1. What the regulation says
The care and treatment of service users must be appropriate, meet their needs, and reflect their preferences. (Reg 9(1): the headline duty)
carrying out, collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment of the service user (Reg 9(3)(a): collaborative assessment)
The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/9. Where this policy and the regulation diverge, the regulation wins. The non-statutory primary guidance for this topic is CQC guidance on Regulation 9 (person-centred care).
2. Plain-English summary
Care and treatment must be appropriate, meet the service user's needs, and reflect their preferences. The regulation lists nine specific things you have to do to deliver person-centred care, including: assessment with the service user, designing care to meet their preferences, involving them and the people supporting them in decisions, providing information, making reasonable adjustments, and considering well-being when meeting nutritional and hydration needs.
3. Purpose
The purpose of this policy is to make sure that [Service Name] provides care and treatment that is appropriate, meets the person's needs and reflects their preferences.
Person-centred care is not a slogan. It requires assessment, planning, communication, consent, review, reasonable adjustment, risk management and escalation when the service can no longer meet a person's needs safely.
This policy applies across regulated services including clinics, independent doctors, dental, diagnostics, adult social care, domiciliary care, patient transport, private hospitals, GP services and specialist services.
4. Policy warning
The service must not accept, continue or change care or treatment without understanding the person's needs, preferences, risks, consent position and whether the service can meet those needs safely.
If the service cannot safely meet the person's needs, this must be explained, recorded and escalated. Staff must not allow commercial pressure, convenience, rota pressure or fear of complaint to override safe scope-of-service decisions.
5. Scope
This policy applies to:
- initial assessment
- referral screening
- admission or onboarding decisions
- consultation and treatment planning
- care planning
- review of needs and preferences
- risk assessment
- reasonable adjustments
- communication support
- consent and capacity considerations
- shared care and transfers
- escalation when needs change
- discharge, refusal, signposting or transfer where the service cannot meet needs safely
6. Principles
The service will:
- involve the person as much as they wish and are able
- assess needs and preferences before care or treatment is delivered
- provide information in a way the person can understand
- support informed decision-making
- consider risks, benefits and alternatives
- make reasonable adjustments
- respect consent and refusal
- consider capacity and lawful decision-making
- work with other services where responsibility is shared
- review plans when needs change
- record decisions clearly
- escalate when needs move outside service scope
7. Responsibilities
The provider is responsible for making sure the service model, staffing, premises, equipment and governance arrangements can meet the needs of the people the service accepts.
The Registered Manager is responsible for ensuring assessment, planning, review and escalation systems are in place and used.
Clinical leads or senior staff are responsible for reviewing complex, high-risk or borderline cases.
All staff are responsible for acting within role, identifying changes in needs, recording concerns and escalating where the person's needs may not be safely met.
8. Initial assessment
Before care or treatment starts, the service must assess the person's needs and preferences proportionately to the service type and risk.
The assessment should consider:
- reason for referral or attendance
- presenting needs
- health, care, emotional, social, cultural, religious and communication needs
- protected characteristics and reasonable adjustments
- capacity and consent
- known risks
- safeguarding concerns
- medicines or allergies where relevant
- mobility, access or transport needs where relevant
- infection prevention considerations where relevant
- nutrition and hydration where relevant
- previous care or treatment information where relevant
- whether the service is within scope to meet the need safely
The person, and where appropriate a lawful representative, family member, advocate or other professional, should be involved as far as appropriate and lawful.
9. Referral and acceptance decision
The service must decide whether it can meet the person's needs safely before accepting the referral, admission, appointment, treatment or ongoing care arrangement.
The decision must consider:
- regulated activities the provider is registered for
- Statement of Purpose
- service-user bands or population served
- staff competence
- equipment and premises
- availability of emergency support
- clinical governance arrangements
- safeguarding risks
- whether specialist input is required
- whether the person's expectations can be met
- whether the service can provide safe continuity
If the service cannot meet the need safely, the person must be told clearly and signposted or referred appropriately where possible.
10. Care or treatment plan
Where ongoing care or treatment is provided, the service must create a care or treatment plan proportionate to the service.
The plan must record:
- assessed needs
- preferences
- agreed goals or outcomes
- risks and controls
- consent position
- capacity or best-interests decisions where relevant
- reasonable adjustments
- communication needs
- medicines or treatment arrangements where relevant
- escalation routes
- review date
- people or services involved
- what the service does not provide
The plan must be available to staff who need it.
11. Information, options and informed choice
The service must give the person enough information to make informed decisions.
Information should cover:
- what care or treatment is proposed
- options available
- expected benefits
- material risks
- alternatives
- consequences of refusing or delaying
- costs and charges where relevant
- limits of the service
- who to contact with questions
- how to complain or raise concerns
Information must be given in a way the person can understand.
12. Reasonable adjustments and accessible communication
The service must identify and make reasonable adjustments where required.
Adjustments may include:
- longer appointments
- accessible formats
- interpreter
- communication aids
- easy-read information
- quiet waiting area
- support person or advocate
- accessible premises or alternative route
- sensory adjustments
- appointment timing
- gender or cultural preference where reasonably practicable
- support with forms or digital access
Where an adjustment cannot be made, the reason must be recorded and alternatives considered.
13. Consent and capacity
Care and treatment must not be provided without valid consent or another lawful basis.
Where there is reason to doubt capacity for a decision, staff must follow the Mental Capacity Act 2005.
The record must show:
- the decision
- information given
- support offered
- capacity assessment outcome where required
- best-interests decision where required
- who was consulted
- least restrictive option considered
- consent, refusal or withdrawal
The service must not treat a diagnosis, disability, age, communication need or unwise decision as proof that the person lacks capacity.
14. Risk and positive risk-taking
Person-centred care does not mean removing all risk. It means understanding risk, discussing it with the person where possible, and managing it proportionately.
The record should show:
- risk identified
- person's wishes
- benefits of the preferred option
- risks of the preferred option
- alternatives considered
- controls agreed
- review trigger
- escalation threshold
Where the person has capacity, staff must respect their right to make decisions that others may see as unwise, unless there is a legal or safeguarding reason to act differently.
15. Review of needs and preferences
Assessment and care planning must not be one-off exercises.
The plan must be reviewed:
- at agreed intervals
- when the person's needs change
- after incident, complaint or safeguarding concern
- after hospital admission or discharge
- after significant treatment change
- after deterioration
- when the person requests review
- when family, advocate or professional raises concern
- when staff believe the service may no longer meet the person's needs safely
Review must consider whether the plan still meets the person's needs and preferences.
16. When needs move outside service scope
If the person's needs move outside the service's safe scope, the service must act.
Actions may include:
- urgent senior review
- discussion with the person
- involving family, advocate or lawful representative where appropriate
- contacting GP, specialist, commissioner, local authority or emergency services where needed
- updating risk assessment
- increasing support temporarily where safe and lawful
- referral to a more suitable provider
- planned transfer or discharge
- safeguarding referral where risk is present
- CQC notification where required
The service must not continue unsafe care because stopping or transferring care feels difficult.
17. Shared care and transfer
Where responsibility is shared with or transferred to another provider, the service must work with the other provider, the person and relevant others to support safe care planning.
Records should include:
- information shared
- recipient
- date and method
- consent or lawful basis
- actions requested
- actions accepted or declined
- outstanding risks
- follow-up required
Handover must be timely and clear.
18. Records
Records must include:
- assessment
- care or treatment plan
- preferences
- risks and controls
- consent and capacity
- reasonable adjustments
- review dates
- decisions made
- people involved
- information shared
- escalation or refusal decisions
- action plan where required
Records must be accurate, complete, contemporaneous and secure.
19. Audit and governance
The Registered Manager must audit person-centred care and care planning at least annually, and more often where risk requires.
The audit should check:
- assessment quality
- involvement of the person
- consent and capacity records
- reasonable adjustments
- care-plan review dates
- risk controls
- escalation decisions
- transfer and shared-care records
- complaints and feedback themes
- action completion
Findings must be added to the action plan or risk register where required.
20. Review
This policy will be reviewed annually, or sooner following a CQC finding, serious incident, safeguarding concern, complaint theme, service-scope change, legal change or governance review.
21. Sources and further reading
This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 9 (person-centred care) (https://www.legislation.gov.uk/uksi/2014/2936/regulation/9)
- CQC guidance on Regulation 9: Person-centred care
- CQC Regulation 10: Dignity and respect
- CQC Regulation 11: Need for consent
- CQC Regulation 12: Safe care and treatment
- CQC Regulation 14: Meeting nutritional and hydration needs, where applicable
- CQC Regulation 17: Good governance
- Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9)
- Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15)
- Human Rights Act 1998, especially Article 8 where autonomy, privacy and family life are engaged (https://www.legislation.gov.uk/ukpga/1998/42)
- Accessible Information Standard, where applicable
- NICE or professional guidance relevant to the service type
22. When to seek further advice
Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement. This includes a capacity dispute, refusal of essential care, clinical scope concerns, transfer of care, or a decision to refuse, withdraw or terminate a service.
23. Document control
| Version | Date | Author | Changes |
|---|---|---|---|
| v1 | 2026-06-10 | Verivius (sample) | Conformed new cross-cutting draft to the Verivius policy standard. |
This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the tenant's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.