Sample policy · Reg 9

Person-Centred Care, Assessment and Care Planning Policy

Statutory anchor: Regulation 9 (person-centred care), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 10 (dignity and respect), Regulation 11 (need for consent), Regulation 12 (safe care and treatment), Regulation 14 (meeting nutritional and hydration needs where applicable), Regulation 17 (good governance), the Mental Capacity Act 2005, Equality Act 2010 and Human Rights Act 1998. · primary source

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Verivius pack version v1, 2026-06-10

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.

Before adoption, replace [Service Name] and record the Service's local referral criteria, assessment tools, review cadence, reasonable-adjustment route, senior escalation contacts, transfer arrangements and the records staff use. The policy must match what the Service can actually provide at each location.

5. Scope

This policy applies to:

6. Principles

The service will:

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.

Training and competence

Staff receive role-appropriate induction and refresher training in person-centred assessment, accessible communication, consent, mental capacity, reasonable adjustments, risk discussion, care-plan recording and escalation. The Service observes practice or reviews records to confirm competence rather than relying only on attendance certificates. Restrictions, support needs and refresher dates are recorded in the training matrix.

8. Step-by-step assessment and care-planning procedure

  1. Receive the referral or request. Gather enough information to understand the presenting need, urgency, communication requirements and immediate risks.
  2. Involve the person in assessment. Ask what matters to them, what outcome they want, what support they need to participate and who they want involved.
  3. Decide whether the Service can meet the need. Compare needs and risks with registration, scope, staff competence, premises, equipment and continuity arrangements. Record acceptance, conditions, further information needed or refusal.
  4. Agree the care or treatment plan. Record needs, preferences, goals, options, consent, risks, reasonable adjustments, responsibilities, review triggers and what sits outside service scope.
  5. Deliver and record care. Staff use the current plan, record what happened and note any difference between the planned and actual care, including the person's response and choices.
  6. Review with the person. Revisit outcomes, preferences, consent, adjustments and risks at the planned interval and whenever a trigger occurs. Update the plan rather than adding an isolated note.
  7. Escalate change or concern. Obtain senior or external advice when needs, risk, capacity, safeguarding or clinical presentation move beyond the current plan.
  8. Transfer, discharge or close safely. Explain the decision, share required information lawfully, confirm who accepts ongoing responsibility and record outstanding risks and follow-up.

Initial assessment fields

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:

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:

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:

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:

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:

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 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:

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:

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:

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:

Handover must be timely and clear.

18. Records

Records must include:

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:

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. Related policies in this pack

22. Related guidance

23. 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.

24. 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.

25. Document control

Version Date Author Changes
v1.1 2026-07-18 Verivius (sample) Added local adoption prompts, the assessment-to-transfer procedure, competence controls and related policies.
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 provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

The distinctive risk in person-centred care is drift: the plan describes the person as they were on the day of assessment, while the person in front of staff today has changed and nobody has written the change down. Care then stays technically delivered and clinically defensible while quietly ceasing to be the care this person needs or agreed to, and the person notices long before any audit does. The second risk runs the other way, when a service holds on to someone whose needs have outgrown it because the referral is familiar, the rota is covered and stopping feels like abandonment. Both are avoidable with the same discipline: assess with the person rather than about them, update the plan instead of bolting an isolated note onto it, and record a scope decision as a decision, with a name, a date and a reason. That trail is what lets the covering clinician, the out-of-hours GP or the receiving service pick the person up safely at three in the morning without starting from nothing.

  1. The service decides it can meet the person's needs safely before accepting them, and records that decision, rather than accepting under commercial, rota or fear-of-complaint pressure. The scope-of-service judgement weighs the person's needs against registration, the Statement of Purpose, staff competence, premises and continuity, so nobody is taken on for care the service cannot actually deliver.

    Strong evidence: The referral and acceptance decision (section 9) and step 3 of the assessment procedure (section 8), recording acceptance, conditions, further information needed or refusal; reinforced by the warning against letting commercial or rota pressure override safe scope decisions (section 4).

    Weak evidence: Acceptance shows up only as a diary entry or a line saying "assessed, suitable", with nothing comparing the person's needs against the registered regulated activities, the Statement of Purpose, staff competence, premises, equipment or continuity of cover. A pull of recent referrals shows every one accepted and none refused, conditioned or held pending further information, and the borderline case is traceable only to a message saying the service could take them.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  2. Assessment is carried out with the person and captures what matters to them, not only the clinical presenting need. The collaborative assessment records the outcome the person wants, the support they need to take part, and who they want involved.

    Strong evidence: Step 2 of the assessment procedure (section 8) and the initial assessment fields, delivering the collaborative assessment required by Regulation 9(3)(a) quoted in section 1.

    Weak evidence: Assessment forms completed from the referral letter or after the person has left, with the "what matters to you" field blank, marked not applicable, or carrying the same sentence across several people's records. There is no note of the outcome the person wanted, the support they needed to take part in the conversation, or who they asked to be involved, and communication needs and reasonable adjustments are recorded as none without any sign the question was asked.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 9(3)(a), with reg 9(3)(d) and reg 9(3)(h)

  3. The care or treatment plan is reviewed on its triggers and updated, not left as a one-off document with isolated notes bolted on. Review follows an incident, a complaint, a deterioration, a discharge or the person's request, so the plan the next colleague picks up reflects the person as they are now.

    Strong evidence: Step 6 of the procedure (section 8: update the plan rather than adding an isolated note) and the review triggers (section 15).

    Weak evidence: A plan agreed at the start and unchanged months later, while the daily or consultation notes describe falls, weight loss, a new medicine or a changed presentation that never reached the plan. Reviews appear as a rolled-forward date and "no change" in the same hand each time, with no sign the person was asked, and after an incident, a complaint or a hospital discharge the learning sits in the incident or complaint file only. Regulation 9 sets no review interval, so the interval and the trigger list in section 15 are a Verivius default: state your own, then show records that match them.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  4. The service acts when a person's needs move outside its safe scope, rather than continuing unsafe care because stopping or transferring felt difficult. Escalating, transferring or referring the person to a service that can meet their needs protects them. Whether the change also requires a statutory notification to CQC is a separate question, considered and recorded in its own right.

    Strong evidence: The when-needs-move-outside-service-scope actions (section 16) and steps 7 and 8 of the procedure (section 8: escalate, then transfer, discharge or close safely with information shared lawfully).

    Weak evidence: Care carries on unchanged for weeks after staff notes have said the person's needs have outgrown what the service can safely provide, with escalation surviving only as a corridor conversation rather than a dated record naming who reviewed it, what was decided and who accepts ongoing responsibility. Transfer or discharge records list no outstanding risks and no follow-up. A safeguarding referral to the local authority and a CQC statutory notification are handled as one box rather than two separate questions, so neither carries a named decision-maker, a date and a reason, and the notification question in particular sits blank or marked not applicable with nobody attached to that judgement.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 12(1) and reg 12(2)(i); Care Quality Commission (Registration) Regulations 2009, reg 18

  5. Consent and capacity are recorded properly and unwise decisions respected, so a diagnosis, disability, age or unwise choice is never treated as proof that the person lacks capacity. Where capacity is in doubt for a decision, the Mental Capacity Act 2005 is followed.

    Strong evidence: The consent and capacity record fields (section 13: decision, information given, support offered, capacity assessment and best-interests decision where required) and the positive risk-taking record (section 14).

    Weak evidence: Consent held as a signature on a pre-printed form with no record of the information given, the options, the material risks, the alternatives or the consequences of declining. Capacity recorded at the level of the person rather than the decision, so a diagnosis, an age, a communication need or a disagreement with staff advice is used as the reason, and best-interests records name nobody consulted and no less restrictive option considered. A capacitous person's unwise refusal appears as non-compliance to be worked around rather than a decision to be respected and recorded.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Mental Capacity Act 2005 s.1(4), s.2(1)-(3) and s.4; Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11

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Last verified 20 July 2026

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Last reviewed 10 June 2026