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Initial Assessment and Care Planning Policy

1. Introduction

Our Home Care business is committed to ensuring that all service users receive a comprehensive, person-centred, and outcome-focused initial assessment and care plan, in line with Care Inspectorate Wales (CIW) regulations, the Social Services and Well-being (Wales) Act 2014, and the Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA). Our approach ensures that individuals receive care that is tailored to their specific needs, preferences, and aspirations, while promoting dignity, independence, and well-being. This policy applies to all employees, including Care Coordinators, Registered Managers, Senior Carers, and Care Assistants, and provides clear guidance for CIW inspectors on how we ensure compliance with regulatory requirements.

2. Key Principles of Initial Assessment and Care Planning

• Person-Centred Approach: Each service user is actively involved in designing their own care plan.
• Holistic Needs Assessment: Care planning considers physical, emotional, social, and cultural needs.
• Risk Management and Safety: Individual Risk Assessments (RA) are conducted to minimise potential risks.
• Outcome-Focused Planning: Care plans are designed to promote independence, choice, and control.
• Regular Review and Adaptability: Care plans are reviewed every six months or sooner if needs change.
• Compliance with Regulatory Standards: Care planning adheres to CIW’s Quality Standards for Home Care.

3. How We Manage Initial Assessments and Care Planning Efficiently

A. The Initial Assessment Process

Every new service user undergoes a comprehensive initial assessment before care delivery begins.

For Staff:

• Step 1: Receive a referral from the Local Authority, NHS, private client, or family member.
• Step 2: Arrange an Initial Assessment Meeting (IAM) at the service user’s home.
• Step 3: Gather information on medical history, mobility, dietary needs, mental capacity, communication preferences, personal care needs, medication requirements, and lifestyle preferences.
• Step 4: Complete a Holistic Needs Assessment (HNA) to capture all aspects of well-being.
• Step 5: Conduct a Risk Assessment (RA) for falls, home safety, and safeguarding risks.

For CIW Inspectors: Initial assessment records confirm a comprehensive and person-centred approach. Risk assessments demonstrate that potential hazards are identified and managed.

B. Developing the Personalised Care Plan (PCP)

Each service user has a Personalised Care Plan (PCP) detailing their specific care needs, goals, and preferences.

For Staff:

• Step 1: Create a Person-Centred Care Plan (PCCP) based on the assessment findings.
• Step 2: Include information on personal preferences, religious or cultural needs, and social interests.
• Step 3: Set SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals to promote well-being.
• Step 4: Document all care routines in the Care Management System (CMS) for digital access.
• Step 5: Obtain written consent from the service user or their representative before care begins.

For CIW Inspectors: Care plans demonstrate clear, achievable goals and service user involvement. Consent forms confirm that individuals understand and agree to their care plans.

C. Risk Assessments and Safeguarding Considerations

A key part of care planning is risk identification and management.

For Staff:

• Complete Risk Assessments (RA) covering:
  • Falls Prevention (home environment, mobility aids)
  • Medication Management (self-administration, assistance required)
  • Nutritional Risks (swallowing difficulties, meal preferences)
  • Safeguarding and Abuse Prevention (vulnerable adults, financial exploitation)
• Implement Risk Reduction Strategies (RRS) based on findings.

For CIW Inspectors: Documentation confirms that risks are assessed and managed proactively. Care plans include mitigation strategies for identified risks.

D. Outcome-Focused Care Planning

We design care plans that focus on achieving meaningful outcomes for service users.

For Staff:

• Set individual goals, such as improving mobility, increasing social engagement, or regaining independence.
• Encourage active participation in decision-making.
• Regularly assess progress towards goals and adjust plans accordingly.

For CIW Inspectors: Service user feedback confirms that care plans are personalised and empowering. Outcome reviews demonstrate that care is achieving measurable benefits.

E. Involving Families and Multi-Disciplinary Teams

Collaboration with families, healthcare professionals, and social workers is key to effective care planning.

For Staff:

• Engage family members and next of kin in care planning, if appropriate.
• Coordinate with GPs, district nurses, and occupational therapists to ensure holistic care.
• Use the Multi-Disciplinary Team (MDT) approach for complex cases.

For CIW Inspectors: Care plans show clear records of MDT involvement and professional recommendations. Communication logs demonstrate family involvement and regular updates.

F. Reviewing and Updating Care Plans

Care plans must be reviewed and updated regularly to reflect changing needs.

For Staff:

• Conduct a Formal Care Review (FCR) every 6 months.
• Update care plans immediately if a service user’s condition changes.
• Ensure service users and families are consulted during reviews.

For CIW Inspectors: Care plans include dated review logs to confirm compliance with regulations. Changes in care delivery are well-documented with service user consent.

4. Governance and Continuous Improvement

We ensure high standards of assessment and care planning through regular audits, staff training, and quality monitoring.

What We Do:

• Conduct Quarterly Care Plan Audits (QCPA) to review care plan effectiveness.
• Hold Annual Service User Feedback Sessions (ASFUS) to improve assessment processes.
• Train staff in Person-Centred Planning (PCP) and Risk Assessment (RA) best practices.

For CIW Inspectors: Audit records confirm regular reviews and quality monitoring. Training logs demonstrate staff competency in care planning.

5. Compliance Monitoring and Audit Procedures

• Internal Audits: Conducted quarterly to assess assessment and care planning compliance.
• Annual Reviews: Full compliance check against CIW regulations and Social Care Wales standards.
• Staff Supervisions & Appraisals: Used to ensure staff maintain care planning competency.

6. Conclusion

We are committed to delivering comprehensive, person-centred, and outcome-focused care planning in compliance with CIW regulations, RISCA, and the Social Services and Well-being (Wales) Act 2014. This policy ensures that service users receive care that is tailored, safe, and continuously reviewed to meet their evolving needs.

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