People supported in adult social care are often invited to take part in national health promotion programmes such as cervical screening, breast screening, bowel screening, health checks, dental reviews and vaccinations. These invitations usually arrive as letters, texts or GP notifications.
In theory, this shows that people are being offered access to preventative healthcare. In practice, many of these appointments are not attended.
What matters to the CQC is not simply whether someone attended a screening.
It is how the decision was reached, how it was supported, how it was recorded and how it was reviewed.
This article explores how services can confidently evidence good practice when supporting access to health promotion even where capacity is complex, distress is likely, or attendance is not ultimately possible.
It also sets out what inspectors look for under:
Regulation 9 – Person-centred care
Regulation 11 – Need for consent
Regulation 12 – Safe care and treatment
Regulation 17 – Good governance
Equality Act duties around reasonable adjustments
Health Promotion Is Part of Safe Care, Not an Optional Extra
Health promotion is often viewed as something led by primary care. In reality, adult social care services play a critical role in whether people can access, understand and tolerate preventative healthcare.
Inspectors increasingly recognise that people in care settings face barriers such as:
anxiety or trauma linked to medical procedures
communication difficulties
sensory sensitivities
cognitive impairment
previous negative healthcare experiences
lack of support to attend appointments
CQC do not expect services to force people into appointments. They do expect services to show that access was actively supported, decisions were made properly and risks were understood.
A screening letter placed on file with no follow-up is not evidence of good care.
Capacity Must Be Decision-Specific and Time-Specific
One of the most common inspection weaknesses is the assumption that a person either “has capacity” or “lacks capacity” in general.
Capacity must relate to:
this specific screening
at this specific time
with appropriate support offered
For example:
A person may lack capacity to understand the long-term benefits of bowel screening, but still be able to express preferences about distress or dignity.
A person may initially refuse due to anxiety, but later accept with adjustments or familiar support.
Good practice includes:
explaining what the screening involves in accessible language
checking understanding in different ways
allowing time, not rushing the decision
documenting how capacity was assessed and supported
Inspectors will often ask:
“How did you support the person to understand this decision?”
Best Interest Decisions Must Show the Thinking, Not Just the Outcome
Where a person lacks capacity, a best interest decision may be required. What inspectors look for is process, not perfection.
A strong best interest record shows:
who was involved in the discussion
what information was considered
what the person’s past wishes or values were
what distress or harm was weighed
what alternatives were explored
why the final decision was reached
when it will be reviewed
A weak record simply says:
“Best interest decision made not to attend.”
That tells the inspector nothing.
A Carevia principle applies well here:
If the decision cannot be clearly explained, it is unlikely to be robust.
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When Screening Is Not Possible: How Services Still Protect Health and Safety
There will be situations where a person does not attend a screening programme and is unlikely to do so in the future. This may be due to distress, trauma, communication differences, physical limitations, or a best interest decision that attendance would cause more harm than benefit.
This in itself is not poor practice. What matters to CQC is what happens next.
The absence of screening does not remove risk. In many cases, it increases the importance of day-to-day observation, staff awareness, and timely escalation. Where a screening pathway is not available, services must be able to demonstrate how health risks are still identified, monitored and responded to in practice.
Strong services recognise that when screening is not possible, care planning, staff training and leadership oversight must adapt to compensate.
Care Planning When Screening Is Not Undertaken
Where a person does not attend screening, care plans should clearly reflect:
the reason screening is not in place
how the decision was reached, including capacity and best interest considerations
known risk factors relevant to that screening
how staff should observe, record and escalate concerns
when the decision will be reviewed
This ensures screening decisions do not become a blind spot.
Inspectors often identify risk where screening is declined or not tolerated, but no alternative monitoring is documented. Phrases such as “they wouldn’t cope” or “screening not appropriate” appear in records without clear guidance for staff on what to do instead.
Good care plans answer a different question: If we cannot rely on screening, how will we still notice deterioration early?
Training and Staff Awareness: Recognising Deterioration When Communication Is Different
Where people have communication differences, cognitive impairment or sensory needs, deterioration is often communicated indirectly.
In these situations, services cannot rely on verbal reporting alone. Staff must be trained and supported to recognise changes from the person’s usual presentation, not just obvious clinical symptoms.
This includes noticing changes such as:
increased distress or agitation
withdrawal or reduced engagement
changes in appetite, bowel habits or continence
unexplained pain behaviours
increased fatigue or sleep
changes in mobility or posture
attempts to carry out tasks the person could previously manage safely, but which now present increased risk
These signs are particularly important where a person cannot clearly describe pain, discomfort or internal symptoms.
CQC do not expect staff to diagnose conditions. They do expect staff to notice change, record it accurately and escalate appropriately.
Turning Training Into Practice, Not Just Certificates
Training alone is not enough. Inspectors regularly find that staff have completed relevant training but lack confidence in applying it when situations are subtle or unclear.
Strong services can evidence that staff:
understand how deterioration may present differently for each person
know what is normal for the individual
can explain what would concern them and why
know who to escalate to and when
feel confident raising concerns early rather than waiting
This is best demonstrated through:
supervision discussions linked to real situations
observation of practice
reflective questioning in team meetings
clear escalation pathways built into care plans and handovers
Inspectors often ask staff:
“What would you look out for if this person became unwell?”
If staff cannot answer confidently, the system is not doing its job.
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Daily health notes become especially important where screening is not in place.
Good practice includes:
factual, descriptive recording rather than vague reassurance
linking repeated low-level changes together
recognising patterns over time
reviewing health notes as part of governance and oversight
escalating when concerns persist rather than waiting for a crisis
For example:
“Appeared unsettled again”
does not provide the same assurance as:
“Third consecutive day of reduced appetite, pacing and reluctance to sit. Discussed with senior. GP contact planned.”
Inspectors often identify risk where changes are recorded but not connected, reviewed or acted upon.
What Inspectors Look For in These Situations
When screening is not undertaken, inspectors typically look for:
evidence that risk has been actively considered, not quietly accepted
care plans that guide staff on what to monitor and why
staff who understand how deterioration may present
training that supports applied understanding, not just attendance
timely escalation and review when concerns arise
leadership oversight of health monitoring
The key inspection question becomes: How does the service ensure health risks are still identified early when screening is not in place?
Services that can answer this clearly demonstrate safe, thoughtful and responsive care.
Reasonable Adjustments Are a Legal Duty, Not a Courtesy
Under the Equality Act, people must not be disadvantaged in accessing healthcare due to disability or long-term conditions.
For adult social care providers, this means evidencing that reasonable adjustments were considered and attempted, such as:
longer appointment slots
quiet clinic times
familiar staff support
pre-visit discussions or photos
desensitisation visits
alternative settings
liaison nurses or learning disability teams
clear, honest explanation of what will happen
Inspectors frequently probe:
“What adjustments were explored before deciding this wasn’t possible?”
Saying “they wouldn’t cope” without evidence is rarely sufficient.
The Learning Disability Register and Annual Health Checks
Where people are eligible, being on the Learning Disability Register is a key enabler of safer, more accessible healthcare.
Strong services:
check registration status on admission
support GP registration where needed
actively promote access to the annual health check
follow up outcomes and actions from the check
record how health needs are monitored across the year
Inspectors may ask:
who ensures people are on the register
how annual health checks are supported
what changed as a result of the check
This is also an important governance link between health promotion, deterioration monitoring and preventative care.
Dental Care: Often Missed, Often Risky
Dental appointments are frequently overlooked in adult social care, yet oral health has a significant impact on:
nutrition
pain
infection risk
dignity and confidence
communication
Common issues inspectors identify include:
no clear record of last dental review
repeated non-attendance with no review
pain or behavioural distress linked to dental issues
no reasonable adjustments explored
Good practice includes:
clear dental history on admission
support with registration
consideration of sedation or specialist services where appropriate
factual recording of symptoms
escalation when dental pain is suspected
Dental care is health promotion, not an optional extra.
Hospital Passports and Continuity of Care
Hospital passports play a crucial role in enabling safe and dignified healthcare access.
Inspectors expect:
passports to be current, not historic
staff to know where they are stored
passports to reflect communication needs, distress triggers and adjustments
evidence that passports are used, not just completed
Where people attend hospital or outpatient appointments, passports should:
support understanding
reduce repetition
improve reasonable adjustments
reduce risk of distress or misunderstanding
A passport that sits unused does not protect anyone.
Factual Health Notes Must Lead to Action
Recording health information is not enough.
Inspectors often find:
factual notes describing missed appointments
no follow-up recorded
no review of decision-making
no escalation or alternative explored
Strong services use health notes to trigger:
review
escalation
MDT discussion
re-offering support
updating care plans
For example:
“Screening letter received. Person appeared anxious. Discussed with GP who is making a referral to the learning disability team to support assessing decision specific capacity and accessible information.”
That shows awareness, not avoidance.
This links directly to good daily notes, governance and learning culture.
What Inspectors Look For in Practice
Inspectors do not expect perfection. They expect thinking, curiosity and evidence.
They often look for:
clear decision-making records
evidence of reasonable adjustments
consistency between notes, plans and staff explanation
involvement of GPs and MDTs
review over time, not one-off decisions
staff confidence when explaining why something did or did not happen
The key question is rarely:
“Did they attend?”
It is:
“How did you support access and manage risk?”
A Carevia Leadership Reflection
Ask yourself:
How do we know people are not missing out on preventative healthcare?
How do we evidence capacity and best interest decisions clearly?
When a screening is declined or not tolerated, what happens next?
How do we review decisions over time?
Could staff confidently explain this decision to an inspector?
If the answer feels unclear, that is where learning should begin.
Final Thoughts
Supporting access to health promotion in adult social care is rarely straightforward. It sits at the intersection of consent, dignity, equality, safety and governance.
Strong services do not measure success by attendance alone. They measure it by how well decisions are supported, recorded, reviewed and explained.
When done well, this protects people, supports staff confidence and demonstrates high-quality, person-centred care.
When done poorly, people quietly miss out on preventative healthcare and services struggle to explain why.
Health Promotion FAQs (Capacity, Best Interests, Reasonable Adjustments)
Practical answers to common questions managers and teams ask when supporting access to screening, annual health checks, dental care and hospital appointments.
Do CQC expect everyone to attend screening appointments?
No. CQC do not expect forced attendance. They expect evidence that access was actively supported, decisions were made properly, risks were understood, and the decision was recorded and reviewed.
Show the steps taken to support understanding and choice.
Evidence any reasonable adjustments explored.
If the person did not attend, show what monitoring and follow up happens next.
If your records or evidence shows “letter filed” with no follow up, that rarely reads as person centred or safe.
Which regulations does this link to and what does that mean in practice?
Health promotion and screening decisions commonly link to Regulation 9 (person centred care), Regulation 11 (consent), Regulation 12 (safe care and treatment) and Regulation 17 (good governance).
Reg 9: care is designed around the person’s needs, preferences, history and communication.
Reg 11: consent is sought properly, and capacity is supported and assessed decision by decision.
Reg 12: risks are identified and managed, including deterioration when screening is not possible.
Reg 17: decisions, follow up and learning are tracked and reviewed, not left to drift.
How do we evidence a good capacity assessment for screening decisions?
Capacity must be decision specific and time specific. Evidence is strongest when it shows how you supported the person to understand the choice, not just the conclusion.
What information you used and how you made it accessible.
How you checked understanding, including more than one attempt where appropriate.
How you reduced distress and allowed time, rather than rushing.
What the person could explain back, or how they communicated preference.
Whether advocacy or family input was needed and how it was used.
A practical test is: could a staff member confidently explain the assessment to an inspector without guessing.
What should a best interest decision record include?
A best interest record should show the thinking, not just the outcome. It should read as a careful decision made with the person at the centre.
Who was involved and why, including the person as far as possible.
What benefits and risks were weighed, including distress and dignity.
The person’s past wishes, values, beliefs and known preferences.
What reasonable adjustments and alternatives were explored.
The decision reached, how it will be communicated, and when it will be reviewed.
What counts as reasonable adjustments for screening and appointments?
Reasonable adjustments are practical changes that reduce barriers. CQC often probe whether adjustments were considered before concluding “they would not cope”.
Longer appointment slots or a quieter clinic time.
Familiar staff support and a clear plan for travel and waiting areas.
Pre visit preparation using photos, social stories, or a short practice visit.
Clear explanation of what will happen, including dignity and privacy steps.
Learning disability liaison, community team input, or specialist services.
Record what you tried, what helped, and what did not. That evidence is often what improves inspection confidence.
If screening is not possible, how do we manage risk and spot deterioration early?
If screening is not undertaken, the risk does not disappear. Your system needs an alternative way to notice change early and escalate appropriately.
Update care plans and risk assessments to reflect what monitoring replaces screening.
Ensure staff know the person’s baseline and what “change” looks like for them.
Use factual daily health notes that connect patterns over time.
Set clear escalation routes, including who to contact and when.
How should daily health notes be written to support health promotion and follow up?
Inspectors gain confidence when notes are factual, specific, and clearly linked to action. Vague reassurance creates risk because it hides patterns.
Describe what changed, when, and what the impact was.
Record what was done, who was informed, and what is planned next.
Track whether actions happened, not just that they were planned.
Where communication differs, record observed signs rather than assumptions.
If you want a practical template approach, your daily notes guide is a good internal link: Inspection Ready Daily Notes.
How can we promote the Learning Disability Register and annual health checks?
Make it a routine, not a one off. Strong services can evidence who checks registration, how appointments are supported, and how outcomes are followed up.
Confirm GP registration and LD register status on admission and at review.
Create a simple annual health check plan: who supports, how preparation happens, and what reasonable adjustments are needed.
Track outcomes and actions from the health check in a central place.
Ensure staff know what has changed as a result, not just that it happened.
What do we need to evidence for dental care in adult social care?
Oral health is often missed, but it strongly links to pain, nutrition, infection risk, dignity and behaviour that communicates distress.
Clear record of dental registration and last review.
Plan for support to attend, including reasonable adjustments.
Factual recording of symptoms and prompt escalation when pain is suspected.
Follow up when appointments are missed, including review of barriers.
If dental distress links to behaviour, your person centred behaviour guidance is a useful internal link: Dignity in Action Through Language.
How should we use hospital passports so they actually improve safety and dignity?
A hospital passport protects people when information is needed quickly and communication is harder. Inspectors often check whether it is current, accessible, and used in real situations.
Keep it updated, including communication needs, distress triggers, consent guidance and reasonable adjustments.
Ensure staff know where it is stored and how to use it for appointments and admissions.
Record when it was used and what was learned after hospital visits.
What will inspectors probe further if screening is declined or not attended?
Inspectors usually probe the decision making and what happened next. They are checking whether risk was actively managed or quietly accepted.
How capacity was supported and assessed for that specific decision.
What reasonable adjustments were explored and recorded.
Whether the decision is reviewed and how often.
How staff monitor health risk when screening is not in place.
Whether MDT input was requested early enough.
Consistency between care plans, daily notes, and what staff say in interviews.
