1.1
PROCESS OF ASSESSMENT AND CARE MANAGEMENT
MAIN RESPONSIBILITY / : / Head of Service (Community Care)
Service Managers (Community Care)
Senior Care Managers
Home Care Managers
Lead Assessors
LEGISLATION / : / Social Work (Scotland) Act 1968
Community Care and Health (Scotland) Act 2002

1PURPOSE

1.1This guidance is designed to provide guidance for staff on the process of assessment and care management. It replaces previous departmental guidance and procedures to incorporate changes in legislation and policy, including single, shared assessment.

2INTRODUCTION

2.1This guidance describes the process of assessment and care management which now incorporates single, shared assessment. It includes the different stages of assessment and care management and identifies at each stage the responsibilities of staff working with service users and carers. It will assist staff when they are completing a single, shared assessment by informing them when to use particular forms and how to share information with colleagues not only within their own department but also with colleagues in other agencies. It also includes the protocol for accessing services.

2.2A separate procedure details the standards for assessment and care management which staff are expected to follow.

2.3Staff should familiarise themselves with their responsibilities in relation to the relevant legislation and also with the following guidance:

  • 'Guidance on Single, Shared Assessment' (Scottish Executive CCD 8/2001)
  • Care Management and Assessment: Practitioners' Guide (SSI/SWSG 1991a),
  • Care Management and Assessment: Managers' Guide (SSI/SWSG 1991b),
  • Community Care Needs of Frail Older People - Integrating Professional Assessments and Care Arrangements (SWSG 10/1998)
  • Community Care and Health (Scotland) Act 2002 New Statutory Rights for Carers: Guidance (Scottish Executive CCD 2/2003)

3POLICY CONTEXT

3.1Assessment of need has been a prominent feature of policy and legislation in the United Kingdom, particularly since the 'Griffith's Report' (1988) and the NHS and Community Care Act 1990. The White Paper preceding the 1990 Act identified assessment and care management as " the cornerstone of high quality care"(Secretaries of State, 1989,1.11). Several publications and circulars appeared subsequently to advise on policies and practice for assessment and care management, including SWSG11/91, SSI/SWSG 1991a, 1991b, SWSG 10/1998; CCD 8/2001. Each of these emphasised the need to improve collaboration and joint working between professionals across agencies. This was clearly stated in 'Modernising Community Care: An Action Plan' (Scottish Office 1998) and echoed in the 'Care Development Group Report' (2001) and the recent White Paper 'Partnership for Care' (2003), receiving further legal endorsement in the Community Care and Health (Scotland) Act 2002.

3.2Implementing single, shared assessmentis part of therecommendations of the Joint Future Group, as detailed in Community Care: A Joint Future, Report by the Joint Future Group (Scottish Executive, 2000). The Joint Future Group was set up at the end of 1999 shortly after devolution and the formation of the Scottish Executive, to look at the balance of care for older people. The report made many recommendations that would have a significant impact not only on older people, but also on any individual who may require community care services.

3.3Local authorities have a duty under Section 12A of the Social Work (Scotland) Act 1968 to assess those in need of community care services, in consultation with health and housing colleagues where necessary. The legal framework remains the same with the introduction of single, shared assessment although local authorities can delegate the assessment responsibilities to others. Single, shared assessment encourages a wider range of professional to undertake assessment of community care needs.

3.4Carers needs have also gained recognition and legislation places a responsibility on the local authority to offer a carer's assessment, whether the cared for person is being assessed or not (Carers (Recognition and Services) Act 1995, Community Care & Health (Scotland) Act 2002).

3.5TheScottish Executive published guidance in November 2001 (CCD 8/2001), with the following definitions of single, shared assessment:

Single, shared assessment:

  • Seeks information only once
  • Has a lead professional who co-ordinates documents and shares appropriate information
  • Co-ordinates all contributions
  • Produces a single summary assessment of need

Single, shared assessment:

  • Actively involves people who use services and their carers
  • Is a shared process that supports joint working
  • Provides results acceptable to all agencies

Single, shared assessment:

  • Is person centred and needs led
  • Relates to level of need
  • Is a process

4ASSESSMENT AND CARE MANAGEMENT

4.1Care management has been around for more than ten years. Single, shared assessment attempts to build on this and should be incorporated into existing assessment and care management systems. In introducing single, shared assessment our objectives are based upon two broad principles: to reduce duplication of assessments and speed up access to services. These should result in improved outcomes for service users. This will be achieved by identifying the appropriate practitioner to be a lead assessor, and by developing efficient and secure methods for exchanging assessment information.

4.2Who can be lead assessor?

  • District Nurses & Health Visitors
  • Care Managers
  • Home Care Staff
  • Community Psychiatric Nurses
  • Occupational Therapists
  • Occupational Therapy Assistants
  • Social Workers
  • Social Work Assistants
  • Day Care & DayHospital staff
  • Professionals in the acute and secondary care sectors, including Allied Health Professionals

4.3In most agencies all staff can undertake simple assessments. In some agencies unqualified staff may be lead assessors for simple assessments with supervision from qualified staff. Professionally qualified staff in any agency can undertake comprehensive assessments, while care managers usually undertake complex assessments.

4.4Who decides who is the lead assessor?

This will vary in each agency, depending upon who receives and screens referrals. It is crucial that referrals contain accurate, clear information to assist this process. A guiding rule is that the lead assessor will be determined by the predominant needs of the individuals, e.g. health staff may be the lead assessor when there are predominantly health needs; social work staff may be the lead assessor when there are predominantly social care needs. Care managers usually undertake complex assessments.

4.5The decision on who should be the lead assessor may not be straightforward and will require discussion and negotiation between agencies. It is important to bear in mind that in undertaking any assessment, it should be appropriate to the role of the worker. A worker should not become involved in assessment of needs that are not relevant to their primary role; however they may begin an assessment process and transfer responsibility.

4.6On the other hand, workers should try to do as much as possible for the service user before referring on to another department. Consideration will have to be given as to whether the benefit to the service user justifies the additional time spent, especially if this is to the detriment of other service users.

Example 1

A District Nurse is visiting a patient to remove stitches. She would not normally expect to visit again or remain involved. She identifies some social care needs, e.g. meal provision. The nurse completes D1 as part of her records. She can also use the D1 to request meals, and to request a change of lead assessor / care coordinator / monitor.

Example 2

A CPN visits a patient following a request by a GP. The CPN completes D1 as part of her records. During her assessment she identifies needs that could be met at Day Care. She can use the D1 and D2 to request this service from Day Care and use the FIIM to maximise the patient's income. While the CPN remains involved she would maintain the lead assessor role.

Example 3

A Social Care Organiser has provided home care services to a service user for a few months and has completed a D1, D2 and FIIM as part of their assessment. However the service user's health has deteriorated and the needs of the service user are becoming increasingly complex. The home care organiser can negotiate the transfer of the case to a care manager for ongoing care management.

4.7There are seven stages in the process of assessment and care management, as described in “Care Management and Assessment, Practitioners’ Guidance (SSI/SWSG1991a) which is still the core reference document. These stages are set out below, identifying the key principles and showing how single, shared assessment fits into the process.

Stage One: Publishing Information

“Making public the needs for which assistance is offered and the arrangements and resources for meeting those needs”.

This information is available in the leaflets 'Community Care Services in Dundee' and 'Single, Shared Assessment in Tayside'. An updated version of 'Meeting Your Needs', which is a more detailed booklet of Community Care Services in Dundee, will be available shortly.

It is the responsibility of the assessor / care manager to:

Ensure that published information reaches potential service users and carers and those who are requesting or receiving assistance

Ensure that any deficiencies in information or lack of availability of information is identified and drawn to the attention of management

Stage Two: Determining the Level of Assessment

“Making an initial identification of need and matching the appropriate level of assessment to that need “

Screening is the key part of this process and should determine not only the level and type of assessment required but also agreement on who should be the lead assessor. The following levels and types of assessment are available:

3 levels of assessment:

  • Simple - low level intervention is required; needs may be met by a single agency; some care co-ordination may be required
  • Comprehensive - A medium/high level of intervention is required; may involve more than one agency and will require care co-ordination
  • Complex - A high level of intervention is required; multi-agency involvement; frequently changing or unstable circumstances; care management required

3 additional types of assessment:

  • Specialist - e.g. psychiatry, occupational therapy
  • Self - undertaken by the service user
  • Carers' assessments

It is the responsibility of the assessor / care manager to:

  • Gather the essential, basic information in order to aid the screening process
  • Provide information and advice if that alone is required
  • Record the information on the designated documentation and ensure this is directed to the appropriate place/person

Stage Three: Assessing Need

“Understanding individual needs, relating them to agency policies and priorities, and agreeing the objectives for any intervention.”

Assessment should focus on the needs, aspirations and preferences of the individual and acknowledge what the individual feels will make a difference to attaining and maintaining quality of life.

It is the responsibility of the assessor / care manager to:

  • Establish contact with the individual within 2 working days of being allocated the referral and complete the assessment within 20 working days. If these timescales cannot be met, the reasons must be recorded in writing
  • Gather relevant, sufficient information from service users, carers and other professionals in order to identify need. Specialist assessments may be requested as part of the process
  • Gather and share informationonly on a need to know basis
  • Ensure the consent, involvement and participation of the individual throughout the assessment. Where others (including carers) are involved this will be with the consent of the service user
  • Promote the entitlement and rights of the individual
  • Ensure the individual has access to advocacy services where appropriate
  • Be clear on the legislative framework for acting or intervening to protect the welfare of the individual. (See procedures relating to incapacity & the protection of vulnerable adults)
  • Consider the need for a risk assessment as part of the assessment process. Where risk is identified, clear and comprehensive information must be gathered and shared with the individual or their representative. The assessment should also be shared (with the individual's consent) with all relevant parties. Where consent is not given, any sharing of information must be within legal frameworks
  • Offer all service users a Financial Information & Income Maximisation assessment as part of the overall assessment. This should be carried out by the lead assessor in most instances, but can be done by the service user or other person if appropriate
  • Establish carer views and needs separately and consider whether an independent assessment is necessary
  • Record in writing any disagreements with service users and significant others (including carers) about identified needs
  • Share the outcomes of the assessment with the service user

Stage Four: Care Planning

“Negotiating the most appropriate ways of achieving the objectives identified by the assessment of need and incorporating them into an individual care plan.”

It is the responsibility of the assessor / care manager to:

  • Provide the service user and significant others (including carers) with information detailing choices and options about ways of meeting needs
  • Give consideration to the preference of the service user and significant others (including carers), in terms of service provision, and record in writing any differences of opinion
  • Involve the service user throughout the process of planning care
  • Negotiate and identify a care plan that takes account of the service user’s current supports network
  • Provide a care plan which identifies the service user’s needs, preferences, and aspirations and how these will be met
  • Provide a care plan that clearly identifies tasks, responsibilities, purpose and frequency of service inputs and the date of the initial review of the care plan
  • Ensure that care plans are signed by the service user and significant others (including carers if relevant) and are available to the service user in their place of residence
  • Identify any costs to the service user and any contributing party where appropriate
  • Make service requests to other social work professionals, i.e. Occupational Therapists, other Departments and other agencies when necessary
  • Record in writing any unmet need(s) and/or service deficit(s) identified during care planning. Unmet need is defined as a situation where the client's needs cannot be met because the resource is not available or does not exist. Service deficit is defined as a situation where a service exists but is not available to the client
  • Ensure that service providers have all the necessary documentation, where appropriate prior to delivery of service
  • Ensure that the service user, significant others (including carers) and service providers are aware of their responsibility to inform the Social Work Department of any major changes affecting the service user within 24 hours of the changes occurring. These major changes would include physical or mental deterioration, any suspected abuse or neglect, change of residence, admission to hospital and changes seriously affecting the carers functioning
  • Ensure that the service user and significant others (including carers) are able to visit or have adequate information about resources e.g. day centre, nursing home. If this is not possible, record in writing the reason(s)

Stage Five: Implementing the Care Plan

“Securing the necessary resources or services”.

It is the responsibility of the assessor / care manager to:

  • Provide service users and carers with information on the resource/service to be used
  • Consider departmental services where appropriate in the first instance when securing services
  • Try to secure services from one provider if possible to aid consistency of care
  • Work with service providers who are approved by the Social Work Department and be familiar with any contract conditions agreed with these agencies
  • Specify clearly to service providers the exact nature of the service requirement, and the expectations for the service including the quality of provision
  • Cost and submit the identified care plan for approval of funding as required on the specified documentation
  • Co-ordinate the different elements or service provision where appropriate
  • Establish the monitoring arrangements for the care plan and care package

Stage Six: Monitoring

“Supporting and controlling the delivery of the care plan on a continuing basis”

It is the responsibility of the assessor / care manager to:

  • Ensure that a care plan is monitored to meet identified and changing needs
  • Monitor the quality of provision and encourage service users and carers to be part of the monitoring process
  • Ensure that arrangements are made for any proposed or actual adjustments to the care plan to be discussed with the service user and significant others (including carers)
  • Keep the service user informed of any proposed or actual adjustments to the care plan
  • Respond within 24 hours to any notification about any major changes in circumstances and consider and record in writing whether these changes have any implications for the individual's care plan, either immediately or in the future
  • Take immediate action if it is identified that a safer environment is required, proceed according to agreed procedures and advise the immediate line manager of the situation and the proposed actions
  • Make arrangements to visit a service user at least one every three months when he/she is in residential or nursing home care, if it has been established that they have neither family nor carer(s). Where this is not practicable, arrangements must be made with an independent party, other than the service provider, to undertake this duty. These arrangements should be recorded in writing

Stage Seven: Reviewing

“Reassessing needs and the service outcomes with a view to revising the care plan at specified intervals.”

It is the responsibility of the assessor / care manager to:

  • Ensure that the service user, significant others (including carers) and service providers are given an opportunity to be involved in the review process
  • Ensure that all care plans are reviewed, in the first instance within 6 weeks, and thereafter with a frequency that reflects the complexity of the needs of the service user
  • Review care plans at least once a year
  • Re-evaluate, reassess and determine the objective of the care plan
  • Consult all those involved in the original care plan
  • Co-ordinate annual reviews with establishment reviews where possible. In the case of a service user in residential or nursing care, the establishment reviews and the establishment care plans are the responsibility of the staff of the residential or nursing unit. The outcome of the establishment review should be passed to the lead assessor who should consider in all cases the implications for the client's care plan, and record these implications in writing. The annual review of the care plan should be co-ordinated by the lead assessor to coincide with the establishment care plan review. These arrangements must be made clear to the service user and be included in the care plan
  • Ensure that any new plans identified during the review process are included in any revised care plans
  • Record in writing any unmet need(s) and/or service deficit(s) identified during reviews
  • Seek the service user's consent, or where appropriate, their advocate or representative(s) prior to circulating any review forms and/or revised care plans to all those attending or consulted about the review
  • Co-ordinate reviews and chair them where appropriate
  • Review the quality of the service provision as part of the review process

5REFERRALS/SPECIALIST ASSESSMENTS/SERVICE REQUESTS