Assessment and eligibility Care Act 2014

Training Objectives To enable delegates to:  Revisit and understand the key principles of the Care Act  Highlight the key aspects arising from the Prevention and Information and Advice duties  Identify the duties and powers relating to assessment  Adopt a strengths based approach in assessment  Use the revised assessment forms for customers and carers  Understand and adopt the minimum eligibility threshold for customers and carers  Identify and record evidence in decision making 2

Legislation, regulations and guidance 3 Primary legislation – the Care Act 2014 Legal duties and powers Secondary legislation – the regulations More detail on critical requirements Statutory guidance Guidance on how to meet the legal obligations in the Act

The Law The law defines duties and powers  Duties are written as ‘musts’, ‘shall’ and ‘will’  Powers are written as ‘can’ and ‘may’ The Care Act consultation response states that You Musts relates to a legal duty either in the Act or in the regulations Where should is used, it is intended to set a clear expectation, but not to create a legal requirement 4

The Care Act 2014 replaces many previous laws … 1970… … 2000… 2010… National Assistance Act 1948 NHS and Community Care Act 1990 Carers (Recognition and Services) Act 1995 Chronically Sick and Disabled Person Act 1970 Community Care (Direct Payments) Act 1996

What is the Act trying to achieve? That care and support:  is clearer and fairer  promotes people’s wellbeing  enables people to prevent and delay the need for care and support, and carers to maintain their caring role  puts people in control of their lives so they can pursue opportunities to realise their potential  A key emphasis is on meeting needs, rather than providing services 6

What might this mean for people needing care and support?  Better access to information and advice, preventative services, and assessment of need  An entitlement to care and support  A cap on care expenditure which an individual is liable for comes into effect from April 2016  A common system across the country:  Continuity of care  Fair Access to Care Services (FACS) replaced by a national eligibility threshold 7

What does this mean for carers? The Care Act strengthens the rights and recognition of carers:  Improved access to information and the duty to provide advocacy where there is ‘substantial difficulty’ in communicating wishes, understanding, retaining and assessing information during the assessment should make it easier for carers to access support and plan for their future needs  The emphasis on prevention will mean that carers should receive support early on and before reaching crisis point 8

What does this mean for carers?  Adults and carers have the same rights to an assessment on the appearance of needs (replacing the current law for carers relating to regular and substantial care)  Children and Families Act 2014 – reinforces aspects of the Care Act  A local authority must meet eligible needs of carers and prepare a support plan – this is a new duty  A carer should be kept informed of the care and support plan of the person they care for 9

The wellbeing principle  Wellbeing broadly defined: 9 areas in particular  Practitioners are required to consider it when carrying out any care and support function, or making a decision in relation to a person  Local authorities should also have regard to other key principles when carrying out their activities, such as beginning with the assumption that the individual is best- placed to judge their well-being 10 “The general duty of a local authority, … in the case of an individual, is to promote that individual’s wellbeing”.

Wellbeing – 9 Principles  personal dignity (including treatment of the individual with respect);  physical and mental health and emotional wellbeing;  protection from abuse and neglect;  control by the individual over day to day life (including over care and support provided and the way it is provided);  participation in work, education, training or recreation;  social and economic wellbeing;  domestic, family and personal;  suitability of living accommodation;  the individual’s contribution to society. 11

Prevention Summary  Key emphasis on prevention and early intervention  Local Authorities’ responsibilities apply to all adults, not just those eligible for care and support and applies equally to carers 3 types of prevention:  Prevent: primary prevention/promoting wellbeing  Reduce: secondary prevention/early intervention  Delay: tertiary prevention 12

Prevention Summary Prevent: primary prevention/promoting wellbeing  Aimed at those who have no particular health or care and support needs  Universal services – generally available to all, give access to good quality information, support safer neighbourhoods, promote healthy and active lifestyles, reduced isolation through community activities and encourage conversations in families about future needs 13

Prevention Summary Prevent: primary prevention/promoting wellbeing Can help individuals by avoiding or reducing the need for them from developing needs for care and support Can help carers by maintaining their independence and good health and by promoting wellbeing 14

Prevention Summary Reduce: secondary prevention/early intervention  Targeted intervention aimed at individuals who have an increased risk to developing needs where the provision of services may slow down or reduce any further deterioration or prevent other needs from developing.  Early intervention can prevent a crisis from occurring 15

Prevention Summary Delay: tertiary prevention  Interventions aimed at minimising the effect of disability or deterioration in people with established or complex health conditions 16

Preventing needs  Assessment is a key element of any prevention strategy  The assessment must consider whether the person concerned would benefit from the available preventative services, facilities or resources  Where a preventative measure is taken, the pause button can be pressed on the assessment 17

Information and Advice Summary  Local authorities must establish and maintain a service for providing people in its area with information and advice relating to care and support for adults and support for carers  The LA must take an active role in providing this information and advice and ensure it is coherent, sufficient, available and accessible across the population 18

Information and Advice Summary The advice needs to cover a broad range, including  Prevention of care and support needs  Finances  Health, Housing  Employment  Support for carers  What to do in cases of abuse or neglect of an adult 19

Information and Advice Summary Local Authorities must also have regard to identifying people that contact them who may benefit from financial information and advice independent of the LA and actively facilitate those people to access it 20

Key Points It is vital that the following are considered and acted upon, as required, throughout the support planning process and beyond  Is there a safeguarding concern?  Does the person have mental capacity?  Does the person need support for involvement, including independent advocacy?  What is the impact on the whole family? Should there be a carer’s assessment?  Prevent, reduce, delay 21

Safeguarding The Care Act Guidance chapter on Safeguarding replaces the No Secrets guidance The Care Act requires that each LA must:  Make enquiries, or cause others to do so  Set up a Safeguarding Adults Board (SAB) 22

Safeguarding  Arrange, where appropriate, for an independent advocate to represent and support an adult who is the subject of a safeguarding enquiry or Safeguarding Adult Review (SAR) where the adult has ‘substantial difficulty’ in being involved in the process and where there is no other suitable person to represent and support them  Co-operate with each of its relevant partners in order to protect the adult 23

Assessment Assessment is both a key process AND a critical intervention An assessment should identify:  care and support needs  what outcomes the individual is looking to achieve to maintain or improve their wellbeing  how care and support might help in achieving those outcomes 24

Carer’s assessment A carer’s assessment must explore:  the carer’s needs for support AND  sustainability of caring role It must also consider impact on the carer’s activities beyond their caring responsibilities, including the carer’s:  desire and ability to work  ability to partake in education, training or recreational activities  opportunities to have time to themselves 25

Refusal of assessment The local authority is not required to carry out assessment where a person with possible care and support needs or a carer:  feels that they do not need care  may not want local authority support This can be overridden where they:  lack capacity to take that decision and an assessment would be in their best interests  are experiencing, or at risk of experiencing, any abuse or neglect 26

Appropriate and proportionate assessment  People should receive an assessment that is appropriate and proportionate  The process can be flexible and include e.g. telephone, on- line and combined assessments  To be appropriate, assessments should meet the person’s communication needs  Appropriate assessments can include a pause to check the value of preventative services or interventions, reablement, or aids and adaptations 27

Proportionate Assessments An approach to determining an appropriate and proportionate assessment is to consider the following questions: 1. How severe/extensive are needs? 2. Do needs fluctuate? 3. How complex are the circumstances? 4. How significant are the impacts of these needs? 28

Proportionate Assessments 5. What are the strengths of the person, any carers, and any community & family support available? 6. What are desired outcomes/preferences? 7. Does the person have capacity? 8. Does the organisation have historical information that can inform assessment? 9. Does the person have any difficulty engaging in the assessment? 29

Integrated assessments  All of the agencies involved should work closely together to prevent a person having to undergo a number of assessments at different times  To achieve this local authorities should:  ensure healthcare professionals’ views and expertise are taken into account  work with healthcare professionals to ensure people’s health and care services are aligned and set out in a single care and support plan  In cases of abuse, the local authority should lead the assessment and ensure that all agencies follow the local multi-agency procedures to ensure coordination of information and possible evidence 30

Fluctuating needs In establishing the on-going level of need local authorities:  must consider the person’s care and support history over a suitable period of time to take account of potential fluctuation of needs  may also take into account at this point what fluctuations in need can be reasonably expected based on experience of others with a similar condition 31

Supported self-assessment  The local authority must offer the individual the choice of a supported self-assessment if they are able and willing.  The person should be asked to complete the same assessment questionnaire that the authority uses in their needs or carer’s assessments  The individual must have capacity to fully assess and reflect their own needs  The local authority must assure itself that the person’s supported self-assessment is an accurate and complete reflection of their needs because there may be a difference of opinion  Regardless of the format a needs assessment takes, the final decision on eligibility is with the local authority 32

A strengths-based approach  The local authority must also consider what - other than the provision of care and support - might help the person in meeting the outcomes they want to achieve: a strengths-based approach  This strengths-based approach recognises personal, family and community resources or ‘assets’ that individuals can make use of Group Exercise 33

Whole family approach  Takes a holistic view of a person’s needs  Considers the impact of needs on family and wider networks, in particular any children providing care:  The impact of the person’s needs on the young carer’s wellbeing, welfare, education and development  Whether their caring responsibilities are appropriate  Sees the family and wider network as a source of support, where they are willing and able 34

Supporting a person’s involvement 35  Duty to arrange for independent advocate Is there an ‘appropriate individual’ – a carer, friend or relative – that can facilitate their involvement?  Agree ‘appropriate individual’  Provide support and make adjustments Yes No Might this person have difficulty in being involved? Can they be better supported to enable their involvement? [Reasonable adjustments under the Equality Act 2010] Yes Do they still have ‘substantial difficulty’ in being involved? Yes

Advocacy The 2 criteria which trigger the duty to arrange an independent advocate are therefore:  Where the person has ‘substantial difficulty’ in being involved, and  Where there is no ‘appropriate individual’ who can facilitate their involvement 36

Judging ‘substantial difficulty’ in being involved Understanding relevant information Retaining information Using or weighing up the information Communicating their views, wishes and feelings 37

Exercise Using the case study and working in groups of 4 where one person is the customer, one is the carer and two are assessors, complete the revised core assessment form, up to the eligibility section 38

National eligibility framework  After completion of the assessment process, the local authority will determine whether the individual has eligible needs  The Act introduces a national eligibility threshold:  whether the person has needs due to a physical or mental impairment or illness  whether those needs mean that they are unable to achieve two or more specified outcomes  as a consequence there is, or is likely to be, a significant impact on their wellbeing  Local authorities can also decide to meet needs that are not deemed to be eligible if they chose to do so – this is a power 39

40 Interpreting the eligibility criteria An adult meets the eligibility criteria if: Their needs are caused by physical or mental impairment or illness As a result of the adult’s needs they are unable to achieve two or more specified outcomes As a consequence there is or is likely to be a significant impact on the person’s well-being The specified outcomes are: Managing and maintaining nutrition Maintaining personal hygiene Managing toilet needs Being appropriately clothed Being able to make use of the home safely Maintaining a habitable home environment Developing and maintaining family or other personal relationships Accessing and engaging in work, training, education or volunteering M aking use of necessary facilities or services in the local community including public transport and recreational facilities or services Carrying out any caring responsibilities the adult has for a child

41 Interpreting the eligibility criteria An adult meets the eligibility criteria if: Their needs are caused by physical or mental impairment or illness As a result of the adults needs they are unable to achieve two or more specified outcomes As a consequence there is or is likely to be a significant impact on the person’s well-being An adult is to be regarded as being unable to achieve an outcomes if the adult: is unable to achieve it without assistance; is able to achieve it without assistance but: doing so causes them significant pain, distress or anxiety; doing so endangers or is likely to endanger health or safety; takes significantly longer than would normally be expected.

An adult meets the eligibility criteria: Their needs are caused by physical or mental impairment or illness As a result of the adults needs they are unable to achieve two or more specified outcomes As a consequence there is or is likely to be a significant impact on the person’s well-being An adult is to be regarded as being unable to achieve an outcome if the adult: is unable to achieve it without assistance; is able to achieve it without assistance but doing so causes the adult significant pain, distress or anxiety; is able to achieve it without assistance but doing so endangers or is likely to endanger the health or safety of the adult, or of others; or is able to achieve it without assistance but takes significantly longer than would normally be expected. The specified outcomes are: Managing and maintaining nutrition Maintaining personal hygiene Managing toilet needs Being appropriately clothed Being able to make use of the home safely Maintaining a habitable home environment Developing and maintaining family or other personal relationships Accessing and engaging in work, training, education or volunteering Making use of necessary facilities or services in the local community including public transport and recreational facilities or services Carrying out any caring responsibilities the adult has for a child 42 Customer’s Eligibility threshold

National carers eligibility framework  After completion of the assessment process, the local authority will determine whether the carer has eligible needs  Carers can be eligible for support in their own right  The Act introduces a national carers’ eligibility threshold:  whether the carer’s needs are due to providing necessary care for an adult  whether those needs puts the carer’s health at risk or means that they are unable to achieve specified outcomes; and  as a consequence there is, or is likely to be, a significant impact on their wellbeing  Local authorities can also decide to meet carers’ needs that are not deemed to be eligible if they chose to do so – this is a power 43

44 Interpreting the carers’ eligibility criteria A carer meets the eligibility criteria if: Their needs are caused by providing necessary care for an adult. As a result: their health is at risk or they are unable to achieve specified outcomes As a consequence there is or is likely to be a significant impact on the carer’s well-being The specified outcomes are: Carrying out any caring responsibilities the carer has for a child Providing care to other persons for whom the carer provides care Maintaining a habitable home environment Managing and maintaining nutrition Developing and maintaining family or other personal relationships Engaging in work, training, education or volunteering M aking use of necessary facilities or services in the local community including recreational facilities or services Engaging in recreational activities

45 Interpreting the carers’ eligibility criteria A carer meets the eligibility criteria if: Their needs are caused by providing necessary care for an adult. As a result: their health is at risk or they are unable to achieve specified outcomes As a consequence there is or is likely to be a significant impact on the carer’s well-being A carer is to be regarded as being unable to achieve an outcome if the carer: is unable to achieve it without assistance; is able to achieve it without assistance but: doing so causes them significant pain, distress or anxiety doing so endangers or is likely to endanger health or safety

A carer meets the eligibility criteria if: Their needs are caused by providing necessary care for an adult. As a result: their health is at risk or they are unable to achieve specified outcomes As a consequence there is or is likely to be a significant impact on the carer’s well-being A carer is to be regarded as being unable to achieve an outcome if the carer: is unable to achieve it without assistance; is able to achieve it without assistance but doing so causes significant pain, distress or anxiety, or is likely to endanger health or safety The specified outcomes are: Carrying out any caring responsibilities the carer has for a child Providing care to other persons for whom the carer provides care Maintaining a habitable home environment Managing and maintaining nutrition Developing and maintaining family or other personal relationships Engaging in work, training, education or volunteering Making use of necessary facilities or services in the local community including recreational facilities or services Engaging in recreational activities 46 Carers’ eligibility threshold

Eligibility  The unable to achieve aspects – 4 for customers, 3 for carers is an extended definition of eligibility  The determination is made ‘carer neutral’ – this means that a carer’s input is not taken into account until the care and support planning stage, so the presenting needs are eligible needs, regardless of whether and how they are being currently met  Significant impact on wellbeing – there is no definition given of significant  It will be necessary to understand the adult’s needs in the context of what is important to him or her 47

How to determine eligibility - customer In the assessment, determine which of the listed outcomes in Condition 2 the customer is unable to achieve, and to what extent In being unable to achieve one or more of the outcomes, the extended definition of eligibility applies (four circumstances apply). An adult is seen as being unable to achieve an outcome if they are: (a - unable to achieve it without assistance; (b) - able to achieve it without assistance but doing so causes the adult significant pain, distress or anxiety; (c) - able to achieve it without assistance but doing so endangers or is likely to endanger the health or safety of the adult, or of others; or (d) - able to achieve it without assistance but takes significantly longer than would normally be expected Record these

How to determine eligibility - customer  Acknowledge and record input from informal carer/s, but do not take this into considering when determining eligibility. It will be referred to again at the support planning stage.  Decide on the consequential significant impact on the person’s wellbeing referring to the definition, resulting from their inability to achieve two or more of their outcomes. In the absence of a definition of significant, practitioners will need to demonstrate how the person’s wellbeing is impacted. This will determine whether they are eligible or not.  Record this  Summarise and record with evidence the reasons for the person meeting the eligibility threshold. 49

How to determine eligibility - customer If there are:  needs that not already met by informal carer/s, and will continue to be unmet, and/or  needs which the carers is currently meeting, and/or  needs which are not eligible but which the local authority has decided to use its powers to meet,  proceed to the care and support planning stage. 50

How to determine eligibility - carer  In the assessment, once it is established that the first condition is met ie the carer’s needs have arisen as a result of providing necessary care for an adult, the assessor needs to decide which aspect of condition 2 applies. Is the carer’s physical or mental health at risk of deteriorating, or is the carer unable to achieve any of the specified outcomes? For carers this can be one outcome only.  In being unable to achieve one or more of the outcomes, the extended definition of eligibility applies (three circumstances apply). 51

How to determine eligibility - carer A carer is seen as being unable to achieve an outcome if they are: (a) unable to achieve the outcome without assistance; (b) able to achieve the outcome without assistance, but doing so causes, or is likely to cause significant pain, distress or anxiety; or endangers (c) able to achieve the outcome without assistance but doing so endangers or is likely to endanger the health or safety of the carer or any adults or children for whom the carer provides care. Record these.

How to determine eligibility - carer  Determine as a consequence of condition 2, whether there is, or is likely to be, a significant impact on the carer’s wellbeing.  In the absence of a definition of significant, practitioners will need to demonstrate how the carer’s wellbeing is impacted. This will determine whether they are eligible or not. Record this.  Summarise and record with evidence the reasons for the carer meeting the eligibility threshold. 53

Record-keeping and informing individuals Informing the individual of their eligibility determination The local authority must: produce a written record of whether any of the individual’s needs meet the eligibility criteria, and the reasons for why they do and why they do not Informing individuals who are not eligible Where the individual does not have eligible needs, the local authority must also provide: information and advice on what support might be available in the wider community; or what preventative measures might be taken to prevent or delay the condition progressing? 54

Importance of Evidence Given the requirement to produce written information on the eligibility decision, it will be important to record the status of evidence. Types of evidence  Testimony – what the person says  Direct observation – what the assessor observes  Verifiable factual information - these are hard undisputed facts, for example, a date of birth, who attended a visit  Written reports – eg from the OT, hospital consultant 55

Importance of evidence Types of evidence  Understandings are statements about how things appear and are assumed to be true but must not be considered as facts.  Hearsay is second hand information and should not be considered as fact. The source needs to be clearly identified.  Opinions, judgements and recommendations – The basis and reasoning for the opinion must be given with supporting information.  Expert opinion – an opinion expressed by someone of expert status that their opinion seems beyond question and becomes accepted as fact. Care must be taken to provide the necessary detail. Practitioners should be particularly cautious about recording unsubstantiated diagnoses, for example, dementia, or unsubstantiated risks eg risk of falls. In giving their own opinion, the practitioner should state ‘In my professional opinion…’ 56

Exercise – Case Study Return to your small groups and complete the remaining eligibility section of the case study 57

Next steps 58 Assessment What are the needs and outcomes the person wants to achieve? Eligibility determination Are the person’s needs eligible? Met needs What needs can be/are being met through non- service provision? Unmet needs Are included in the personal budget

Summary  Assessment based on appearance of need for care and support:  Consider the person’s needs and the outcomes they want to achieve  Be appropriate and proportionate  Take a strengths-based approach  Involve the person needing care in the assessment, and consider if they would have substantial difficulty being involved  Throughout the process, also consider the 4 aspects highlighted earlier  National eligibility threshold, for people needing carer and carers, based on outcomes and wellbeing 59