The CHC Assessment
The 12 Care Domains Explained
The CHC assessment does not simply ask whether someone is unwell. It maps their needs across 12 specific domains, each scored on a scale from No Needs to Priority. Understanding how each domain is scored — and how to evidence it — is one of the most important things a family can do before an assessment takes place.
How domain scoring works
Each domain is scored at one of the following levels, depending on the domain:
- No Needs — no relevant need identified in this domain
- Low — some needs present but manageable without significant care input
- Moderate — needs that require regular care input
- High — significant, ongoing needs requiring substantial care input
- Severe — needs that are severe in nature, complexity, or intensity
- Priority — needs so severe or unpredictable that they require immediate and ongoing professional response
Not every domain uses all six levels. Priority is only available in certain domains where it is clinically meaningful.
The scoring is intended to reflect the person's typical presentation — not their best day or their worst. Families who know the person well are often the most accurate source of evidence for this.
The 12 domains
1. Behaviour
Covers behaviours that challenge — aggression, self-harm, wandering, resistance to care, and behaviour arising from cognitive impairment. Scores reflect how frequently the behaviour occurs, its severity, and the level of skill or intervention required to manage it safely. A person with frequent, unpredictable, or dangerous behaviour scores higher.
2. Cognition
Covers cognitive impairment, including dementia, acquired brain injury, and other conditions affecting memory, orientation, and judgement. Scores reflect the degree of impairment and its impact on the person's ability to make decisions and keep themselves safe. Severe disorientation or complete loss of short-term memory typically scores High or Severe.
3. Communication
Covers the person's ability to communicate their needs, understand information, and make themselves understood. This includes speech, comprehension, and the use of communication aids. Where communication breakdown creates risk — for example, the person cannot report pain — this increases the score.
4. Psychological and Emotional Needs
Covers mental health needs, including anxiety, depression, trauma, and psychological distress related to the person's condition or circumstances. This domain considers needs that require active professional intervention, not general emotional support.
5. Mobility
Covers the person's ability to move safely — in bed, in a chair, between surfaces, and around their environment. Scores reflect the degree of assistance required, the risk of falls or injury, and the level of skill needed from those providing care. Profound immobility requiring two-person hoisting scores High or Severe.
6. Nutrition (Food and Drink)
Covers the person's ability to take food and fluid safely. This includes swallowing difficulties (dysphagia), feeding via PEG tube or nasogastric tube, and significant weight loss or nutritional risk. Tube feeding or a clinically significant swallowing disorder typically scores High or Severe.
7. Continence
Covers bladder and bowel continence. Scores reflect the degree of incontinence, the management regime required (including catheterisation, stoma care, or complex bowel management), and any associated risks such as skin breakdown.
8. Skin (Including Tissue Viability)
Covers skin integrity, including pressure ulcers, wounds, and conditions requiring specialist tissue viability input. Active pressure ulcers at Grade 3 or 4, or wounds requiring specialist nursing care, typically score Severe or Priority.
9. Breathing
Covers respiratory needs, including the use of supplemental oxygen, ventilatory support (including tracheostomy), and chronic or acute respiratory conditions requiring clinical monitoring. Dependency on mechanical ventilation typically scores Severe or Priority.
10. Drug Therapies and Medications
Covers the complexity of the medication regime and the skill required to administer it. This includes complex pain management, parenteral medication, and regimes that require registered nurse administration rather than support worker or family administration.
11. Altered States of Consciousness
Covers seizures, episodes of altered consciousness, and conditions such as epilepsy. Scores reflect frequency, severity, and the risk and skill required to manage episodes safely. Frequent, uncontrolled, or life-threatening seizures score High, Severe, or Priority.
12. Other Significant Care Needs
A catch-all domain for significant needs that do not fit elsewhere. Used where a person has needs that materially affect their care requirements but are not captured by the other 11 domains.
What families should do before an assessment
Keep a care diary for at least two weeks before assessment. Record the person's needs day by day: what help was needed, when, how frequently, and what happened when it was not available. This diary is powerful evidence.
Ask care home or domiciliary care staff to document what they observe. Their records of interventions — particularly at night, and in response to behaviour or deterioration — are often the most detailed evidence available.
Request copies of all clinical records. GP notes, hospital discharge summaries, and specialist letters all bear on domain scoring. You are entitled to these under UK GDPR.
Do not accept a domain score you believe is wrong. You have the right to see the completed DST and to submit written representations before the ICB makes its decision.