Assessments, care plans and reviews
| Work | Where | Permission |
|---|---|---|
| Build questionnaires | Care → Assessment templates | care.assessment.template.manage |
| Complete assessments | profile → Assessments | view care.assessment.view; complete care.assessment.manage |
| Write care plans, goals, actions and reviews | profile → Care plan | view care.careplan.view; write care.careplan.manage |
| Approve a care plan | profile → Care plan | care.careplan.approve |
| See what is due | Care → Reviews due | the view permissions above |
Build an assessment template
No templates are provided. Licensed tools (for example Braden, Waterlow or MUST) are not included. Build only questionnaires your organisation is allowed to use.
Where: Care → Assessment templates → New template.
1. Header
| Field | What to enter | Example |
|---|---|---|
| Code | Unique; cannot be changed | MOVE-RISK |
| Name | What staff will see | Moving and handling risk |
| Intended for | All, Child or Elderly | Elderly |
| Later-life summary | Not summarised, or the area this template feeds in the functional summary: Functional, Cognitive, Falls risk, Nutrition, Pressure areas or Mood | Falls risk |
| Review every (days) | Optional. Sets each assessment's next due date. | 90 |
| Description | Optional instructions | Complete on admission and every 3 months |
2. Sections and questions
Select Add section, enter a Section title, then Add question. Each question has a text, an Answer type and an optional Required tick.
| Answer type | How it scores | Example |
|---|---|---|
| Yes / No | Score for yes and Score for no | "Has the person fallen in the last 12 months?" Yes = 3, No = 0 |
| Single choice | Each Option has its own Score (use Add option) | "Mobility": Walks unaided = 0 · With a frame = 2 · Needs two carers = 4 |
| Number | Score per unit, within an optional Minimum and Maximum | "Medicines taken daily" × 1, from 0 to 20 |
| Date | Not scored | "Date of last fall" |
| Text | Not scored | "Any other concerns" |
Remove items with Remove, Remove question or Remove section.
3. Outcome bands
Bands turn the total score into a result. Add band, then enter From, To, Label and an optional Risk level (Low, Medium, High or Critical). A band applies when the total is between its From and To, inclusive. Bands must not overlap.
| From | To | Label | Risk level |
|---|---|---|---|
| 0 | 4 | Low risk | Low |
| 5 | 9 | Moderate risk | Medium |
| 10 | 40 | High risk: refer to physio | High |
4. Check, save and publish
Use Preview and score check to answer the questions as a test and see "Score 7 · Moderate risk".
| Button | What it does |
|---|---|
| Save draft | Saves; you can keep editing |
| Publish | Asks "Publish this version? It cannot be changed afterwards." Once published, staff can use it. |
| New version | Copies a published template into a new draft, for example to fix a question |
| Retire | Stops a published version being used for new assessments |
Versions: a published version is frozen. To change it, select New version, edit and publish again. The list shows every version (Code, Version, Name, For, Questions, Status). Assessments already completed keep the version they used. Only one draft per template can exist at a time ("A draft of this template already exists").
Complete an assessment
Where: profile → Assessments → Start an assessment.
- Choose the template, for example "Moving and handling risk (v2)". Only published templates are offered. If none appear, "No published templates yet": ask a template author.
- Answer the questions. Required ones are marked with
*. The running score shows as "Score so far: 7 · Moderate risk". - Select Save draft to finish later; the row then shows Continue.
- Select Complete when done.
The table then shows the Template, Date, Status, Score, Outcome, and Next due (assessment date plus the template's review interval).
| Rule | Message |
|---|---|
| A completed assessment is final | "A completed assessment cannot be changed". Start a new one if things change. |
| Only published templates | "Assessments can only use a published template" |
Example: Tom completes "Moving and handling risk" for Ruth on 10 January. Score 11 gives High risk: refer to physio, next due 10 April. On 10 April it appears under Reviews due → Assessments due.
Care plans
A care plan sets out what the person needs and how staff will help. Each person has one live plan at a time.
1. Start a draft
Profile → Care plan: enter Plan starts and Review every (days), then select Start a
draft plan. It gets a number such as CP-000009 and status Draft.
2. Add goals
| Field | What to enter | Example (Maya) |
|---|---|---|
| Area | Health, Emotional wellbeing, Education, Identity, Family and relationships, Social, Self-care, Independence, Daily living, Mobility, Nutrition or Spiritual | Family and relationships |
| Goal | What should be achieved | Maya keeps regular, safe contact with her mother |
| Target date | When | 31/08/2026 |
| In their own words | The person's own view: quote them | "I want to talk to Mum every Sunday." |
Select Add goal. Change progress later with Goal status: Proposed, Active, Achieved, Partially achieved, Not achieved or Cancelled.
3. Add actions to each goal
Enter the New action, choose who is responsible (either a member of staff or another person, not both), and a Due date, then select Add action. Mark it Done when finished.
| Action | Responsible | Due |
|---|---|---|
| Set up a Sunday 5pm phone call | Sara Ahmed (staff) | 15/03/2026 |
| Arrange a supervised visit each month | Aisha Khan (mother) | monthly |
4. Approve
A plan needs at least one goal ("A care plan needs at least one goal before approval"). A user with
care.careplan.approve selects Approve and confirms "Approve this plan? Any current plan will be
completed."
When a new plan is approved, the person's previous live plan is completed automatically. Check that you are approving the right draft.
5. Review
Open Reviews due to see plans due, or open the profile. Select Start review to move the plan to Under review, then record the review:
| Field | What to enter | Example |
|---|---|---|
| Reviewed on | Date of the review meeting; not before the plan started | 01/06/2026 |
| Outcome | Continue, Amend or Complete the plan | Continue |
| Next review | Required for Continue or Amend; must be after the review date. Not used when completing. | 01/09/2026 |
| Who took part | Participants | Maya, Aisha Khan, Sara Ahmed, social worker |
| Summary | What was agreed | Calls going well; add a second weekly call. |
Select Record review. Reviews can only be recorded on an Active or Under review plan. Complete the plan ends it; use Back to active to carry on after a review without a formal outcome.
Other endings
- Cancelled: asks "Why is this plan being cancelled?", for example "Drafted for the wrong person".
- Completed: the plan has run its course.
Completed and cancelled plans stay in the list as history.
Reviews due
Where: Care → Reviews due. One page shows three lists for the homes you can see. Overdue items are marked.
| List | Shows | Example line |
|---|---|---|
| Care plan reviews | Plans whose next review date is near or past | BEN-000014 · CP-000009 · review 2026-06-01 |
| Assessments due | Assessments whose next due date is near or past | BEN-000015 · MOVE-RISK v2 · due 2026-04-10 |
| Health due | Immunisations, appointments, follow-ups and directive reviews (health access only) | BEN-000015 · Flu vaccine · 2026-10-01 |
Select the number to open the person.