provider other than an NHS health service body, this includes an unintended or unexpected incident occurring during the provision of a regulated activity which, in the reasonable opinion of a healthcare professional, appears to have resulted in, or requires treatment to prevent, one or more of the statutory outcomes specified in Regulation 20.

Where the statutory threshold is met, {{org_field_name}} will:

· Notify the relevant person as soon as reasonably practicable.

· Provide a factual account of what is known.

· Explain any further enquiries or investigation considered appropriate.

· Provide a sincere apology.

· Provide reasonable support.

· Follow up the notification in writing.

· Provide the outcome of further enquiries where required.

· Maintain an appropriate written record of the Duty of Candour process.

Incidents that do not meet the specific notifiable safety incident threshold will still be managed openly and transparently where appropriate and will be reviewed for learning and improvement.

Where necessary, assessment forms, care plans, risk assessments, staff training or organisational procedures will be amended following identified learning.

9. Policy Review and Updates

This policy will be reviewed at least annually, or sooner where necessary, to ensure that it remains accurate, effective and consistent with current legislation, CQC requirements, statutory guidance and the operational needs of {{org_field_name}}.

An earlier review will be undertaken where:

The Health and Social Care Act 2008 or Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 are amended in a way that affects assessment or care planning.
CQC changes its regulatory or assessment requirements relevant to person-centred care, consent, risk management, safeguarding or care planning.
The Mental Capacity Act 2005 or its Code of Practice is amended or replaced.
Requirements relating to deprivation of liberty materially change.
The Oliver McGowan Code of Practice or statutory learning disability and autism training requirements change.
Data protection legislation materially affecting assessment and care records changes.
Safeguarding legislation or statutory guidance materially affecting assessment or care planning changes.
A serious incident, safeguarding enquiry, complaint or Duty of Candour case identifies weaknesses in assessment or care planning.
Internal audits identify recurring deficiencies in assessments, risk assessments or care plans.
Service-user, representative or staff feedback identifies required improvements.
The organisation introduces significant changes to services, assessment processes, care-planning systems or digital technology.
The policy is found to be unclear, ineffective or no longer reflective of current practice.

The Registered Manager is responsible for ensuring that this policy remains current and that assessment and care-planning systems comply with applicable requirements.

As part of the review process, {{org_field_name}} will consider:

Initial assessment audits.
Care-plan audits.
Risk-assessment audits.
Mental capacity and best-interest decision records.
Consent records.
Safeguarding concerns.
Incidents and near misses.
Duty of Candour cases.
Complaints and compliments.
Service-user and representative feedback.
Staff feedback.
Training and competency records for staff undertaking assessments and care planning.
CQC inspection or assessment findings.
Changes in legislation, statutory guidance and nationally recognised good practice.

Any amendments made to this policy will be:

Recorded with the date of review and, where appropriate, a summary of the changes made.
Approved by the appropriate responsible person within {{org_field_name}}.
Communicated to relevant staff.
Reflected in assessment forms, care-plan templates, risk-assessment tools and associated procedures where necessary.
Incorporated into staff training, supervision or competency assessment where required.
Monitored to ensure that revised arrangements are implemented effectively.

All staff involved in assessment and care planning must follow the current version of this policy.

{{org_field_name}} will use findings from audits, incidents, complaints, safeguarding concerns, service-user feedback and regulatory findings to continuously improve the quality, safety and person-centred nature of assessment and care planning.

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.