Assessment

1. Introduction

Assessment is a very important part of service provision to adults with care and support needs.

The process should be person centred and involve supporting them to have as much choice and control as possible. It is a significant intervention in its own right, in that it can help people to understand their situation and the needs they have, to reduce or delay the onset of greater needs and to access other types of support if and when they need it.

The assessment process starts from when the service starts to collect information about the adult, prior to admission. It is an integral part of their involvement with the service, especially if their needs change.

Whilst the assessment must follow the service’s agreed format, the process should be flexible and be adapted to best fit with the adult’s needs, wishes and goals.

Assessment should help the adult to understand their strengths and capabilities and the support available to them from other services, networks and community resources as well as what the service can provide.

2. Principles of Assessment

The assessment of the adult’s care and support needs should include:

• focusing on them as an individual and considering all aspects of their individual circumstances, and their immediate and longer term needs;
• undertaking the assessment with them, and / or those acting on their behalf;
• reflecting their individual needs, preferences and diversity;
• identifying risks, and stating how these will be managed and reviewed (see Positive Risk Taking and Risk Assessments);
• ensuring that risk assessments balance safety and effectiveness with the right of the adult to make their own choices, taking account of their capacity to make those choices and their right to take informed risks;
• ensuring that plans of care are implemented, flexible, regularly reviewed for their effectiveness, and kept up to date in recognition of the changing needs of the adult;
• maintains their welfare and promotes their wellbeing by taking account of all their needs, including:
  • physical;
  • mental;
  • social;
  • personal relationships;
  • emotional;
  • daytime activity;
• ensuring continuity in their care and support as a result of effective communication between all of those who provide it, including other providers;
• enablings adults to maintain, return to, or manage changes in their health or social circumstances;
• reducing the risk of deterioration in their health and encourages prevention and early detection of ill health, including relapse, wherever there are real factors that present a risk to their health and welfare;
• enabling them to make healthy living choices concerning exercise, diet and lifestyle.

Assessment should also follow the principles of Promoting Wellbeing, Preventing, Reducing or Delaying Needs, and providing Information and Advice.

3. Conducting an Assessment

An assessment for new adults should be undertaken prior to the provision of a personal care service (or within two working days in exceptional circumstances). It should be conducted by staff who are trained to do so, using appropriate methods of communication so that the adult, their carer and / or their representative are fully involved (see Section 4, Involving Adults in the Assessment). Reasonable steps must be taken by the member of staff to first acquire adequate information to inform the assessment process.

Where an adult has previously been assessed as not having the mental capacity to make certain decisions (see Mental Capacity), it does not mean that they cannot participate at all in an assessment. They may be able to express their views about certain aspects of their life, such as what activities they like to participate in, what types of food they like to eat and what clothes they like to wear. They may need assistance to participate in the assessment, however, from a family member, carer or advocate.

Where a staff member conducting the assessment has concerns that the adult does not have the mental capacity to participate and no mental capacity assessment has previously been carried out, the assessment should be terminated until a mental capacity assessment has been undertaken by the appropriate person. This should be explained to the adult, where possible, their carer and the person who referred them to the service, if that is someone else.

The service will not provide care and support interventions to anyone unless:

• their needs have been assessed by a suitably qualified or suitably trained person;
• the service has obtained a copy of the assessment;
• there has been appropriate consultation regarding the assessment with the adult or their carer / representative;
• the service has confirmed in writing to the adult that following the assessment, the decision has been made that the service is suitable for the purpose of meeting their care and support needs.

For individuals referred through care management, the service should obtain a summary of the single care management (health and social services) assessment (integrated with the Care Programme Approach (CPA) for people with mental health problems) and a copy of the local authority’s care and support plan should be obtained.

For individuals who are self-funding (that is without a care management assessment / care and support plan), an assessment should be carried out, meeting the person in their her own living environment where possible.

Throughout the assessment, the staff member should emphasise that a care worker will work with the adult to support their independence as far as possible.

Any potential restrictions on choice, freedom, services or facilities based on specialist needs and risk, which are likely to become part of an adult’s individual care and support plan where they join the service, should be discussed with them and their carer / representative during assessment (see .

Family and carers’ interests and needs are taken into account, subject to the adult’s agreement.

4. Involving Adults in the Assessment

Adults should:

• be able to visit the service prior to using it so that they can decide whether or not they wish to use it, or to allow them to become familiar with it in order to allay anxiety or fear. This is made available wherever it is practical or appropriate to do so, and there is potential for the adult to substantially benefit from the visit;
• be involved in identifying their care options and the alternatives, risks and benefits of each are explained;
• be supported to make informed decisions where they are unable to do this by themselves;
• have sufficient information to enable them, or a person acting on their behalf, to make informed choices and decisions about the service;
• know the names and job titles of the people who provide their care, and how to contact them;
• be provided with a keyworker of choice who will meet with them on a regular basis according to their keyworker agreement which will be set up with the service user;
• have adequate plans in place for when they leave the service and are fully involved in this planning, where they have capacity and the wish to do so.
• be provided with information about how to make a complaint or raise a safeguarding concern.

5. Working with Other Providers

The company will support adults, or persons acting on their behalf, to obtain appropriate health and social care support, and cooperate with other agencies and professionals involved in their care and support. The input of other such services may be identified during the assessment.

Any sharing of information about the adult required to facilitate this will be undertaken in an appropriate and confidential manner, and in line with data protection legislation and other relevant guidance. See Data Protection and Information Sharing and Confidentiality.

Adults should register with a general practitioner, dentist and any other health service they may require, which as far as possible should be of their choice.

6. Action Following Assessment

If it is agreed with the adult that the service can provide a suitable service, the appropriate member of staff / manager will confirm funding arrangements.

In the event that the service is inappropriate, the member of staff who conducted the assessment will attempt to direct them to alternative specialist provision.

When funding has been agreed the member of staff will agree with the adult and their carer / representative how and when the support is provided. A key worker who closely matches the skills and personality to meet the needs of the adult will be allocated to work with them.

It is the responsibility of the care / support worker providing services to report to their manager any significant changes in a service user’s needs and circumstances or level of risk. The manager is responsible for assessing the observed change, and considering whether any change in the service, or further assessment is required as a result of the change in the service user’s needs.

Following the adult starting to receive care and support interventions from the service, a follow up assessment will be carried out as soon as practicably possible by service staff with a care and support plan being drawn up as a result of the assessment (see Care and Support Planning).