Key Points

  • All care and support needs should be evident in assessments irrespective of whether they are eligible needs.
  • Assessments should always explore how the person might address need through the assets and opportunities in their networks and communities.
  • Assessments should state how needs not being met impact on the person’s wellbeing.
  • Impact on the person’s wellbeing should be reflected when making eligibility determinations.

December 2018: This chapter was revised as a result of local review.

1. Introduction

This chapter outlines Adult Care’s procedures for undertaking and recording assessments and application of the Care Act eligibility regulations and statutory guidance.

Promoting independence and wellbeing, utilising community assets, sustaining informal support arrangements and developing innovative ways of meeting care and support needs are themes which underpin the Care Act.

The eligibility guidance shall continue to provide the basis for ensuring Adult Care resources are channelled to where there is most need and where opportunities for alternative means of meeting needs have been fully explored.

Whilst eligibility decisions are fundamental to determining where local authority funding is targeted, it is important to note that the Care Act also places a duty on local authorities to ensure that we help address people’s non eligible needs. This may be through providing information and advice or directing people to other sources of support.

2. Lincolnshire’s Adult Needs Assessment

Lincolnshire’s needs assessment tool reflects the Care and Support Statutory Guidance to ensure that customers and practitioners can work through the key steps of the assessment process as simply as possible culminating in an eligibility determination. The stages are:

  • exploring and understanding the person, their situation, their strengths and the networks around them prompted by the guidance windows at each section of the assessment;
  • identifying needs for care and support – ‘raw need’ irrespective of who/how they may be alleviated; this is done by stating whether there are needs in relation to the sections of the assessment that need to be addressed in the person’s plan;
  • identifying and evaluating risks – considering capacity and how the person wants to address risk;
  • making an eligibility threshold determination;
  • determining which needs are eligible for support;
  • determining an indicative personal budget using the Resource Allocation System

Assessments should be proportionate. Assessors should be guided by the person and their professional judgements in deciding which elements of the assessment need the most attention.

3. Let’s Start with You!

The Adult Care assessment builds from a free text section intended to capture a summary pen picture of the person and their current situation. It prompts people being assessed to:

Tell us about you – what you do, what you’ve done, what are your strengths and accomplishments, what’s important to you now and before? What are you keen to keep doing or get back, what do you want to change? Where do we fit in? How can we help?

This section is important to set the scene and tone of the assessment going forward to ensure that the discussions that follow in exploring the person’s situation are grounded in an understanding of what is important and what matters to the person.

The next part of the assessment is divided into nine sections:

  • My family, friends and support networks;
  • Communicating and expressing my wishes;
  • Mobility and getting around my environment;
  • Personal care;
  • Eating and drinking;
  • Running my home;
  • Participating in my community;
  • Maintaining my health and wellbeing;
  • Living safely and taking risks.

Each section includes a free text box to capture the conversation in relation to the areas of the person.

These boxes should reflect what is working well for the person, where they have strengths both in their own abilities or aspirations and where they have networks of support that do or could potentially help. We should also record how any difficulties impact on the person’s wellbeing. Any conversations which start to identify what outcome the person wants to achieve may also be captured here.

NB The person’s outcomes will be recorded more fully in the care and support planning process and covered in the Care and Support Planning guidance

4. Guidance Windows

The assessment uses free text boxes and tries to minimise prescriptive questioning to support a more conversational approach and enable practitioners to make judgements about what they need to record to remain proportionate.

The assessment includes guidance windows throughout indicated by a question mark icon.  Opening these windows provides additional guidance to practitioners which may prompt discussion. They also include additional prompts / headings which may be copied and pasted in to free text boxes where assessors feel elements of the assessment would benefit from them.

5. Prisma 7 Frailty Screening Tool

The Maintaining my health and wellbeing section of the assessment includes the Prisma 7 Frailty screening tool as an optional element.  PRISMA 7 is an internationally recognised basic screening tool to identify people likely to be categorised as frail and that would benefit from a full frailty assessment, undertaken by either the person’s primary care or Neighbourhood working team.

A person hitting three or more of the triggers should be referred to their primary care team using the Lincolnshire Frailty Pathway Letter.

See Frailty and the Lincolnshire Frailty Pathway for more information.

6. Identifying Needs

Each section of the assessment has a simple tick box to select whether the person has care and support needs in relation to that area.  By selecting ‘yes’ Mosaic pulls the section heading through to build the person’s statement of needs.  For example a person could have identified needs in relation to:

  • mobility and getting around their environment;
  • personal care;
  • participating in their community.

6.1 Identifying and evaluating risks

The Living safely and taking risks section of the assessment is to ensure that risks identified in the assessment are clearly considered and evaluated and effective measures are in place to address them (see Assessing and Managing Risk). It remains an integral part of our assessment process that we can robustly evidence any issues of risk or concerns of harm within the assessment, and respond appropriately and proportionately.

7. Eligibility

One of the key aims of the Care Act 2014 was to achieve a more consistent approach to determining who was eligible for support across the country. The Act sets out the national eligibility threshold.

7.1 Eligibility guidance

The Care and Support Statutory Guidance, Chapter 6. Assessment and Eligibility provides detailed guidance on interpreting the Care Act and the Care and Support Regulations regarding eligibility and also includes case examples.

The eligibility guidance also needs to be considered in conjunction with the Wellbeing Principle set out in section 1 of the Act (see Chapter 1, Care and Support Statutory Guidance, Promoting Wellbeing).

Additional resources to help develop understanding around eligibility are available through the Social Care Institute of Excellence (SCIE)  and Skills for Care.

The Care Act introduces three steps to determining eligibility for care and support. The following is adapted from the statutory guidance to provide a summary of how to determine eligibility.

Care and Support Statutory Guidance Extract (from Chapter 6)

The eligibility threshold for adults with care and support needs is set out in the Care and Support (Eligibility Criteria) Regulations 2015 (the ‘Eligibility Regulations’). The threshold is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing.

In considering whether an adult with care and support needs has eligible needs, local authorities must consider whether:

  • Step 1 – The adult’s needs arise from or are related to a physical or mental impairment or illness
  • Step 2 – As a result of the adult’s needs the adult is unable to achieve two or more of the specified outcomes (which are described below)
  • Step 3 – As a consequence of being unable to achieve these outcomes there is, or there is likely to be, a significant impact on the adult’s wellbeing

An adult’s needs are only eligible where they meet all 3 of these conditions.

Interpreting the eligibility criteria

Step 1 – The adult’s needs arise from or are related to a physical or mental impairment or illness

The first condition that local authorities must be satisfied about is that the adult’s needs for care and support are due to a physical or mental impairment or illness and that they are not caused by other circumstantial factors. Local authorities must consider at this stage if the adult has a condition as a result of either physical, mental, sensory, learning or cognitive disabilities or illnesses, substance misuse or brain injury. The authority should base their judgment on the assessment of the adult and a formal diagnosis of the condition should not be required.

Step 2 – As a result of the adult’s needs, the adult is unable to achieve two or more of the outcomes set out in the regulations

The second condition that authorities must consider is whether the adult is “unable” to achieve two or more of the outcomes set out in the regulations. Authorities must also be aware that the regulations provide that “being unable” to achieve an outcome includes any of the following circumstances, where the adult:

  • is unable to achieve the outcome without assistance. This would include where an adult would be unable to do so even when assistance is provided. It also includes where the adult may need prompting for example, some adults may be physically able to wash but need reminding of the importance of personal hygiene
  • is able to achieve the outcome without assistance but doing so causes the adult significant pain, distress or anxiety. For example, an older person with severe arthritis may be able to prepare a meal, but doing so will leave them in severe pain and unable to eat the meal
  • is able to achieve the outcome without assistance, but doing so endangers or is likely to endanger the health or safety of the adult, or of others – for example, if the health or safety of another member of the family, including any child, could be endangered when an adult attempts to complete a task or an activity without relevant support
  • is able to achieve the outcome without assistance but takes significantly longer than would normally be expected. For example, an adult with a physical disability is able to dress themselves in the morning, but it takes them a long time to do this, leaves them exhausted and prevents them from achieving other outcomes.

The 10 ‘Eligibility Outcomes’

The Eligibility Regulations set out a range of outcomes. Local authorities must consider whether the adult is unable to achieve two or more of these outcomes when making the eligibility determination. The following section of the guidance provides examples of how local authorities should consider each outcome set out in the Eligibility Regulations (which do not constitute an exhaustive list) when determining the adult’s eligibility for care and support:

  1. Managing and maintaining nutrition – Local authorities should consider whether the adult has access to food and drink to maintain nutrition, and that the adult is able to prepare and consume the food and drink
  2. Maintaining personal hygiene – Local authorities should, for example, consider the adult’s ability to wash themselves and launder their clothes
  3. Managing toilet needs– Local authorities should consider the adult’s ability to access and use a toilet and manage their toilet needs
  4. Being appropriately clothed– Local authorities should consider the adult’s ability to dress themselves and to be appropriately dressed, for instance in relation to the weather to maintain their health
  5. Being able to make use of the home safely– Local authorities should consider the adult’s ability to move around the home safely, which could for example include getting up steps, using kitchen facilities or accessing the bathroom. This should also include the immediate environment around the home such as access to the property, for example steps leading up to the home
  6. Maintaining a habitable home environment– Local authorities should consider whether the condition of the adult’s home is sufficiently clean and maintained to be safe. A habitable home is safe and has essential amenities. An adult may require support to sustain their occupancy of the home and to maintain amenities, such as water, electricity and gas
  7. Developing and maintaining family or other personal relationships– Local authorities should consider whether the adult is lonely or isolated, either because their needs prevent them from maintaining the personal relationships they have or because their needs prevent them from developing new relationships
  8. Accessing and engaging in work, training, education or volunteering– Local authorities should consider whether the adult has an opportunity to apply themselves and contribute to society through work, training, education or volunteering, subject to their own wishes in this regard. This includes the physical access to any facility and support with the participation in the relevant activity
  9. Making use of necessary facilities or services in the local community including public transport and recreational facilities or services– Local authorities should consider the adult’s ability to get around in the community safely and consider their ability to use such facilities as public transport, shops or recreational facilities when considering the impact on their wellbeing. Local authorities do not have responsibility for the provision of NHS services such as patient transport; however they should consider needs for support when the adult is attending healthcare appointments
  10. Carrying out any caring responsibilities the adult has for a child– Local authorities should consider any parenting or other caring responsibilities the person has. The adult may for example be a step-parent with caring responsibilities for their spouse’s children

Step 3 – As a consequence there is, or there is likely to be, a significant impact on the adult’s wellbeing

The third condition that must be met is that local authorities must consider whether the adult’s needs and their inability to achieve the outcomes above cause or risk causing a significant impact on their wellbeing. The meaning of “wellbeing” is set out in Section 1. Promoting wellbeing of the Care and Support Statutory Guidance.

Local authorities must determine how the adult’s inability to achieve the outcomes above impacts on their wellbeing. Where the adult is unable to achieve more than one of the outcomes, the local authority does not need to consider the impact of each individually, but should consider whether the cumulative effect of being unable to achieve those outcomes is one of a “significant impact on wellbeing”. In doing so, local authorities should also consider whether:

  • the adult’s inability to achieve the outcomes above impacts on at least one of the areas of wellbeing (as described in Section 1 of the Act in a significant way or
  • the effect of the impact on a number of the areas of wellbeing mean that there is a significant impact on the adult’s overall wellbeing

The term “significant” is not defined by the regulations, and must therefore be understood to have its everyday meaning. Local authorities will have to consider whether the adult’s needs and their consequent inability to achieve the relevant outcomes will have an important, consequential effect on their daily lives, their independence and their wellbeing.

In making this judgment, local authorities should look to understand the adult’s needs in the context of what is important to him or her. Needs may affect different people differently, because what is important to the individual’s wellbeing may not be the same in all cases. Circumstances which create a significant impact on the wellbeing of one individual may not have the same effect on another.

Considering needs met by carers in eligibility determinations

The eligibility determination must be made based on the adult’s needs and how these impact on their wellbeing. Authorities must only take consideration of whether the adult has a carer, or what needs may be met by a carer after the eligibility determination when a care and support plan is prepared. The determination must be based solely on the adult’s needs and if an adult does have a carer, the care they are providing will be taken into account when considering whether the needs must be met.

Local authorities are not required to meet any eligible needs which are being met by a carer, but those needs should be recognised and recorded as eligible during the assessment process. This is to ensure that should there be a breakdown in the caring relationship, the needs are already identified as eligible, and therefore local authorities must take steps to meet them without further assessment. (Care and Support Statutory Guidance chapter 6)

7.2 Recording eligibility in the needs assessment

To determine eligibility the assessor should consider the needs identified in the assessment against the three step model set in the national eligibility threshold:

  • Step 1 – The adult’s needs arise from or are related to a physical or mental impairment or illness;
  • Step 2 – As a result of the adult’s needs, the adult is unable to achieve two or more of the 10 ‘eligibility outcomes’;
  • Step 3 – As a consequence of being unable to achieve these outcomes, there is, or there is likely to be, a significant impact on the adult’s wellbeing.

Determining which needs are eligible for support: Once the eligibility threshold determination has been made the assessor should review the list of needs identified in the assessment and indicate which are the ‘eligible needs’. The need will be eligible if by it not being met it is preventing one or more of the ‘eligibility outcomes’ being met or contributing to the significant impact on the person’s wellbeing.

If, in the view of the assessor, the need remaining unmet would not contribute to inability to achieve one of the eligibility outcomes or it remaining unmet does not have a significant impact on the person’s wellbeing, then it should be marked as a non-eligible need.

7.3 Equipment and eligibility

See also Occupational Therapy and Independent Living

At all stages of the assessment process, customers should have access to information and advice about how equipment could help them, where they may purchase it and how to access fitting services.

Where required, equipment will be provided by Adult Care to people who are assessed as having eligible needs relating to the outcomes equipment is intended to address;

People not meeting the eligibility threshold will be advised about where they can purchase equipment for themselves, or will be referred to the Wellbeing Service (Lincolnshire County Council website).

Adult Care will not prescribe and supply equipment through the community equipment service as a preventative measure to people who do not meet the eligibility threshold.

7.3.1 Equipment issued during episodes of care provided through the Reablement Service

Reablement provided through the Reablement Service is usually provided prior to an Adult Care eligibility assessment taking place. Adult Care assessors asked to undertake assessments with a view to equipment provision for people receiving short term reablement support should undertake a proportionate Needs Assessment and may issue equipment, as follows:

  • minor equipment may be issued during an episode of reablement where it is required to support reablement goals;
  • major equipment should only be issued to people eligible for on-going support. Consequently, major equipment should only be issued during reablement where it is vital to the safe provision of that service or to complete the assessment;
  • as a general rule, equipment, such as bath lifts, should not be issued in reablement until it is evident the person meets eligibility for the ongoing support;
  • any circumstances where it is felt necessary to issue council-funded major equipment for people not meeting eligibility criteria should be discussed with Lead Practitioners. Any major equipment issued during reablement episodes is done so on the understanding with the person that it is a short term loan and will be withdrawn where people do not meet criteria for ongoing support.

People not meeting eligibility criteria should be advised about where they can purchase suitable equipment themselves.

8. Hospital Discharges and Trusted Assessors

The council operates a trusted assessor scheme to enable health professionals working in acute hospital settings to provide equipment deemed as essential to safe discharge. The trusted assessor scheme operates across Lincolnshire hospitals and some hospitals in neighbouring areas.

The eligibility threshold does not need to be considered by hospital based occupational therapists when requesting equipment through the trusted assessor scheme.

9. Telecare

Telecare equipment will not be prescribed by Adult Care practitioners unless there are exceptional circumstances.

Telecare installation and monitoring costs will be met by the customer.

More information about the Telecare procedures can be found in Work Force Matters (Lincolnshire County Council intranet).

10. Carers Eligibility

The Care Act also provides an eligibility framework to determine carers’ eligible needs for support in their own right. Details of carers’ eligibility threshold can be found in the Carer’s chapter.