CARE ACT 2014
The Act requires the local authority to carry out an assessment, referred to as ‘needs assessment,’ where it appears an adult may have care and support needs. It also sets out what is to happen where adult or a carer refuses to have a needs or carer’s assessment. It also requires the local authority to carry out an assessment (‘carer’s assessment’) where it appears a carer may have needs for support, now or in future.
MANCHESTER SPECIFIC INFORMATION
Mental Capacity and DOLs Guidance (Manchester Council Website)
Mental Capacity and DOLs Guidance (Adult Social Care Intranet)
- 1. Introduction
- 2. Aim of Assessment
- 3. Purpose of Assessment
- 4. Needs Assessment
- 5. Assessment for People who are Deafblind
- 6. Carer’s Assessment
- 7. Refusing Assessment
- 8. First Contact
- 9. Supporting Involvement in Assessment
- 10. Independent Advocacy
- 11. Appropriate and Proportionate Assessment
- 12. Supported Self-Assessment
- 13. Safeguarding
- 14. Fluctuating Needs
- 15. Preventing Needs
- 16. Strengths and Capabilities
- 17. Whole Family Approach
- 18. Combined Assessments
- 19. Integrated Assessments
- 20. NHS Continuing Healthcare
- 21. Roles and Responsibilities
- 22. Training
- 23. Record Keeping
- 24. Delegating Assessments
- 25. Children and Young Carers
Assessment is one of the most important elements in the care and support system. It should consider the most relevant aspects of wellbeing to the adult being assessed, how their needs impact on those aspects of wellbeing and how care and support – or other services or resources in the local community – can help the adult to achieve the outcomes they seek. The process should be person centred and involves supporting them to have as much choice and control as possible. It is not only the gateway to care and support but a significant intervention in its own right that can help people to understand their situation and the needs they have, to reduce or delay the onset of greater needs and to access support when they require it.
The assessment process starts from when the local authority begins to collect information about the person, and will be an integral part of the person’s journey through the care and support system as their needs change. It should not just be seen as a gateway to care and support, but should be a critical intervention in its own right, which can help people to understand their situation and the needs they have, to reduce or delay the onset of greater needs, and to access support when they require it.
People may approach the local authority for an assessment, or be referred by someone else for a number of reasons. The assessment which they receive must follow the core statutory obligations, but the process should be flexible and be adapted to best fit with the person’s needs, wishes and goals. The nature of the assessment will not be the same for all people and depending on the circumstances, it could range from an initial contact or screening process which helps a person with lower needs to access support in their local community, to a more intensive, ongoing process which requires the input of a number of professionals over a longer period of time.
Assessment should help the adult to understand their strengths and capabilities and the support available to them from services, networks and community resources. The process should be flexible and adapted to fit the adult’s needs, wishes and goals, ranging from an initial contact that helps someone with low level needs to access support in their local community, to an ongoing process that requires the input of a number of professionals.
1.1 Assessment formats
An assessment should be appropriate and proportionate. It can come in different formats and can be carried out in various ways, including, but not limited to:
- face to face assessment between the adult and an assessor, whose professional role and qualifications may vary depending on the circumstances, but who must always be appropriately trained and have the right skills and knowledge;
- supported self-assessment uses the same assessment materials as a face to face assessment, but where the adult completes the assessment themselves and the local authority assures itself that it is an accurate reflection of the adult’s needs, for example by consulting with other relevant professionals and people who know the adult, with their consent;
- online or telephone assessment may be used when an adult’s needs are not complex or where an adult is already known to the local authority and an assessment is following a change in their needs or circumstances;
- joint assessment where relevant agencies work together to avoid the adult undergoing multiple assessments;.
- combined assessment where an adult’s assessment is combined with a carer’s assessment and / or an assessment relating to a child so that interrelated needs are properly considered.
Where there is concern about an adult’s capacity to make a decision, for example, as a result of a mental impairment, such as dementia, acquired brain injury, learning disabilities or mental health needs, a face to face assessment should be arranged. The assessment should be carried out in a way that enables the needs of those who may not be able to put them into words to be recognised. See also Mental Capacity and Deprivation of Liberty Safeguards.
An assessment should be undertaken over an appropriate and reasonable timescale, taking into account the urgency of the adult’s needs and any fluctuation in those needs. They should be given an indicative timescale for their assessment and should be kept informed throughout the assessment process.
2. Aim of Assessment
The aim of the assessment is to identify what needs the adult may have and what outcomes they want to achieve to maintain or improve their wellbeing.
It should provide a full picture of the adult’s needs so that the local authority can provide an appropriate response at the right time to meet the level of their needs. This might range from offering guidance and information to arranging for services to meet those needs. As the assessment may be the only contact the local authority has with the adult at that point in time, it is critical that the most is made of this opportunity.
Assessment should provide a framework to identify any level of need for care and support so that consideration can be given to how to provide a proportionate response at the right time, based on the individual’s needs. Prevention and early intervention are central and even if the adult has needs that are not eligible at that point in time, information and advice or other preventive services may be provided. (See also Preventing, Reducing or Delaying Needs and Eligibility). The adult’s own strengths should be considered, together with any support that might be available in the community to meet their needs.
Assessment should be characterised by ongoing engagement with the adult so that if they have eligible needs they are involved in the arrangements put in place to deliver the outcomes they want to achieve.
3. Purpose of Assessment
The purpose of an assessment is to:
- identify the adult’s needs and how these impact on their wellbeing and the outcomes they wish to achieve in their day to day life;
- support decision making about needs that are eligible for care and support from the local authority;
- understand how the provision of care and support may assist the adult in achieving their desired outcomes;
- establish the total extent of needs before the local authority considers the adult’s eligibility for care and support and what types of care and support can help to meet those needs. This includes looking at the impact of the adult’s needs on their wellbeing and whether meeting their needs will help them achieve their desired outcomes;
- provide the opportunity to take a holistic view of the adult’s needs in the context of their wider support network so that consideration can be given to how the adult, their support network and the wider community can contribute towards meeting the outcomes the adult wants to achieve.
An assessment should be adult centred, involving not only the adult but also any carer that they have, and any other person / professional they might want to be involved. For example, they could ask for their GP or a district nurse to be contacted to provide information relevant to their needs.
The adult may be unable to request an assessment or may struggle to express their needs. In these situations supported decision making takes place, with the adult being assisted to be as involved as possible in the assessment, and a capacity assessment carried out. The requirements of the Mental Capacity Act (2005) and access to an Independent Mental Capacity Advocate apply for all those who lack capacity (see also Mental Capacity and Deprivation of Liberty Safeguards).
3.2 Eligibility determinations
The decision about whether the adult’s needs are eligible needs can only be made on the basis of an assessment and cannot be made without having first carried out an assessment, unless urgent needs have to be met.
Eligibility determinations must be made on the basis of an assessment, and cannot be made without having first carried out an assessment. Once an eligibility determination has been made, and the local authority has determined whether it will meet the person’s needs (whether eligible or not), it must then carry out a financial assessment if it wishes to charge the adult and confirm that the adult if ordinarily resident in the authority. The eligibility determination cannot take place until an assessment has been completed, except in cases where the local authority is meeting urgent needs. The financial assessment may in practice run parallel to the needs assessment, but it must never influence an assessment of needs. Local authorities must inform individuals that a financial assessment will determine whether or not they pay towards their care and support, but this must have no bearing on the assessment process itself.
Throughout the Process Flowchart:
Please note: if you are viewing this on a small screen you can click the image below to open a full size version. This diagram is taken from the Care and Support Statutory Guidance (2016; paragraph 6.12)
It should be noted that during the first contact assessment, needs can be met through either a community alarm or simple equipment. This is a well evidenced approach in Manchester.
4. Needs Assessment
An assessment is undertaken for any adult who appears to need care and support, regardless of whether or not they are thought to have eligible needs (see also Eligibility) or of their financial situation.
Wherever an adult expresses a need, or any challenges and difficulties they face because of their condition/s, the assessment should ensure that the impact on their day to day life has been established. The assessment must also consider whether the adult’s needs impact upon their wellbeing beyond the ways identified by them. For example where someone expresses a need arising from their physical condition and mobility, the impact of this on the adult’s desired outcomes is established, as well as considering whether their need/s have further consequences for their wider wellbeing such as the impact they have on their health or the suitability of their living accommodation.
4.1 Support provided by carers
During an assessment, all of the adult’s care and support needs should be considered, regardless of any support being provided by a carer.
Where the adult has a carer, information on the care that they provide should be recorded in the assessment. This should not influence the decision about whether the adult has eligible needs.
After the decision about eligibility has been made, if the needs are going to be met the care provided by a carer can be taken into account during the care and support planning stage (see Care and Support Planning).
Needs that are being met by a carer who is willing and able to do so do not have to be met by the local authority, but when that is the case it should be recorded. This ensures the adult’s entire needs are identified and if the carer feels unable or unwilling to carry out some or all of the caring they were previously providing, an appropriate response can be made by the local authority.
5. Assessment for People who are Deafblind
The local authority must always ensure that an expert is involved in the assessment of adults who are deafblind, including where a deafblind person is carrying out a supported self-assessment jointly with the authority. People are regarded as deafblind ‘if their combined sight and hearing impairment causes difficulties with communication, access to information and mobility. This includes people with a progressive sight and hearing loss’ (Think Dual Sensory, Department of Health 1995).
During an assessment if there is the appearance of both sensory impairments, even if when taken separately each sensory impairment appears relatively mild, the assessor must consider whether the person is deafblind as defined above. If a person is deafblind, this must trigger a specialist assessment. This specialist assessment must be carried out by an assessor or team that has training of at least QCF or OCN level 3, or above where the person has higher or more complex needs.
Training and expertise should in particular include: communication, one to one human contact, social interaction and emotional wellbeing, support with mobility, assistive technology and rehabilitation. The type and degree of specialism required should be judged on a case by case basis, according to the extent of the person’s condition and their communication needs. Local authorities should also recognise that deafblindness is a dual sensory condition which requires a knowledge and understanding of the two respective conditions in unison, which cannot be replicated by taking an individual approach to both senses.
The combined loss of sight and hearing can have a significant impact upon the individual even where they are not profoundly deaf and totally blind, as it is the impact of one impairment upon the other which causes difficulties. Deafblindness can have significant impact on the adult’s independence and their ability to achieve their desired outcomes. In particular deafblindness may have impact on the adult’s:
- autonomy and ability to maintain choice and control;
- health and safety and daily routine;
- involvement in education, work, family and social life.
Local authorities should recognise that adults may not define themselves as deafblind. Instead they may describe their vision and hearing loss in terms which indicate that they have significant difficulty in their day to day lives. The assessment must therefore take the initiative to establish maximum possible communication with the adult to ensure that individuals are as fully engaged as possible and have the opportunity to express their wishes and desired outcomes. This is particularly important where the person is carrying out a supported self-assessment jointly with the local authority. The person ensuring that the self-assessment is a complete and accurate reflection of needs must have specific training and expertise that will enable maximum possible communication and an accurate and complete assessment.
Whilst the person carrying out the assessment must have suitable training and expertise, it may not be possible for them to carry out the assessment without an interpreter, for instance where the adult uses sign language. Therefore, where necessary a qualified interpreter with training appropriate for the deafblind adult’s communication should be used. It is not normally appropriate to use a family member or carer as an interpreter, though sometimes this is appropriate, for instance where the adult’s communication is idiosyncratic or personal to them and would only be understood by those close to them. This should only take place where the adult agrees or – if they lack capacity – where it is in their best interests.
The assessment should take into account both the current and future needs of the person being assessed, particularly where the adult’s deafblindness is at risk of deteriorating. In such cases the adult may benefit from learning alternative forms of communication before their condition has deteriorated to a point where their current or preferred form of communication is no longer suitable.
6. Carer’s Assessment
Where someone provides or intends to provide care for an adult and it appears that they may have any level of need for support, a carer’s assessment should be carried out, unless the person provides care under contract (for example, is employed) or as part of voluntary work when they should not be normally regarded as a carer and so the local authority would not be required to carry out an assessment.
If the person providing care, either under contract or through voluntary work, also provides care for the same adult outside those arrangements, consideration must be given to carrying out a carer’s assessment for that part of the care they are not providing under contract or on a voluntary basis.
In some cases where a person is providing care as voluntary work or under contract, the nature of the relationship with the adult cared for may be such that they are considered as a carer, in which case the local authority has the power to carry out an assessment if it judges there is a reason to do so.
To allow the local authority to make a realistic evaluation of the carer present and future needs a carers assessment should:
- establish the carer’s needs for support and whether the caring role is sustainable, taking into account the practical and emotional support a carer provides at present;
- establish a carer’s future needs for support in the longer term, including whether the carer is, and will continue to be, able and willing to provide care;
- provide support in to the carer in recognising their own needs and in considering whether the care they provide is sustainable;
- consider the outcomes that the carer wants to achieve in their daily life, their activities beyond their caring responsibilities and the impact of caring upon those activities, including the impact of caring responsibilities on a carer’s desire and ability to work and to participate in education, training or recreation or simply to have time to themselves. The impact should be considered in the immediate / short term and long term cumulative sense.
It may be appropriate for a carer’s views to be sought separately from the needs assessment of the adult they care for so that they can express their views freely.
The Children and Families Act 2014 introduced parent carer needs assessments. The local authority must assess whether a parent carer in their area has needs for support (and, if so, what those needs are) upon request by the parent carer, or where it appears to the local authority that there may be a need for support.
7. Refusing Assessment
An adult with possible care and support needs or a carer may choose to refuse to have an assessment. The person may choose not to have an assessment because they do not feel that they need care or they may not want local authority support. In such circumstances local authorities are not required to carry out an assessment.
However, where the local authority identifies that an adult lacks mental capacity and that carrying out a needs assessment would be in the adult’s best interests, the local authority is required to do so. The same applies where the local authorities identifies that an adult is experiencing, or at risk of abuse or neglect. Where the adult who is or is at risk of abuse or neglect has capacity and is still refusing an assessment, local authorities must undertake an assessment so far as possible and document this. They should continue to keep in contact with the adult and carry out an assessment if the adult changes their mind, and asks them to do so.
In instances where an individual has refused a needs or carer’s assessment but at a later time requests that an assessment is carried out, the local authority must do so.
Where an individual has previously refused an assessment and the local authority establishes that the adult or carer’s needs or circumstances have changed, the local authority must consider whether it is required to offer an assessment, unless the person continues to refuse.
8. First Contact
Getting the initial response right can save time and costs on assessment later. Some local authorities have found that putting in place a single access point for all new requests and people currently receiving care can speed up and simplify the process for people approaching the authority, and can also free up time for professional staff to focus on more complex cases.
Local authorities should not, however, remove people from the process too early. Early or targeted interventions such as universal services, a period of reablement and providing equipment or minor household adaptions can delay an adult’s needs from progressing. The first contact with the authority which triggers the requirement to assess, may lead to a pause in the assessment process to allow such interventions to take place and for any benefit to the adult to be determined. Local authorities must ensure that their staff are sufficiently trained and equipped to make the appropriate judgements needed to steer individuals seeking support towards information and advice, preventative services or a more detailed care and support assessment, or all of these. They must also be able to identify a person who may lack mental capacity and act accordingly.
The assessment process should start from when information begins to be collected about the adult. As soon as possible after this first contact full information about the assessment process should be given, including detail of what to expect during the assessment process (such as the format and timescale of assessment, complaints processes (see Complaints) and possible access to independent advocacy (see Independent Advocacy). This allows the adult to be as involved in the process as possible. Information must be in an accessible format for those with social requirements, for example Braille is available for people with partial sightedness or who are blind (see also Interpreting, Signing and Communication Needs).
From this stage onwards, consideration should be given to whether the individual is likely to have substantial difficulty in being involved in the assessment process and, if so, the possibility independent advocacy should be introduced. Also considered is whether the adult may have difficulty communicating (for example those with Autistic Spectrum Disorder or Profound and Multiple Learning Disabilities), and whether a specialist or interpreter may be needed to support communication. (For information on reasonable adjustments see Equalities Act 2010.)
There should be a single access point for all new requests for assessment and for people who are already receiving care and support, to ensure the process of approaching the local authority is as straightforward as possible.
The outcome of first contact may be:
- early or targeted interventions such as universal services;
- a period of reablement provision of equipment or minor household adaptions to delay an adult’s needs from progressing;
- directing people towards information and advice (see Information and Advice);
- preventive services (see also Preventing, Reducing or Delaying Needs);
- a more detailed care and support assessment (see Care and Support Planning);
- identifying those who lack mental capacity;
- or a combination of these.
Staff who are involved in this first contact must have the appropriate training and should have the benefit of access to professional support from social workers, occupational therapists and other relevant experts as appropriate, to support the identification of any underlying conditions or to ensure that complex needs are identified early and that people are signposted appropriately.
8.1 Urgent needs
In these circumstances the local authority should provide an immediate response to meet the adult’s care and support needs. For example, where someone’s condition deteriorates rapidly or they have an accident, they will need a swift response to ensure their needs are met by the local authority or by NHS Continuing Health Care Fast Track Pathway Tool (Department of Health, 2012).
Following this initial response, the adult is informed that a more detailed needs assessment will follow.
Once urgent needs have been met, the adult’s ordinary residence and finances can be considered.
9. Supporting Involvement in Assessment
Putting the person at the heart of the assessment process is crucial to understanding the person’s needs, outcomes and wellbeing, and delivering better care and support. The local authority must involve the person being assessed in the process as they are best placed to judge their own wellbeing. In the case of an adult with care and support needs, the local authority must also involve any carer the person has (which may be more than one carer), and in all cases the authority must also involve any other person requested. The local authority should have processes in place, and suitably trained staff, to ensure the involvement of these parties, so that their perspective and experience supports a better understanding of the needs, outcomes and wellbeing (see also Promoting Wellbeing).
If someone is unable to engage effectively in the assessment process independently, somebody else should be sought who can assist them in engaging with the process and help them to articulate their needs and preferred outcomes as early as possible. This may include some people with mental impairments who nevertheless have capacity to engage in the assessment. They may require assistance in the form of an assessment tailored to their circumstances, their needs and their ability to engage. They should be supported in understanding the assessment process and assisted to make decisions wherever possible.
Where there is concern about an adult’s capacity to make a specific decision, for example as a result of a mental impairment such as dementia, acquired brain injury or learning disabilities, an assessment of capacity is carried out under the Mental Capacity Act 2005 (see also Mental Capacity and Deprivation of Liberty Safeguards). Those who may lack capacity are given extra support to identify and communicate their needs and make decisions and may need an Independent Mental Capacity Advocate. The more serious the needs, the more support people may need to identify their impact and the consequences. Professionally qualified staff such as social workers, can advise and support assessors when they are carrying out an assessment with a person who may lack capacity.
10. Independent Advocacy
At the point of first contact, request or referral (including self-referral), the ability of the adult to be involved in their assessment should be ascertained and consideration given to whether they would experience substantial difficulty in any of these four areas:
- understanding the information provided;
- retaining the information;
- using or weighing up the information as part of the process of being involved;
- communicating their views, wishes or feelings.
When the adult has substantial difficulty in any of these areas, they need assistance. Someone appropriate and independent should support and represent the adult for the purpose of facilitating their involvement. This should be done as early as possible in the assessment process so the adult’s involvement can be supported throughout all stages of the process.
Where there is a family member or friend who is willing and able to facilitate the adult’s involvement effectively and who is acceptable to the adult and considered to be appropriate, they may be asked to support the adult in the assessment process.
Where there is no one thought appropriate for this role – either because there is no family member or friend willing and available or if the adult does not want them to be a part of the assessment – an independent advocate must be appointed.
11. Appropriate and Proportionate Assessment
Local authorities must ensure that any adult with an appearance of care and support needs, and any carer with an appearance of need for support, receives a proportionate assessment which identifies their level of needs. Where appropriate, an assessment may be carried out over the phone or online. In adopting such approaches, local authorities should consider whether the proposed means of carrying out the assessment poses any challenges or risks for certain groups, particularly when assuring itself that it has fulfilled its duties around safeguarding, independent advocacy and assessing mental capacity. Where there is concern about a person’s capacity to make a decision, for example as a result of a mental impairment such as those with dementia, acquired brain injury, learning disabilities or mental health needs, a face to face assessment should be arranged. Local authorities have a duty of care to carry out an assessment in a way that enables them to recognise the needs of those who may not be able to put these into words. Local authorities must ensure that assessors have the skills, knowledge and competence to carry out the assessment in question, and this applies to all assessments regardless of the format they take.
An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Local authorities should inform the individual of an indicative timescale over which their assessment will be conducted and keep the person informed throughout the assessment process.
The local authority may decide to use an assessment tool to help collect information about the adult or carer and details of their wishes and feeling and their desired outcomes and needs. Where a local authority has decided that a person does not need a more detailed assessment, it should consider which elements of the assessment tool it should use and which are not necessary. When carrying out a proportionate assessment the assessor should continue to look for the appearance of further needs which may be the result of an underlying condition. Where the assessor believes that the person’s presenting needs may be as a result of or a part of wider needs then the local authority should undertake a more detailed assessment and refer the person to other services such as housing or the NHS if necessary. For example, the Brain Injury Rehabilitation Trust has produced the Brain Injury Needs Indicator, which is a tool that can be used as part of the assessment to help identify deficits of people with a suspected or diagnosed acquired brain injury.
The assessment should be adult centred throughout. The extent to which the adult being assessed wishes to be involved in the assessment should be ascertained and their wishes are met as far as it is practicable do so, as they are best placed to understand the impact of their condition(s) on their outcomes and wellbeing.
Assessment should be a collaborative, transparent and understandable process that enables an adult to:
- develop an understanding of the assessment process;
- develop an understanding of the implications of the assessment process for their condition/s and situation;
- understand their own needs, the outcomes they want to achieve and the impact of their needs on their wellbeing so that they engage effectively with the assessment process;
- begin to identify the options that are available to them to achieve those outcomes and to support their independence and wellbeing;
- understand the basis on which decisions are reached.
To help someone to prepare for an assessment, the list of areas to be covered in the assessment should be provided in advance in an accessible format so that they can think about what their needs are and the outcomes they want to achieve. Any difficulty in communicating, whether as a result of a disability or because English is not the adult’s first language, should be addressed and a specialist worker or interpreter used where needed (see Interpreting, Signing and Communication Needs).
Consideration should be given to the impact of the assessment process itself on the adult’s condition/s. They may feel uncertain and worried about what an assessment involves and may find the process itself strenuous. The preferences of the adult with regard to the timing, location and medium of the assessment should be taken into account.
The assessment should be designed to reflect the wishes of the adult being assessed, taking into account their presenting needs and their circumstances. An assessment process that suits one adult may not be as effective for another. In order to maintain an adult centred approach, assessments should be flexible and adapted to each individual adult.
In carrying out a proportionate assessment, account should be taken of:
- The adult’s wishes and preferences and desired outcomes. For example, an individual who pays for their own care may wish to receive support from the local authority with accessing a particular service, but may not want the same interaction with the authority as someone who wants greater support;
- The severity and overall extent of the adult’s needs. For example, an individual with more complex needs requires a more detailed assessment, potentially involving a number of professionals. An adult with lower needs may require a less intensive approach;
- The potential fluctuation of an adult’s needs. For example, where an adult’s needs fluctuate over time, the assessment carried out at a particular moment may take into account the adult’s history to get a complete picture of the adult’s needs.
When an adult does not need a more detailed assessment consideration should be given to which elements of the assessment should be used and which are not necessary. When carrying out a proportionate assessment the assessor should continue to look for the appearance of further needs which may be the result of an underlying condition. Where the assessor believes the adult’s presenting needs may be as a result of or a part of wider needs, a more detailed assessment should be undertaken and the adult should be referred to other services such as housing or the NHS, if necessary.
12. Supported Self-Assessment
A supported self-assessment is an assessment carried out jointly by the adult with the local authority. It places the adult in control of the assessment process to the point where they complete their assessment form. A supported self-assessment is always offered if the adult is able, willing and has capacity to undertake it.
Whilst the adult fills in the assessment form, the duty to assess the adult’s needs – and in doing so ensure that they are accurate and complete – remains with the local authority.
If an adult or carer is willing, and has the mental capacity to undertake it, a supported self-assessment can be offered.
If the adult does not wish to self-assess, the local authority undertakes the assessment.
In order to support the adult in carrying out a supported self-assessment, any relevant information the local authority has – either about the adult themselves or, for a carer’s self-assessment, about the individual they care for – should be given to them, so the adult undertaking the assessment has a full picture of their care and support history and is equipped with the same information an assessor would have when undertaking an assessment.
Before sharing any information, the adult’s consent to that information being shared should be obtained. If the adult lacks capacity, information should only be shared where the local authority is satisfied that doing so is in the adult’s best interests. In the case of a young carer, consideration is given to whether it is appropriate to share the information about the adult the young carer cares for (see also Transition to Adult Care and Support).
Once the adult has completed the assessment, the local authority has to be assured that it is an accurate and complete reflection of the adult’s needs, desired outcomes and the impact of their needs on their wellbeing. The process of a supported self-assessment should begin with the first contact and is only complete when this assurance has been secured.
Until the assurance process is completed, the local authority will not have discharged its duty.
Where the adult carrying out a supported self-assessment jointly with the local authority requires a specialist, for example, someone who is deafblind, the professional leading this assurance process should be seen as the assessor and must have specific training and expertise relating to the adult’s needs.
Assuring that a self-assessment is comprehensive does not mean repeating the full assessment process again. In assuring self-assessments it may be useful to seek the views of those who are in regular contact with the adult self-assessing, such as their carer/s or other appropriate people from their support network, and any professional involved in providing care or support, such as a housing support officer, a GP, a treating clinician, a district nurse, prison staff or a rehabilitation officer. Before doing this, the adult’s consent is sought. This may be helpful in building an understanding of the individual’s desired outcomes, needs and their impact on their wellbeing.
The adult should be asked to complete the same assessment questionnaire that the local authority uses in their needs or carers’ assessments, which assesses the adult’s needs, their outcomes, and the impact of their needs on their wellbeing. When supporting and assuring an adult’s self-assessment, other considerations should be taken into account, such as those around independent advocacy, and if at any point there is a suspicion that the adult is experiencing, or is at risk of, abuse or neglect, a safeguarding enquiry is begun (see Adult Safeguarding).
12.1 Self-assessment and capacity
- Mental Capacity and DOLs Guidance (Manchester Council Website)
- Mental Capacity and DOLs Guidance (Adult Social Care Intranet)
- Mental Capacity (chapter in this APPP).
Before offering a supported self-assessment the adult’s capacity to assess and reflect on their own needs fully should be ascertained. The adult’s mental capacity is established in accordance with the Mental Capacity Act 2005). If it is considered that an adult may lack capacity to understand and carry out a self-assessment, a capacity assessment should be undertaken. If this shows that the adult lacks the capacity to carry out a self-assessment, a self-assessment should not be offered.
Where it has been established the adult has capacity to undertake a supported self-assessment but experiences substantial difficulty in understanding, retaining and using the relevant information in relation to their self-assessment, they may wish to involve their carer or any other member of their family or support network in their self-assessment.
Where the adult does not have the support they require from a carer or another member of their family or support network who is willing and able to facilitate the adult’s involvement effectively and who is acceptable to the individual and judged to be appropriate by the local authority, an independent advocate must be introduced to assist them in their self-assessment.
Where local authorities have established that the adult has capacity to undertake a self-assessment but experiences substantial difficulty in understanding, retaining and using the relevant information in relation to their self-assessment, they may wish to involve their carer or any other member of their family or support network in their self-assessment. Where the adult does not have the support required from a carer or family member who is willing and able to facilitate the person’s involvement effectively and who is acceptable to the individual and judged appropriate by the local authority, the local authority must provide an independent advocate to assist them in their self-assessment. When a person who would otherwise receive a specialist assessment (for example, someone who is deafblind) chooses to undertake a self-assessment, the local authority must involve a person who has specific training and expertise when assuring that the person’s assessment taken as a whole reflects the overall needs of the individual concerned.
The local authority should ensure self-assessments are completed in suitable time periods. If there is a delay in the adult returning the self-assessment form the authority assures itself that this is not because the adult’s condition/s has deteriorated and they are unable to complete the self-assessment.
Once the self-assessment is considered to have accurately captured the adult’s needs, the local authority should decide whether the needs identified in it are eligible needs (see Eligibility). Where appropriate, this may include taking into account the adult’s own view.
Although the local authority and the adult should work jointly to ascertain needs and eligibility in the process of a supported self-assessment, the final decision regarding eligibility rests with the local authority.
In all cases, the adult should be informed of the decision about their eligibility and why the local authority has reached that decision. The decision should set out the needs that are eligible and consideration should be given as to how these might be met.
Where the adult has needs that are not eligible, advice and information must be provided on what services are available in the community that can support the adult in meeting those needs (see also Information and Advice).
If it appears that the adult is experiencing, or at risk of, abuse or neglect it is important that the local authority acts swiftly and put in place an effective response.
A safeguarding enquiry should be undertaken and a decision made with the adult about what action, if any, is necessary and by whom.
When carrying out an assessment the local authority must consider the impact of the persons needs on their wellbeing (see also Promoting Wellbeing).
The decision to carry out a safeguarding enquiry does not depend on an adult having eligible needs but should be made whenever there is reasonable cause to think the adult is experiencing, or is at risk of, abuse or neglect. Where this is the case, whatever enquiries are necessary should be carried out in order to decide whether any further action is necessary. In some cases, safeguarding enquiries may result in the provision of care and support (see Care and Support Planning), or the provision of preventive services (see Preventing, Reducing or Delaying Needs) or information and advice (see Information and Advice). In the majority of cases the response will involve other agencies, for example, a safeguarding enquiry may result in referrals to the police, a change of accommodation, or action by the Care Quality Commission.
Where the adult has care and support needs, an assessment should continue, and a decision should be made about whether they have eligible needs and, if so, how these will be met. The assessment should run parallel to the safeguarding enquiry and the enquiry should not disrupt the assessment process or the meeting of eligible needs.
14. Fluctuating Needs
An adult’s needs may fluctuate, at the time of the assessment therefore they may not be indicative of their needs more generally. Consideration should be given as to whether someone’s current level of need is likely to fluctuate and what their ongoing needs for care and support are likely to be. This is the case both for short term fluctuations, which may be over the course of the day, and longer term changes in the level of the adult’s needs. The assessment also considers an adult’s wider care and support needs. This may include types of care and support the individual has received in the past and their general medical history, which may be indicative of their current care and support needs. Account should also be taken of what fluctuations in need can be reasonably expected based on the experience of others with a similar condition/s. The benefit of adopting this comprehensive approach to assessment is the consideration of an individual’s wider wellbeing may allow types of care and support or information and advice to be provided that delay or prevent the development of further needs in the future.
15. Preventing Needs
Assessment is a key element in prevention. During the assessment needs that could be reduced, or where escalation could be delayed, can be identified and people’s wellbeing may be improved by providing:
- specific preventive services see Preventing, Reducing or Delaying Needs;
- information and advice – see Information and Advice – on other universal services available locally;
- early intervention services which can prevent or delay the adult’s needs from progressing. This can include directing people to services such as community support groups that make people feel supported and give them the opportunity to participate in their local community. It may also include helping the adult to access services provided universally by the local authority;
- help for people to understand other types of support available to them, such as from within their own support networks or by promoting access to employment, education or training,
Such interventions at an early stage can help to sustain the independence and wellbeing of people. Where the adult may benefit from such types of support, they should be supported to access them.
In parallel with assessing a person’s needs, local authorities must consider the benefits of approaches which delay or prevent the development of needs in individuals. This applies to both people with current needs that may be reduced or met through available universal services in the community, and those without needs who may otherwise require care and support in the future. This could include directing people to services such as community support groups which ensure that people feel supported, including an ability to participate in their local community. It may also include helping the person to access services which the local authority provides as part of its universal offer on prevention. Local authorities can also support the person in understanding other types of support available to them, such as within their own support networks, for example to seek to promote access to appropriate employment, education or training, which can be an effective way of maintaining independence. Such interventions at an early stage will help to sustain the independence and wellbeing of people (see Preventing, Reducing or Delaying Needs and Information and Advice).
Where the local authority judges that the person may benefit from such types of support, it should take steps to support the person to access those services. The local authority may ‘pause’ the assessment process to allow time for the benefits of such activities to be realised, so that the final assessment of need (and determination of eligibility) is based on the remaining needs which have not been met through such interventions. For example, if the local authority believes that a person may benefit from a short term reablement service which is available locally, it may put that in place and complete the assessment following the provision of that service.
16. Strengths and Capabilities
Assessments must consider what else, other than the provision of care and support, might assist the adult in meeting the outcomes they want to achieve.
In considering what else might help, someone’s strengths and capabilities and the support available from their wider support network or within the community should be included.
Any suggestion that support could be available from family and friends should be considered in the light of their appropriateness, willingness and ability to provide any additional support and the impact on them of doing so.
It should also have the agreement of the adult in question.
Local authorities might also consider the ways a person’s cultural and spiritual networks can support them in meeting needs and building strengths, and explore this with the person. Any suggestion that support could be available from family and friends should be considered in light of their appropriateness, willingness and ability to provide any additional support and the impact on them of doing so. It must also be based on the agreement of the adult or carer in question.
See also Assessment Case Studies.
17. Whole Family Approach
Assessment should adopt a whole family approach to ensure a holistic view is taken of the adult’s needs and identify how the adult’s needs for care and support impact on family members or others in their support network. This requires the local authority to identify the impact of the person’s needs on family members or anyone who may be part of the adult’s wider network of care and support. In considering the impact of the adult’s needs on those around them, consideration must be given as to whether or not the provision of information and advice would be beneficial to those people who are identified (see Information and Advice). For example, this may include signposting to any support services in the local community.
Any children who are involved in providing care should be identified. Being aware that a child is carrying out a caring role may emerge through the assessment of the adult needing care or their carer, or from information from other family members or a child’s school. Identification of a young carer in the family must result in an offer of a needs assessment for the adult requiring care and support and, where appropriate, the young carer should be referred for a young carer’s assessment (see Identifying Young People and Young Carers who are not already receiving Children’s Services, Transition to Adult Care and Support) or a needs assessment under the Children Act 1989. Adults’ and children’s services should work together to ensure the assessment is effective, for example, by sharing expertise and linking processes. If it appears that a child is involved in providing care the following should be considered:
- the impact of the adult’s needs on the young carer’s wellbeing, welfare, education and development;
- whether any of the caring responsibilities the young carer is undertaking are inappropriate.
The assessment must also take into account the parenting responsibilities of the adult, as well as the impact of the adult’s needs for care and support on the young carer. Consideration should also be given as to how supporting the adult with needs for care and support can prevent the young carer from undertaking excessive or inappropriate care and support responsibilities. A young carer becomes vulnerable when their caring role risks impacting on their emotional or physical wellbeing or their prospects in education and life generally. This might include:
- preventing the young carer from accessing education, for example because the adult’s needs for care and support result in the young carer’s regular absence from school or impacts upon their learning;
- preventing the young carer from building relationships and friendships;
- impacting upon any other aspect of the young carer’s wellbeing.
Inappropriate caring responsibilities are anything that is likely to have an impact on the child’s health, wellbeing or education or which can be considered unsuitable in light of the child’s circumstances and may include:
- bathing and toileting an adult;
- carrying out strenuous physical tasks such as lifting;
- administering medication;
- maintaining the family budget;
- emotional support to the adult.
When deciding whether a child has inappropriate caring responsibilities, the child’s own view should be taken into account, wherever possible.
18. Combined Assessments
An assessment of an adult needing care and support or of a carer can be combined with any other assessment being carried out either for that adult or another adult, where both the individual and carer agree and the consent condition is met in relation to a child. This avoids undertaking two separate assessments when they are intrinsically linked. If either of the individuals concerned does not agree to a combined assessment, the assessments should be carried out separately.
19. Integrated Assessments
People may have needs that are met by various bodies. A holistic approach to assessment that aims to bring together all of the adult’s needs may need the input of different professionals such as adult care and support, children’s services, housing, the voluntary sector, relevant professionals in the criminal justice system, health or mental health professionals.
A needs or carer’s assessment can be carried out jointly by the local authority with another body carrying out any other assessment in relation to the adult concerned, provided that the adult agrees.
Assessment processes may be integrated or aligned in order to fit better around the needs of the adult. An integrated approach may involve working together with relevant professionals on a single assessment. It may also include putting processes in place to ensure that the adult is referred for other assessments such as an assessment for after-care needs under the Mental Health Act 1983.
A local authority may carry out a needs or carer’s assessment jointly with another body carrying out any other assessment in relation to the person concerned, provided that person agrees. In doing so, the authority may integrate or align assessment processes in order to better fit around the needs of the individual. An integrated approach may involve working together with relevant professionals on a single assessment. It may also include putting processes in place to ensure that the person is referred for other assessments such as an assessment for aftercare needs under the Mental Health Act 1983. In some settings, for example in prisons, local authorities should engage relevant professionals early to ensure assessors are prepared for carrying out an assessment in that environment.
Where more than one agency is assessing an adult, they should work closely together to prevent the adult having to undergo a number of assessments at different times, which can be distressing and confusing. Where an adult has health and care and support needs, the local authority and the NHS should work together effectively to deliver a high quality coordinated assessment. To achieve this, the local authority should shape the process around the adult, involving the adult and considering their experience when coordinating an integrated assessment.
Where a person has both health and care and support needs, local authorities and the NHS should work together effectively to deliver a high quality, coordinated assessment. To achieve this, local authorities should:
- shape the process around the person, involving the person and considering their experience when coordinating an integrated assessment;
- work with other professionals to ensure the person’s health and care services are aligned. This will require flexibility of systems where possible, for example when sharing information. It will also be strengthened by a culture of common values and objectives at frontline level; joint visits can be helpful here.
Various care and support plans can be linked together to set out a single, shared care pathway, for example when following the Care Programme Approach for people with a severe mental disorder who need multi-agency support or intensive intervention, under the direction of a named care coordinator (see chapter 34 of the revised Code of Practice Mental Health Act 1983). A multi-agency approach is particularly important where people are enrolled on the Proactive Care Programme. The care and support assessment can be undertaken jointly with any other assessment and the other assessment can be undertaken on behalf of the other body by the local authority, where this is agreed. Where an assessment involves a body from outside the local authority, the local authority should provide any resources or facilities required to carry out the assessment. Sharing resources may include the provision of facilities or information relating to the adult being assessed.
20. NHS Continuing Healthcare
Where it appears that an adult may be eligible for NHS Continuing Healthcare (NHS CHC) the local authority should notify the relevant Clinical Commissioning Group (CCG). NHS CHC is ongoing care that is arranged and funded solely by the NHS where the adult has been found to have a ‘primary health need’, as set out in The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2012 revised). CHC is provided to people aged 18 or over to meet needs that have arisen as a result of disability, accident or illness. Eligibility for NHS CHC places no limits on the settings in which the support can be offered or on the type of service delivery.
Whilst the local authority has a duty to carry out an assessment where an adult has an appearance of needs and meets their eligible needs, it cannot arrange services that are the responsibility of the NHS, for example care provided by registered nurses and services that the NHS has to provide because the individual is eligible for CHC.
The local authority may, however, provide or arrange healthcare services where they are incidental or ancillary to doing something else to meet needs for care and support and the service or facility in question is of a nature that a local authority could be expected to provide. Ultimate responsibility for arranging and monitoring the services required to meet the needs of those who qualify for NHS CHC rests with the NHS.
People may require care and support provided by their local authority and / or services arranged by CCGs. Local authorities and CCGs ensure the assessment of eligibility for care and support and CHC respectively take place in a timely and consistent manner. If, following an assessment for NHS CHC, an adult is not found to be eligible for CHC, the NHS may still have a responsibility to contribute to that adult’s health needs, either by directly commissioning services or by part funding the package of care and support. Where a package of care and support is commissioned or funded by both a local authority and a CCG, this is known as a ‘joint package’ of care. A joint package of care could include NHS funded nursing care and other NHS services that are beyond the powers of a local authority to meet. The joint package could also involve the CCG and the local authority both contributing to the cost of the care package or the CCG commissioning part of the package. Joint packages of care may be provided in a nursing or care home or in an adult’s own home and could be by way of joint personal budget.
There must be a local disputes resolution process to resolve cases where there is a dispute between the local authority and the CGC about eligibility for NHS CHC, about the apportionment of funding in joint funded care and support packages and about the operation of refunds guidance. Disputes should not delay the provision of the care and support package and the disputes protocol makes clear how funding is provided pending resolution of the dispute and arrangements for reimbursement to the agencies involved once the dispute is resolved. Where disputes relate to local authorities and CCGs in different geographical areas, the disputes resolution process of the responsible CCG should normally be used.
Local authorities and CCGs in each local area must agree a local disputes resolution process to resolve cases where there is a dispute between them about eligibility for NHS CHC, about the apportionment of funding in joint funded care and support packages, or about the operation of refunds guidance. Disputes should not delay the provision of the care package, and the protocol should make clear how funding will be provided pending resolution of the dispute. Where disputes relate to local authorities and CCGs in different geographical areas, the disputes resolution process of the responsible CCG should normally be used in order to ensure resolution in a robust and timely manner. This should include agreement on how funding will be provided during the dispute, and arrangements for reimbursement to the agencies involved once the dispute is resolved.
21. Roles and Responsibilities
Assessments can be carried out by a range of professionals including social workers, occupational therapists and rehabilitation officers. Registered social workers and occupational therapists are two of the key professions in adult care and support. Adults who need care, carers and assessors should have access to social workers and occupational therapists.
It is essential the assessment is carried out to the highest quality in identifying the adult’s needs, outcomes and how these impact on their wellbeing, considering the adult’s strengths and capabilities and what universal services might help the adult improve their wellbeing.
The local authority must ensure its staff have the skills, knowledge and competence to undertake assessments and that this is maintained. This applies whichever type of assessment is carried out, and means ensuring assessors undergo regular up to date training on an ongoing basis. The training should be appropriate to the assessment, both the format of assessment and the condition/s and circumstances of the adult being assessed. This training should be maintained throughout their career. As part of maintaining their registration, social workers and occupational therapists are required to evidence their Continuing Professional Development.
Local authorities must ensure that assessors are appropriately trained and competent whenever they carry out an assessment. This means ensuring that assessors undergo regular, up to date training on an ongoing basis. The training must be appropriate to the assessment, both the format of assessment and the condition/s and circumstances of the person being assessed. They must also have the skills and knowledge to carry out an assessment of needs that relate to a specific condition or circumstances requiring expert insight, for example when assessing an individual who has autism, learning disabilities, mental health needs or dementia. This training must be maintained throughout their career. As part of maintaining their registration, social workers and occupational therapists are required to evidence their Continuing Professional Development.
When assessing particularly complex or multiple needs, an assessor may require the support of an expert to carry out the assessment, to ensure that the adult’s needs are fully captured. Whether additional relevant expertise is required should be decided on a case by case basis, taking into account the nature of the needs of the individual and the skills of those carrying out the assessment. The local authority must ensure that the adult is involved as far as possible, for example by providing an interpreter where an adult has a particular condition affecting communication, such as autism, blindness or deafness.
Where the assessor does not have the necessary knowledge of a particular condition or circumstance, they should consult someone who has relevant expertise. This is to ensure the assessor can ask the right questions relating to the condition and interpret these appropriately in order to identify underlying needs. A person with relevant expertise can be considered as somebody who, either through training or experience, has acquired knowledge or skill of the particular condition or circumstance. Such a person may be a doctor or health professional or an expert from the voluntary sector but an expert may be found within the local authority.
There is government guidance for certain groups of adults that covers their assessment for care and support. Two specific areas are for people who are deafblind and people with autism. Think Autism (2014), the update to Fulfilling and Rewarding Lives, the Strategy for Adults with Autism in England (2010), sets out that the local authority should:
- make basic autism training available for all staff working in health and social care;
- develop or provide specialist training for those in roles that have a direct impact on access to services for adults with autism;
- include autism awareness training within general equality and diversity training programmes across public services.
The Care Act 2014 strengthens this guidance in relation to assessors having specialised training to assess an adult with autism. The Act places a legal requirement on the local authority that all assessors must have the skills, knowledge and competence to carry out the assessment in question. Where an assessor does not have experience in a particular condition, such as autism, learning disabilities, mental health needs or other conditions, they must consult someone with relevant experience. This is so that the adult being assessed is involved throughout the process and their needs, outcomes and the impact of their needs on their wellbeing are all accurately identified.
23. Record Keeping
Following an assessment, an adult should be given a record of their needs assessment or their carer’s assessment. A copy should be shared with anybody else the individual asks for a copy to be shared with. Where an independent advocate, an Independent Mental Capacity Advocate or an Independent Mental Health Advocate is involved, the advocate should be kept informed so that they can support the adult in understanding the outcome of the assessment and its implications.
24. Delegating Assessments
The local authority can delegate the majority of its care and support functions including assessment (see Delegation of Local Authority Functions). In doing so it should ensure the body carrying out an assessment complies with all the requirements and fulfils all of the relevant duties under the Act and regulations, such as providing an independent advocate. Anything done by the body carrying out an assessment is treated as if done by the local authority. In respect of duties surrounding non-delegated functions, such as safeguarding, the local authority should have appropriate processes in place to ensure it fulfils these functions, for example, agreeing with the body that the local authority is notified if a safeguarding issue arises (see Adult Safeguarding).
25. Children and Young Carers
Some of the duties and powers detailed in this chapter apply to children and young carers in transition, as well as to adults (see Transition to Adult Care and Support).