Assessment and Support Planning Policy and Procedure


The Riverside Group Assessment and Support Planning Policy and Procedure
February 2021

On this page:

1. Procedural Context

A Psychologically Informed Environment (PIE) is defined as one which provides respect, value and hope through the use of processes and tools to create the best and most positive health and wellbeing outcomes for people living and working in services.

This is based on the customers own assessment of their strengths and paths to better health and wellbeing.

A person centred approach means that the customer’s thoughts and views are at the heart of what we do and customers lead on their own support plans focussing on goals, strengths and aspirations.

Through this person centred approach we engage customers in a positive way and ensure that support plans are individual and belong to that customer. This approach leads to greater success in recovery, resilience, sustained independence and improved health and wellbeing.

Our role is to enable customers to achieve their goals and aspirations through the use of high quality, effective and outcome focused tools that strive to meet the highest standards.

Therefore our approach to assessments and the provision of support is based on the following principles:

  • Customers are at the heart of everything we do.
  • Person centred and actively led by the customer in the assessment process.
  • Empowering people who use our services to make choices through setting their own objectives and supporting positive risk taking.
  • Choice and control over their support packages, offering the level of service which enables people to be in control of the services they receive to improve their health and wellbeing.
  • Outcome focused on the aspirations, goals and priorities of the customer to enable them to maximise independence and an enhanced quality of life.
  • Partnership working by proactively involving and working closely with statutory, voluntary and other agencies.

2. Scope

This Assessment and Support Planning Procedure is applicable to Riverside’s Support services where support plans and assessments with customers are carried out and reviewed on a regular basis.

Though there are specific references to using the case management system Support Plan Provider (SPP); the principles of support planning as laid out in this procedure, should be followed irrespective of the Case Management system used.

All services will have contractual arrangements with those commissioning their services. It is essential that our work with customers achieves the obligations agreed in the contract and support planning must ensure it reflects this.

3. The Support Planning and Assessment Process

What is an Assessment?

An assessment is how we gather information about a person’s current situation through discussion. We use this information to make joint decisions about what will go in a customer’s Support Plan.

Reviewing an Assessment

Assessment is a dynamic process that can never be total or complete, and should be reviewed regularly and on an ad-hoc basis responding to changes in a customer’s situation. As a minimum they should be reviewed quarterly but more frequently depending on the customer, service and/or contractual requirements.

Before the assessment

Communication with the customer is vital before the assessment as well as during it. Specifically, you need to explain the purpose of the assessment – i.e. to gather the information you need to ensure the service will work for the customer and the service is the best fit for them.

Assessments should be carried out in a way that makes the customer feel comfortable and fully understands the purpose of it. There are many factors to consider in how to conduct an assessment positively and as a minimum should include the following:

  • Agree the most appropriate time, place and duration of the assessment for the customer. Make sure the assessment is to be held in a quiet, private place free from interruptions.
  • Arrange who will be conducting the assessment with the customer, taking into account their needs (e.g. male or female support worker) and whether they have any specific needs (e.g. interpretation).
  • Explain the purpose of the assessment. If the assessment is to be used in deciding the suitability of the service to meet the customer’s needs, then this should be explained in advance. Furthermore, details of the decision making process (including the appeals process) should be explained in advance.
  • Re-iterate the purpose of the assessment – it is to gather information to help put a plan in place. It is to ascertain the goals and aspirations of the customer, and minimise any potential risks to them while accessing the service.

In the case of direct access an assessment should be completed within 48 hours of the customer moving in.

All Assessments should:

  • Start with an open mind
  • Start where the individual is
  • Empower the customer to be a partner in the process

All prospective customers must have an individual assessment completed by Riverside colleagues on SP Provider (SPP) prior to being offered support or signposted to more appropriate services.

Support Plan Provider (SPP)

SPP is a computer based software system that is used for the completion of:

  • Assessments;
  • support plans;
  • recording of customer contacts;
  • Supporting People workbooks; and
  • Customer Record and Outcomes Monitoring forms.

The system is the basis for recording all assessments and support work undertaken, therefore will be continually referred to in this procedure.

All assessments and support plans should be completed using SPP and should be completed by following the guidance contained in the training manual/online tutorial.

Assessment is broken down into a number of different areas, which include both generic needs (e.g. accommodation social networks, physical health) and more specific needs.

The assessment is an ongoing process which should give the individual time and control over their situation.

Support work is all about change, and the assessment is an opportunity to identify areas for positive change in an individual’s circumstances and situation.

Using SPP

The level of need should be assessed using SPP which rates severity of need at levels of between 0 and 10. Detailed guidance for each area is provided on SPP. Comments must be entered in the space provided. These comments will show on the printable version of the assessment.

Customer agreement must be sought and entered on the system following completion of the assessment for each individual need area.

As assessments are led by the customer, if they disagree with any findings of an assessment, this should be discussed with the customer and a solution sought. Their comments must be documented. It is expected that the majority of problems raised can be resolved by support colleagues through negotiation.

The outcomes of all assessments must be explained clearly to customers, ensuring they understand.

Other sources of information, effective liaison and partnership working with other agencies (mental health services, probation services etc.) where consent has been granted by the customer, helps to ensure that vital information is included in assessments for customers who are known to those services.

Referring agencies can often provide important information for assessment purposes and may have carried out a needs and/or risk assessment. Where colleagues feel an agency withholds risk information, management level liaison may be necessary.

Where no other information is available, the only source of information for assessment may be observation. Managers should coach colleagues in developing their skills in observation and recording observation through training and support.

Allocation of Support Workers

Support Workers should be allocated to customers within 24 hours of being assigned to a service unless there are different contractual requirements. This can be done on SPP by editing “customer details” and adding a key worker. The customer should be informed of the name of their support worker in writing.

Support Workers can be allocated on a caseload basis, or on the basis of specialist skills, or (in the case of accommodation based services) they can be linked to a particular set of room numbers.

Where possible, customers’ should be involved in choosing their Support Worker.

Initial Support Planning Meeting

Within 48 hours or in line with local procedures and/or local contracts, the first Support Plan should be completed. This meeting should consist of a review of both the needs and risks, in order to check the accuracy of the assessments carried out prior to being accepted onto the service. The circumstances of individuals in some customer groups can change very rapidly and this second assessment should pick up any relevant changes. A Support Plan (see below) should then be completed including the contact schedule detailing the dates of future support meetings.

The Support Plan

Once the customer has gone through their assessment, the identified areas directly populate the Support Plan on SPP and the Support Plan can be completed. The Support Plan is accessed through the support plan tab on the “customer details” screen. The Support Plan consists of four main areas:

  • Risk management plan – this is broken down into the three main areas. These relate to how to keep myself safe and well, how to keep others safe and well and to keep myself safe and well from others. Any identified areas are populated directly from the assessment.
  • Needs management plan – the identified needs are populated directly from the needs assessment.
  • Regular Contact Schedules
  • Additional One off Contact

4. Risk Assessment

Employers have a duty to identify factors in the workplace which may reduce the likelihood of keeping colleagues and customers safe and well.

These are referred to as Risk assessments. They should be completed in a positive way and should focus on how the customer can be supported to keep themselves and others safe and well. This should be a continuous process and part of the day-to-day running of the service.

Risk assessments are carried out using SPP and broken down into three broad areas:

1.Risk to self
2.Risk to others
3.Risk from others

When discussing these areas with a customer it is important to frame them in a positive way, for example:

1. How to keep myself safe and well
2. How to keep others safe and well (including colleagues, visitors and the wider community)
3. How to keep myself safe and well from others (including colleagues, visitors and the wider community).

These can be further broken down into a number of different areas including generic (e.g. violence and aggression, suicide and self-harm) and specialist areas that are more appropriate to individual customer groups (e.g. self-neglect, relapse, re-offending).

The level of impact should be assessed using SPP’s level of risk scales that place measures of both likelihood and seriousness at levels of between 1 and 5. These figures give a total rating that can be viewed on the system.

Under each area the relevant evidence should be recorded in the comments box along with the source of that evidence. Wherever possible, it should include details of what, how, when, why, to whom, where, and any outcomes or consequences of the incident. The factual comments made in the comments box will show on the printable assessment. The information should be assessed both for its reliability and for gaps in knowledge. It will sometimes be necessary to get an expert opinion from, for example, the local mental health team or GP.

Any factors impacting on a customer or others likelihood to stay safe and well should be recorded, including any known ‘triggers’ (events that might lead to incidents), factors that increase the likelihood and those that decrease the likelihood or ‘warning signs’ (behaviour that may indicate a potential situation were a customers’ safety and wellness may be impacted on). Comments made in both the ‘triggers’ and ‘warning signs’ fields will show on the printable assessment, although the system can be configured to not show certain fields.

Triggers and warning signs will be different for each individual but may include the following:

  • Increased Alcohol / substance misuse
  • Stress (e.g. delayed benefits payments, issuing of a warning or notice)
  • Impact of others in the project
  • Explicit intentions or threats
  • Not taking prescribed medication
  • Emotional distress, experiencing a bereavement

Customer agreement with the assessment must be sought and entered on the system following completion of the assessment for each individual risk area.

If a customer disagrees with any findings of an assessment their comments must be documented. It is expected that the majority of problems raised can be resolved by support staff through negotiation.

The Risk Management Plan

All areas raised from the assessment will automatically be included in the Risk Management Plan part of the Support Plan (see below) on SPP and must be completed. The objectives and actions entered must be relevant to the aim of ensuring the customer and others stay safe and well.

Typically, management of safety and wellbeing in relation to customers operates at two levels:

  • A range of service and organisational policies and working practices which provide an overall control framework (e.g. medication policy, lone working, dealing with violence and aggression).
  • Individual assessment and support planning arrangements that allow for the development of specific controls that are led by and tailored to the individual.

The outcomes of all assessments must be explained to customers.

Risk assessment and recording is an area of professional development and colleagues should seek to continually develop their skills in this area, supported through supervision and training.

Support Plan

Each area identified through the assessment will show if there is an active support objective for that area and the rating from the most recent assessment. Support objectives can then be added or viewed.

Each area identified on the support plan must have a corresponding active support objective.

For each area identified the following fields must be completed:

  • Objective of support
  • What action should be taken?
  • Timescales sections must be completed
  • Party to perform action

5. Objectives and action planning

Setting objectives and actions must always be led by the customer except in exceptional circumstances (e.g. a customer is in hospital and no contact is possible). All objectives set should be mutually agreed between the customer and the Support Worker.

Once an objective is agreed there should be goals and targets set and led by the customer in order to meet it. These goals could include issues that are personal to the customer or which are organisational, for example relating to the rules of a service.

All objectives and actions must be entered clearly on the system as they will appear on the printable version of the Support Plan without showing the corresponding need or risk area. For example, if it is an objective under the self-harm area then self-harm should be mentioned in the objective itself for example: to reduce self-harm.

Actions should involve appropriate risk taking activity. This does not mean that customers should be encouraged to engage in hazardous activities but rather that they should be empowered and encouraged to do things outside of their comfort zone – engaging in activities they would not usually do because they feel nervous or uncomfortable (e.g. meeting new people at a social event).

All objectives and actions must be relevant to the risk or need area.

All objectives and actions must be SMART and should be set as ongoing.

S – SPECIFIC The objective and action should specify exactly what needs to be done.

M- MEASURABLE You should be able to measure whether or not the service and the customer are meeting the objectives or not.

A- ACHIEVABLE Are the objectives set, achievable and attainable based on the skills available and constraints imposed?

R- REALISTIC Can the objectives realistically be achieved with the available resources?


Drawing up a comprehensive plan with a customer can take some time and needs to be reviewed and built upon at each support meeting. Initially it is probably desirable to concentrate on more urgent short term issues and expand the range and detail of the objectives as work progresses.

Regular/one off and unscheduled Contact Schedules

Regular, unscheduled and scheduled contacts such as weekly support sessions must be added onto SP Provider. This is done via the Milestones.

Please refer to the SP Provider manual for further guidance on completing these.

Assessment and Support Plan Reviews

All Customer assessments and support plans should be reviewed with appropriate frequency as set out by the service contract/local procedure, and following any incident which may impact on the customer.

The frequency of individual reviews should reflect the areas of support identified by the assessment process, individuals with higher levels should be reviewed more frequently.

Reviews of needs, risk assessments and support plans can be initiated by the customer at any time and this right should be clearly explained to all customers within the service description, customers’ handbook and other media as may be appropriate.

Colleagues should be proactive in identifying and reviewing changing need and risk.

All reviews should be scheduled and completed on SPP. A ‘review imminent’ warning will show on the system close to the time that the review is due. Reviews are completed through the reviews tab on the customer details screen. The following actions can be completed: Schedule a review, record an unscheduled review and forthcoming review dates can be viewed, re-scheduled, cancelled or reviews can be recorded. Review history shows details of previous reviews.

Please note that following an incident, the risk assessment for a customer must be reviewed within 72 hours. It does not need to be the named ‘keyworker’ who does this – another member of staff can conduct the review if necessary.

Recording a review

The following is entered:

  • Name of Support Worker
  • Date
  • Description
  • Milestones which are either completion of or steps towards the objectives on the support plan
  • Tick boxes for reviewed items,
  • Support plan (which can be updated through the Support Plan tab)
  • Risks and needs (which can be re assessed through the assessments tab)
  • Contact schedule (which can be updated through the Contacts tab)

Customer Support Objectives should be made ‘ongoing’ by not putting an end date in the box when they are being set. If Objectives change or there is no longer a Risk or Need identified, then Objectives can be closed down at Review stage.

The date of the next review must always be completed.

The Service Manager must ensure that all customers receive reviews at the appropriate frequency and that reviews are completed as per the review schedule on SPP.

Customer Record Forms and CLG Outcomes

(Customer Record Forms only relates to services who still complete this. Please check if this is a requirement of your service)

A number of documents, reports and returns are also completed on the Outcomes system.

Customer Record Forms (CRFs) are completed automatically when the customer’s details are entered as a new customer. All fields must therefore be correctly completed and can be checked from the customer details screen using the Validate CRF return function. This will show any missing information that needs to be added before the CRF can be sent.

The Support Worker entering the new customer must ensure that all CRF data is correct and is validated prior to the individual being offered a service.

The Service Manager must ensure that all completed CRFs are submitted on the system by the 1st of each month. All completed CRFs are batched by the system and can be viewed through Reports and Returns/Customer Record Forms. This will show all customer records due.

The system will carry out a validation check on all completed records before the export and any incorrect or missing data will have to be completed before the batch can be exported.

CRF history can also be viewed including sent batches or individual CRFs by name.

Short term outcomes returns

When removing a customer from a service the option is given to open the CLG Outcomes form when exiting the page. If this option is selected the Outcomes form will be opened on ceasing the service. Alternatively forms can be viewed and completed at a later date through Reports and Returns/CLG Outcomes, then by editing the relevant customers form, also on this screen can be viewed the current status of the form (not completed etc.) and due date.

The Service Manager must ensure that all Outcomes forms are completed by the due date.

License and Tenancy Support and Evictions

On SPP, needs and risk assessments feed directly into the Support Plan, where the customer can be supported to look at how they can avoid negative behaviours and build positive change towards stability. Within this supportive environment, issues previously identified such as anger management, self-neglect or substance abuse can be addressed with the customer.

Risk assessments may also lead to the use of License and Tenancy Support Procedure. This may be needed where a customer’s behaviour is not in line with their intended outcomes.

Eviction should always be seen as a last resort and colleagues should be able to demonstrate they have followed all other routes before this decision is made. Please see License and Tenancy Support Procedure for further guidance.

Supplementary information regarding License and Tenancy Support is added to SPP through the Notices tab on the customer details page. These may include Notices to Determine (NTDs), Notices to Quit (NTQs) and Development Plans. An information window can be selected to be displayed on the customer details screen relevant to any notices, so any colleagues viewing the customer details will be aware if the individual is currently under any notices. These should be reviewed regularly to ensure that the notice is current and appropriate.

6. Staff Training

Assessment and Support Planning Procedure and SPP must be covered in colleague induction and training programmes for all colleagues carrying out assessments and support planning. The e-learning module on the RIC should be completed by all colleagues and can be found on the RIC and all of the manuals for completing the SPP system can be found on the RIC in SP Manuals.

7. Support Worker One to One

All support colleagues should receive one to one support from their Line Manager every four to eight weeks. Whilst this may be part of general supervision meetings it is helpful to have a dedicated section for support related issues.

Time should be allocated in team meetings to discuss support work and customer views. Colleagues should share ideas on particular ways of working.

It is the responsibility of Service Managers to ensure they formally line manage the support work within their service and provide one to one support.

At every one to one the Service Manager and the Support Worker should complete the quality benchmarking tool for at least one customer. Guidance on completing these as well as the actual tool can be found on the RIC.

8. Support Worker cover

All services should ensure that provision is made for back up cover in the event of a particular support workers absence. One method of doing this is to have an arrangement where two colleagues work together to provide support and cover for the customers of each other, a ‘buddy system’. The system is useful because the partner support worker has some responsibility for ensuring that they keep up to date with their back up cases, and means that if one support worker is absent there is another familiar with the customer.

It is the responsibility of the Service Manager to check an absent Support Worker’s contact schedule and either (i) contact the customer to reschedule the planned contact or (ii) ensure that the planned contact is covered by another colleague.

In the event of a departure of a support worker a handover session should be held with the new support worker where possible. Where no colleague is yet in post the Service Manager should allocate an existing member of staff to cover the case or the Service Manager should themselves hold the case.

A customer should never be left without an allocated Support Worker or be in any doubt who their Support Worker is. The support worker allocated on SPP can be changed by editing the customer’s details.

9. Involving other services

All Riverside Care and Support services should proactively seek to involve other services, both statutory and voluntary, in the support of the customer. This may involve attendance at reviews or support sessions.

Mechanisms should be put in place to enable joint working For example: Joint Working agreements, Service Level agreements, regular liaison meetings which are recorded and case conferences.

The Support Plan, including the Risk Management plan, should complement any statutory care plan (e.g. CPA, Probation) or support plans provided by other agencies and reviews should be coordinated to complement reviews of any statutory care plan or support plan provided by other agencies.

Other contacts can be added to each individual’s entry on SPP through customer details/addresses. These contacts may be other statutory or voluntary agencies (e.g. probation) or personal (e.g. next of kin).

When entered the system will ask if the customer has given permission for Riverside to make contact with that individual regarding various activities, for example ‘Invite to Support Plan review’ this can then be printed and signed by the customer and is to be kept on file.

10. Customer Involvement

Customers are at the heart of the process and must be fully involved as partners in both the assessment process and the support planning process. Their views must be sought at all stages and agreement sought. A printed version of all completed assessments and support plans must be signed by the customer, their comments can be made in the spaces provided, and held on file. The customer must be offered a copy of each assessment and support plan.

There can be ethical and practical challenges in relation to involving customers in risk assessment. Some of these may include:

  • Under-representation of risks through fear of exclusion
  • Over representation of risk to increase likelihood of allocation
  • Difficulties getting accurate information from other services.
  • Risk of jeopardising a police investigation if the customer was aware of content

Whenever safe and possible, colleagues should carry out the risk assessment with the customer’s involvement, explaining carefully the reasons for the procedure.

Accurate recording of information is crucial. Customers have a right under the GDPR and Data Protection Act 2018 to see information recorded about them and correct any inaccurate information about them, including risk assessments.

Customers will provide valuable information for risk assessment and, generally, should be supported to talk about the information provided by others. A customer may offer their own insight, for example, on situations in where they have exhibited negative behaviour in the past and even suggest how colleagues might respond to defuse such a situation. Customers may play down previous incidents and careful probing and

follow-up is essential. Getting any concerns out in the open with the customer also helps staff with fear and concerns.

Colleagues should be careful about how they record information. .Records must always be both factual and accurate.

Customers have a right to access their support files. Their rights and how to enable this, can be found on the RIC.

Appendix 1: Procedure Flowchart

  • Complete Needs and Risk Assessment and update SP.

  • Customer is provided with a copy of their risk assessment and signs a copy for Riverside staff to securely store in file.

  • Complete Support Plan agree objectives and actions with customer involved.

    Agree with customer review dates and key work sessions.

  • Customer is provided with a copy of their support plan and signs a copy for Riverside colleagues to securely store in file.

  • Reguarly meet with customer and review the actions set, monitor proress and set new actions when required.

  • Provide CGL Return at the end of the services.