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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, thorough, and person-centred approach to the initial assessment and care planning process within {{org_field_name}}. This ensures compliance with Regulation 9 (Person-Centred Care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and aligns with Care Quality Commission (CQC) Fundamental Standards.

This policy ensures that:

• The individual’s needs, preferences, and aspirations are fully assessed before support begins.
• Risk factors are identified and managed effectively to protect health and well-being.
• Personalised care plans are created, implemented, and regularly reviewed.
• Staff are trained and competent in conducting assessments and managing care planning efficiently.
• Multi-agency collaboration ensures that care is holistic and addresses all aspects of well-being.

2. Scope

This policy applies to all staff involved in the initial assessment, care planning, and ongoing review of individuals receiving support from {{org_field_name}}. It covers:

• Pre-admission assessments and suitability checks.
• How care and support plans are developed, reviewed, and adjusted.
• The involvement of individuals, families, and advocates.
• Risk assessments and safeguarding considerations.
• Coordination with healthcare and social care professionals.
• The use of technology and tools in assessment and planning.

3. Principles of Initial Assessment and Care Planning

At {{org_field_name}}, we are committed to delivering high-quality, person-centred care. Our approach follows these key principles:

Pre-Admission and Suitability Assessment

Before an individual is accepted into our service:

• A pre-admission assessment is conducted to ensure that our service can meet the individual’s needs effectively.
• The individual (or their representative) is invited for an initial discussion to gather relevant medical, personal, and social information.
• If the person has complex needs, a multi-disciplinary team meeting is arranged with relevant healthcare professionals to discuss appropriate support strategies.
• Suitability is assessed based on:
  • The person’s care and support needs.
  • Our staff expertise and service capacity.
  • Environmental factors and accessibility.

If {{org_field_name}} cannot meet the individual’s needs safely and effectively, alternative recommendations will be provided.

Comprehensive Initial Assessment

Once an individual is accepted into our service, a full initial assessment is conducted. This assessment includes:

• Physical health and medical needs (including existing conditions, mobility, and medication requirements).
• Mental health and emotional well-being.
• Communication needs, including sensory impairments or language barriers.
• Personal care preferences (bathing, dressing, continence support).
• Nutritional and hydration needs (dietary restrictions, assistance required for eating/drinking).
• Daily living activities, including domestic tasks and community engagement.
• Social networks and family involvement.
• Religious, cultural, and spiritual preferences.
• Risk factors (falls, self-neglect, substance misuse, challenging behaviour, safeguarding concerns).
• Assistive technology requirements (mobility aids, communication devices).
• Emergency and contingency planning, including crisis intervention strategies.

A named key worker is assigned to each individual to oversee the assessment and ensure all concerns are addressed.

Developing a Personalised Care and Support Plan

Following assessment, a detailed, outcome-focused care plan is developed in collaboration with the individual, their family, and professionals involved in their care. The care plan includes:

• Goals and aspirations: What the individual wants to achieve through the support provided.
• Specific interventions and support arrangements: How staff will assist with daily living, medication management, and social engagement.
• Preferred routines: Sleeping, eating, personal care, and activities.
• Mental well-being support: Coping strategies, therapy involvement, and emotional support.
• Health monitoring requirements: Regular check-ups, physiotherapy, occupational therapy, or medical reviews.
• Safeguarding measures: Any identified risks and agreed protective interventions.
• Contingency and emergency plans: Actions to be taken in case of sudden health deterioration, hospitalisation, or other emergencies.

Risk Management and Safeguarding in Care Planning

• Risk assessments are conducted alongside the initial assessment to ensure safety and well-being.
• Each risk assessment covers:
  • Environmental hazards (slips, trip risks, accessibility issues).
  • Health risks (medication errors, medical conditions, infection control).
  • Behavioural risks (aggression, self-harm, substance misuse).
  • Financial risks (vulnerability to exploitation, fraud prevention).
• Risk management strategies are documented in the care plan, with clear actions for mitigation.
• If safeguarding concerns are identified, they are immediately reported to the Safeguarding Lead and local safeguarding authorities, following Regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment).

Multi-Agency Collaboration

To ensure holistic, integrated care, we work with:

• GPs and primary healthcare providers to manage medical conditions.
• Community mental health teams for individuals with mental health needs.
• Physiotherapists and occupational therapists to improve mobility and independence.
• Social workers and local authority teams for coordinated care planning.
• Advocates and legal representatives for individuals who require additional support in decision-making.

Review and Ongoing Assessment

• Care plans are reviewed every six months, or sooner if circumstances change.
• Staff conduct regular well-being check-ins with individuals to identify new concerns.
• Reviews are scheduled with multi-disciplinary input where required.
• Individuals and families are encouraged to provide ongoing feedback on the care provided.

Use of Technology in Assessments and Care Planning

• Electronic care planning tools ensure that records are accurate, secure, and up-to-date.
• Digital risk assessments help track changes and implement updates efficiently.
• Assistive technology is explored to enhance independence and communication where applicable.

4. Roles and Responsibilities

• Registered Manager: Oversees all assessments and ensures compliance with CQC regulations.
• Care Coordinators: Conduct assessments, develop care plans, and monitor ongoing care delivery.
• Safeguarding Lead: Ensures that safeguarding risks are identified and addressed appropriately.
• Health and Safety Lead: Oversees environmental risk assessments and ensures safety measures are in place.
• Multi-Disciplinary Professionals: Provide input to ensure care plans are comprehensive and holistic.

5. Related Policies

This policy should be read in conjunction with:

• SL07 – Person-Centred Care Policy
• SL08 – Dignity and Respect Policy
• SL09 – Consent to Care Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• SL16 – Health and Safety at Work Policy
• SL21 – Medication Management and Administration Policy
• SL42 – Communication and Engagement with Service Users and Families Policy

6. Policy Review

This policy will be reviewed annually or sooner if legislative changes, CQC requirements, or organisational needs necessitate an update. Updates will be communicated to all staff to ensure best practices are followed in assessment and care planning.

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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.