Care needs assessment

What you need to know

The plain-English guidance that comes with this document.

• This is the foundation — get it right and everything follows. A thorough, honest needs assessment is what the whole care plan, the risks and the staffing are built on. Rush it and you'll be reacting to problems you could have seen coming.
• Do it with the person. Person-centred means their voice leads — what matters to them, how they want their care, what they can still do for themselves. Involve family and anyone with a lasting power of attorney where appropriate, and record who was there.
• Assess capacity where decisions are involved. Start by assuming the person can make their own decisions. Only where there's real doubt about a specific decision do you assess capacity — using your mental capacity record — and never treat an "unwise" choice as proof they can't decide.
• Flag the risks it surfaces. Moving and handling, falls, swallowing/choking, skin, medication and self-neglect all commonly show up here — carry each into your care risk assessment and care plan, don't leave them in the assessment.
• This is sensitive, special-category data. Health and care information is highly protected under UK GDPR. Store it securely, share only with those who need it, and only keep it as long as required.
• This is a professionally structured starting point — make it yours. A registered manager or experienced assessor should tailor and sign off the assessment for the individual; it isn't a form to file blank, and it isn't "CQC-compliant out of the box".
• Applies UK-wide, with different regulators. Care is regulated by the CQC in England, Care Inspectorate Wales, the Care Inspectorate in Scotland, and RQIA in Northern Ireland. The person-centred assessment approach is expected by all of them; check your regulator's specific standards.