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Assessment, resource allocation and culture change Dr Tim Gollins Y&H ADASS Regional Coordinator and the Think Local Act Personal

Partnership (TLAP); Dr Celia Harbottle Independent Training Consultant working with Doncaster Council, Martin Walker Team Manager, Modernisation & Engagement, Adults and

Communities Directorate and Doncaster Council’s Social Care Rescript Project Team.

June 2014

Introduction

There are some key strategic drivers for adult social care at the beginning of 2014-15: the Better Care Fund (BCF) and integration, the Care Act, localism and sector led improvement, and of course austerity cuts. Personalisation in this complex context has been squeezed – its key concepts developed over a decade ago reviewed and revised amid the practicalities and the politics of change at national, regional and local levels. Through all of this change personalisation remains a key strategic priority for councils, but what its scope is, or has become, is much less clear. This paper considers these contextual factors as they impact on assessment and resource allocation. Practical solutions are offered for doing things differently, focussing on the workforce and culture change, which are seen as critical to delivering personalisation.

Since the introduction of self-directed support, which, for the sake of argument, we take to be when In Control introduced the ‘7-steps of self-directed support’ in about 2003, personal budgets have grown to become the norm. The majority of social care customers receiving a community-based service across England now have a personal budget, and the use of direct payments has become a mainstream activity1. Whether all of the people who have a personal budget know this fact is an important question, but generally, the principles of self-directed support are well established in councils systems: once eligibility is established for a service user there is an up-front allocation, and a care plan is developed, signed off and there is then a subsequent review.

Personalisation, however, is a much broader concept than self-directed support. It is a programme of change that links health and social care policy and practice back to the experiences of service users. It emphasises the need for better outcomes and the need for choice and control, across both the health and social care systems. In a self-assessment document developed by ADASS and TLAP in 2014, 18 separate areas of the health and social care system are identified as relevant to personalisation. These vary from workforce development and commissioning, to re-ablement, channel –shift and active citizenship.

Beyond the strategic policy areas, the detailed elements of self-directed support are also under pressure. Recent work considers the customer pathway and how councils can ‘slim down’ systems (Think Local Act Personal, TLAP), and councils continue to modernize their operating systems, especially in light of integration. Then there are public critiques of current systems and practice from activists and academics2 and service users themselves. This paper addresses many of these concerns. Much of the content is provided by Doncaster Council’s adult social services modernisation team, with contributions from various other councils, networks and individuals in Yorkshire and Humber (Y&H). Specifically, the Y&H personalisation network for ADASS has worked closely with Think Local Act Personal (TLAP) nationally, and all of this collective knowledge is used in the development of this paper. Some key aspects of culture change are developed by Dr Celia Harbottle, and work on the resource allocation process has been supported by OLM, and Dr Simon Duffy worked with Doncaster Council early in 2013

1 ADASS personalisation survey 20132 Simon Duffy – http://www.centreforwelfarereform.org/library/by-date/an-apology.html and Slasberg et al2013.

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http://www.centreforwelfarereform.org/library/by-date/an-apology.html

to identify key issues and strategic direction. This paper is therefore, a collaborative piece, borrowing elements of good practice from various places. Derived from this collective knowledge network is a focus in this paper on three key areas of social care activity:

1. Assessment, taking an asset-based approach

2. Resource allocation, reliant on practitioner competency

3. Culture change, a major challenge

The hope is that providing this analysis will help continue and re-invigorate the delivery of personalised health and social care policy and practice that is informed by the enduring principles of personalisation – choice, control and better outcomes for the service user.

1. Asset-based assessment

The concept of asset-based social care has its origins in three inter-related fields, the first community-based social work, the second community development, and the third is personalisation. Its basic tenet is to view individuals as people who have strengths, skills and abilities. The approach also considers that individuals operate within the context of the family and a friendship network. This social interaction takes place within a community of universal services, voluntary and community sector organisations, pubs, clubs and work. It is in these spheres of the personal, the family, and the community that social care intrinsically operates.

Adopting this asset-based approach to need assessment means balancing deficits with the strengths people have. People may have skills, abilities and are involved in communities in ways which help to reduce need or risk. Alternatively, people could be easily and quickly supported to develop these assets. Therefore, rather than formulating a straight forward idea about what someone’s needs are based on a list of categories in an assessment document, a social care worker must work with the individual concerned to understand whether and how assets can be developed. For example, perhaps professional support for a short period to engage with appropriate community groups, and to develop family relationships or friendships, might be enough to address issues of isolation or loneliness. These activities can be done before any formal assessment of eligibility is made. However, it can only be achieved by co-producing the assessment with a service user.

Taking an asset-based approach prior to establishing eligibility may reduce the overall cost of some care packages, and it might also reduce someone’s eligibility to below the unmet need threshold, but the main reason for doing it is that it makes assessments more meaningful to everyone being assessed, even those who are ineligible for services. For example, people who have to pay for their care themselves get the benefit of having an assessment which provides information and advice about the things they can do to maximise their personal resilience, reduce need and prevent the onset of new needs, and even some professional advice and informal support to help them achieve it, even if they are not eligible for public money via a personal budget3.

Fundamentally, taking an asset-based perspective the job of social work is conceptualised as helping people (whether eligible or not) to make the most of these elements of their lives, - to become resilient. Only when an individual’s needs cannot be contained by developing resilience is the state asked to intervene. In this context the assessment of unmet eligible need is key to social work, or rather more precisely, doing everything possible to create resilience and to prevent the escalation of need is paramount.

Community-care assessments and The Care Act

3 A full discussion of asset-based social care can be provided on request

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The problem that asset-based assessments address is one created by community care assessments. Community care assessments, introduced following the community care act in 1990, responded largely to the need to move people out of large scale institutions into more community-based settings. Achieving this desired outcome required the identification of the problems that individuals would have in living a more independent life less prescribed by an institutions rules and regulations. The focus of assessment became the identification of the extent of absences of independent living skills, and the necessary knowledge and ability to live outside an institution.

The Caring for People White Paper 1989 set out six National Objectives, the first of which was the provision of domiciliary, day and respite services so that people could remain in the community wherever feasible and sensible. This objective largely set out the commissioned landscape of service provision we see today with a limited menu of social care options resulting in a prescription approach to meeting need with outputs rather than responses which reflected the desired outcomes of prospective service users.

The Care Act changes the duties on councils. Clause 1 of the Act places duties on the council to take a holistic view of the individual and promote general wellbeing, whilst Clause 25(6) (a) & (b) requires the local authority to have regard to the outcomes the social care customer wishes to achieve. Clause 2 of the Act places a duty on councils to seek to act to prevent or reduce the development of need, and guidance suggests that social care service users should be helped to consider ways of meeting some needs without recourse to long term state support, and where targeted Interventions are needed, they should be proportionate and responsive to the specific circumstances of each individual case.

Current deficit-based community-care assessments are still relevant post Care Act because Fair Access to Care Criteria (FACs) is still going to be used to establish a customer’s eligibility for public money. However, the Care Act demands that assessments have a broader perspective, namely, to address wellbeing and prevention. Therefore, assessments will need to be holistic and support the development of resilient individuals. Effectively, social care workers will need to maximise a person’s self-management capabilities before assessing the extent of unmet needs, and then whether or not that need is eligible for public money. With government austerity policies only half way through their planned duration and in contrast to the assessments needed after the community care act 1990, the assessments we need post Care Act will need to be about promoting self-care.

Awareness of this stimulated Doncaster Council to develop an asset-based assessment which is provided in appendix 1. It has been produced by them as part of their adult services modernisation programme and is currently being trialled by a small team of social work practitioners to ensure it is fit for purpose.

The assessment

The assessment and review of care and support needs document in appendix 1 is designed to replace the community care assessment in Doncaster and has been designed specifically to work with the RAS grid in appendix 2. The document is self-explanatory but differs from the previous community care assessment in a number of important ways. Firstly it is less prescriptive, allowing the service user to tell their story from their own perspective. Secondly, it draws out a picture of need and the context of that need from what the customer is saying, and thirdly it filters needs into met and unmet needs, and where unmet needs are identified it allows the social worker to discuss informal options prior to establishing the need for statutory services being delivered. It takes into account carer's contributions to the situation and only then identifies the eligible unmet need which enables a FACs decision. The overall purpose of the assessment is different to the previous one Doncaster Council

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used. Whilst the previous one was focused on identifying eligibility and the services needed, this assessment is about supporting independence and wellbeing, only resorting to filling the deficits with services as the last resort.

The assessment works with a RAS grid resource allocation tool (see below). Only if social care workers are rigorously pursuing an asset-based coproduced assessment approach, can a RAS grid resource allocation tool work. The current community care assessment aims to assess eligibility as its primary function and results in what could be described as a service prescription which is then costed by a common RAS based system or ‘black box’ (see below). This new assessment does not. It results in an agreement with the customer about how they are going to maximize their wellbeing and health, and it describes the arrangements that are needed or are already in place to help the service user achieve this. Its purpose is broader to reflect the requirement of the Care Act. However, it must also address eligibility, but it does so at the end of the process, at which point the RAS grid allocates a starter budget on the basis of unmet eligible need, not on the basis of services.

Completing the assessment with a starter budget if there are eligible unmet needs breaks the link between cash and services. It leaves room for the agreement of outcomes with the service user. Doncaster has, as part of their assessment, designed an ‘outcomes statement’ which follows on from the assessment. Further work has resulted in this being developed into a care and support plan that complies with the Care Act (see appendix 4). It is a simple tool which allows the social care worker to agree with the service user what their cash sum is for, not what services it must buy, but what the purchasing must achieve. This care and support plan is then intended to be used with independent brokers, or informal family and friends to guide the purchasing independently of the council. A starter budget will be agreed and made available to spend immediately with a review shortly following (6 weeks is envisaged) of whether the RAS grid allocation is sufficient to enable services to be purchased that address the outcomes statement. A significant step forward is made slimming down systems and process, a primary determinant, alongside involving service users in decision making, which influences positive outcomes4.

2. Resource allocation

Criticisms about resource allocation systems (RAS) are not difficult to find. Two have already been referenced in this paper, but there are many more – there are users and carers (not all of course) from many councils in England who are likely to have experienced some kind of a problem as a result of resource allocation systems that have disempowered them. All too often resource allocation systems lack transparency, do not provide sufficient resources or alternatively they result in major shift between indicative and actual allocated amounts. On top of which, exactly how the RAS itself operates is poorly understood. Indeed, the complex algorithms in use to determine the money people need to meet their needs constitute a ‘black box’ within the council whose workings few but the most IT literate actually understand.

The black box problem is neatly summarised by Dr Simon Duffy (Centre for Welfare Reform) in 2012, where he explains that:

• It disempowers social workers and service providers• It keeps breaking (the allocation is wrong)• It can be used to disguise unfair cuts and cap budgets• The calculations are unclear• It doesn’t empower service users

4 POET 2013 presentation by In Control at TLAP events in Bristol and Newcastle in March 2014

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A fundamental premise of self-directed support, at its inception, was the notion that councils and service users need an ‘up-front’ financial allocation. This is because an early allocation of resources promotes control, independence, responsibility and creativity. Up-front allocation is essentially premised on the notion that no one can plan effectively if they don’t know what their budget is, whether disabled or not disabled. The alternative to up-front allocation seems to be to go back to post care-planning resource allocation where the customer gets what the professional wants / says they can have. Both models have issues. The former entails the problem of how to identify an amount of money that is sufficient to meet needs on an individual basis when you don’t know what services the user wants, and the latter simply ignores the fact that when people control their own lives they achieve better outcomes and live more healthily and happily.

The solution seems straight forwards conceptually - ditch the black box and keep the up-front allocation. However, this may be more easily said than done as any number of councils and their IT providers can probably testify. However, some significant progress has been made in recent years both on making resource allocation systems more transparent and simpler to understand. Some councils, having spent time re-calibrating and explaining their RAS, now report that they are happy with how it is operating. Other councils continue to have problems. Below, is an account of the work Doncaster Council has done to address the long-standing problems they have had with their Common RAS based resource allocation system.

Doncaster council’s approach

There were a number of problems Doncaster’s modernisation team wanted to address:

The current Self Assessment form was far too long

The way the RAS worked was not understood by either social care workers or service users

Social care workers were seen as ‘gaming’ the assessment process so that the RAS would produce the result they wanted. Social care workers knew that if they did not do this, and instead limited allocations to what the common RAS would deliver, the allocations would be insufficient for the customer to meet their needs.

The obvious solution was to re-calibrate the RAS. However, at the same time new thoughts about slimmed down systems and processes were being published by TLAP. A new more radical solution became plausible – rather than re-calibrating a flawed resource allocation system, create a new system that did what service users needed, and which used the skills and abilities of professionals. This fundamentally meant creating processes that support social work, not ones that disempower it. A co-produced competence-based resource allocation system was defined.

Co-production and competence-based resource allocation

A coproduced competence-based RAS focuses on service users as experts on their own need and risks and social work as a solution rather than a problem. Fundamentally, it avoids complex ‘black box’ algorithms. It takes as its starting point the premise that social care workers are trained professionals, who want to do a good job for and with their service users. Unlike the common RAS approach where a community care assessment is ‘translated’ by an algorithm into a cash allocation, a co-production competence–based approach means that social care workers have the job of talking to the service user and considering their needs with them. They must also explore the risks to the person if identified needs are not met. Both these things require a commitment to co-production and competent professional judgement.

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The social care worker, on completing an asset-based assessment as described above, has to review the overall areas of need relevant to the individual, and, with the service user, establish the overall risk if these needs are not addressed. Identifying the number of needs involves the worker using their interpersonal skills; however, judging the overall level of risk from interacting needs and the various contexts people live in is much more nuanced. It requires social care workers to have skills, experience and knowledge of the individual, and to make good decisions, an activity not new to social work, but equally quite often a challenge. Research in Practice for Adults5 make the point very well:

‘There is no ‘quick fix’ to making good decisions in adult social care. Adult social care is a difficult area to work in, with pressure from high demand and limited resources, and with great uncertainty due to the complexity of people’s lives. It is also an area of our society that is of great importance, where decisions can make a real difference and where well-being can be increased.

The best answer to the problem of how to make good decisions is to develop professional judgement alongside genuine partnership with service users and carers, so that decisions are informed and co-produced.’ (Page 79)

A tool to support this process is a simple ‘RAS Grid’ shown in appendix 2.

Using the RAS grid

NeedsNeeds established at assessment are grouped in the RAS Grid. The exact groupings can be a varied locally, but in the example in appendix 2 needs are grouped in sets of 2 across the top of the table. So for example, if a customer has a personal care need, a need for help with cleaning and shopping, addressing social isolation and cooking, given the categories of need defined in section 13 of the assessment document in appendix 1 they would have 4 separate needs areas, placing them in the second column on the grid.

Risk The risk being evaluated in the RAS Grid is the risk to the individual if the eligible unmet needs resulting from the asset-based assessment are not met. The impact of this risk (the hazard) has four possible levels of severity6:

Risk Severity 1-4:

1: Restricted independence

2: Moderate threats to independence

3: Serious threat to Independence

4: Immediate risk of harm/neglect/crisis

The second variable, which to score overall risk is multiplied by the risk severity, is the likelihood of a hazardous event happening if the unmet needs were not addressed. This is evaluated on a scale of 1-7:

Risk Likelihood 1- 7:

1: Occasional incidents

5 Good decision-making: practitioners’ handbook, RIPFA: Dartington, 20136 Anyone not having eligible unmet need would not get to this point, but would of course have the benefit of information and advice about how maintain their resilience independently. See the asset-based assessment section above

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2: An incident every month

3: Some incidents a month

4: An incident a week

5: Several incidents a week

6: An incident a day

7: Several incidents a day

When making a judgement of overall risk severity and risk frequency assessors were asked to consider the factors in appendix 3. This helps to standardise the social work judgements and is the basis for specific training currently being rolled out to the workforce on risk assessment, see sections below on culture and workforce.

Doncaster’s project team are currently using the overall needs and the overall risk scores to calibrate the RAS grid. This is seen as vital to build confidence in the tool to ensure that the improvements envisaged are delivered7.

The whole person

Once the conversation between service user and professional results in an agreed understanding of needs areas and risk, an agreed amount of money can immediately be allocated subject to review.

Complex ‘black box’ computations are not needed; all that is required is simply:

a) An asset-based assessment

b) A coproduced decision on the unmet need areas, and

c) A coproduced decision on the risk to the customer if these needs are not met

The imperative is then, not on computation but on competent judgement about the ‘whole picture’, a professional’s skill in assessing what, at a whole person level, is going on and what it means. In short – consistent social care worker professional competencies being applied.

Seeing the ‘big picture’ is not something that social workers are always that good at. Research shows that current social work decision making is often dominated by narrow thinking, with a restricted number of hypotheses being developed about what need and risk is, rather than looking broadly for a range of different possibilities for what is happening, and what can be done about it8.

Many of the social work competencies and practice techniques are described in other places, for example, the Research in Practice for Adults (RIPFA) Good Decision Making: Practitioners Handbook 2013, which provides a superb array of decision making principles and tools to help practitioners and team leaders develop competencies in this area. The point is, however, that changing from a black box resource allocation system to a social work competence-based resource allocation process has implication for the workforce, and its culture. Before exploring these aspects, however, it is necessary to attend to some technical aspects of developing a ‘RAS Grid’.

Constructing a RAS grid - populating the table

7 How the cash sums are allocated to the boxes in the table is a separate technical process, described in the section below ‘constructing the ready reckoner’8 Research in Practice 2012; Sheppard and Ryan et al 2003

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Resources have to be allocated to meet eligible unmet needs. Doing this requires a number of principles that need to be adhered to; key ones are transparency and sufficiency9 . However, finding a clear and transparent way of allocating resources to people who have very different needs, in a way that provides sufficient allocations for everyone, and yet doing so without overburdening the public purse, is a complex task. Having a needs and risk matrix for decision takers does not solve the problem of how much resource to allocate. There is a technically necessary step of populating the RAS Grid.

Doncaster’s project team allocated an amount of money for each box in the table in appendix 2 by using data from their current resource allocation system, supported by OLM consultancy. The distribution of cash across the boxes, and the ‘granularity’ (the number of boxes) was reviewed through a testing process. A review was conducted of 260 current cases by a small team of social care workers comprising managers, social workers and assessment officers who work between them across all client groups. This was done theoretically – no changes were experienced by customers, indeed the process was completed without their involvement. The theoretical reviews were conducted using existing case information to derive the factors the new asset-based assessment form is designed to elicit, with project officers viewing the information from an asset-based perspective. The result of this're-assessment' produced data about the number of needs and the level of risk. This ‘placed’ the individual in a box on the RAS grid, which was then compared with their already existing RAS amount.

What the re-assessment process highlighted

Reviewing current assessments in this way was revealing, not just in that it resulted in the population of the RAS grid, but because it showed inconsistencies in the application of FACS and in judgements of risk. This resulted in a new training programme for social care workers; see the culture change section below for more details. The process also showed other very positive things:

1. Social care workers felt re-valued as they were asked to make professional competency-based judgements

2. Amongst service users there were ‘winners’ and ‘losers’ from the process. The net financial effect was neutral (see the technical aspects discussion below)

3. The project team did not feel they had to ‘game’ the RAS because the process by which finances are allocated is clear and meaningful to them, - they effectively were the RAS.

4. The process heavily relies on the competencies of the social care workers with implications for workforce training, budget control and line management (explained in detail below)

Technical aspects of moving to a RAS grid

The initial work on populating the RAS grid took over 6 months, as a small team (4-6 people) took time to review 260 current cases on a phased basis. Management fought the pressure to deliver results, sensing the work was of such significant value that case loads were managed to enable project team staff the time both to do the necessary work, and to reflect to ensure lessons were learned at every stage of progress. The key issue that became apparent in the re-assessment process was that the current (deficit-based) assessment could not be used as a reliable benchmark to assess the performance of the new assessment because the two assessments were doing different things. One was lining up services, and the other was supporting resilience. However, comparison

9 In Control: http://www.in-control.org.uk/support/regional-support/north-west-regional-programme-phase-2-201314/ras-challenge.aspx

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http://www.in-control.org.uk/support/regional-support/north-west-regional-programme-phase-2-201314/ras-challenge.aspx

http://www.in-control.org.uk/support/regional-support/north-west-regional-programme-phase-2-201314/ras-challenge.aspx

of the RAS amount generated by the different assessments resulted in important findings:

1. There are winners and losers whilst the overall amount of money remained the same. What became clear was that most allocations fell into relatively few boxes, and that it was therefore important to get the right degree of ‘granularity’ (number of boxes), so that suitably nuanced decisions could be taken for the majority of people10. Working with an organization like OLM with a broad perspective on RAS methodologies enabled them to develop a highly flexible tool to respond to user profile of need and risk across the local population.

2. Making the matrix suitably granular also helped smooth the ‘cliff edge’ between one needs group to the next one.

3. A significant amount of time needs investing in understanding 'outliers' from the calibration work. There needed to be understanding of the whole case in order to make sense of the results.

4. Double-handling inflator. There was need to recognise that when a service user needed double handling their costs went up markedly, so at whatever level of risk, a double handling inflator was needed. This was set at 30% of package costs, based on social care workers experiences, revised down from an initial 50% rate.

Sufficiency issues

Sufficiency of allocation is of prime concern to users and carers, and of course there is a legal requirement on councils to provide an amount of money that will allow them to meet their needs. However, under the Care Act, the ‘sufficiency test’ is that the council provides the amount of money necessary to purchase the needed care. The acid test for this of course, is whether or not the amounts of money allocated using the resource allocation system would buy the council’s commissioned solutions for day care and domiciliary care. This links the allocation to the cost of these services. This relationship would not change under the new resource allocation system. There will always be a legal requirement to show sufficiency of allocation, and the minimum test will remain the same. Over time councils could develop an awareness of local markets and the kinds of services available to individual purchasers, so that a better test of sufficiency could be generated.

Overall, what the re-assessment of cases showed was that there was no technical reason for not moving to a live testing environment with both the new asset-based assessment and the RAS Grid. But it clearly raised workforce and culture issues which needed to be addressed for the new co-production competency-based operating model to be effective.

3. Workforce issues and culture change

Moving to a live testing environment for the new resource allocation system where the new asset-based assessment is being used for new cases alongside an in-the-field RAS grid tool will be a big step. The previous ‘theoretical’ testing phase has highlighted a number of practical but also cultural issues11.

10 Although there was some debate about this, keeping a simple set of boxes, where most people fall into a small number has the advantage of being straightforward.11 Dr. Celia Harbottle’s role has been to translate the vision and messages of culture change created at Doncaster into training and learning opportunities for front line and support staff in adult services. Her position ‘outside’ of the organisation enabled group facilitated discussions to capture the workforce’s perceptions of change from a historical perspective and then similar sessions were used to test the climate of progress. She then wrote a series of programmes to initially nudge thinking along the lines of the culture change being proposed in Doncaster and then delivered a training exploring putting asset based

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Care planning, purchasing and review

Social care workers need to do more assessments, and they need to be doing them in ways which support independence and resilience, this is particularly acute since the Care Act is likely to impose additional assessment requirements for people who want to start their ‘care cost meter’ running as part of the response to Dilnot’s recommendations on the long-term funding of social care. However, taking an asset-based approach means spending longer doing the assessment and working with the customer to support their personal responsibilities and independence. It particularly requires a different approach to risk (see appendix 5 for a training plan to address risk issues).

Asset-based assessments are likely to take more time, not less. To accommodate this significant increase in assessment resources required, means doing less of other things, namely sourcing and purchasing services. With the right circle of support arrangements in place, be they informal or formal, and with support planning services available should customers need them, there is no need for social care workers to get involved in specifying service solutions often called care planning and purchasing arrangements. As described in the assessment section of this paper, purchasing can be done in relation to a desirable outcome statement, not in relation to a service prescription. It can also be done by family friends or the individual themselves. Indeed, many people probably don’t need a ‘plan’, they just need to know what they have to achieve. This is a major shift in approach and requires systematic workforce strategies and training. It changes the responsibilities people have. One key element is reviews, which can no longer be about an audit of services purchased; it has to be broader and deeper, about resilience, outcomes, health, wellbeing and need. This changes the value base, skills set and competencies needed by assessment and reviewing officers in the field (see appendix 6 for a training plan that addresses culture change).

Shifting the focus of formal social care activity towards assessment and away from provision is not just a challenge for front line social care assessment and review staff; it is also an issue for elected members, unions and senior staff, who might all find their traditional portfolio of issues significantly altered as a result. One such case study is that of Shropshire Council operating as a Social Work Practice Pilot site who created a community interest

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organisation for social work teams, operating essentially externally to the council. This facilitated a quick culture

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change that had proved impossible when the teams were working as part of the council12.

Commissioning and market shaping

Personalisation needs a market which can provide services and products that meet the needs of individual purchasers, a ‘retail’ social care market, rather than the ‘wholesale’ market where councils buy in bulk and pass on the services they purchase to their customers. The current personalised social care market is under developed. The market shaping responsibilities of councils are clearly stated in the Care Act. However, taking an asset-based approach to assessment and a co-produced competence-based approach to resource allocation means a very important set of relationships need to be established between social work assessors and commissioners at the front-line. Supporting customers at assessment stage to remain independent and resilient means social care assessors need to know what is available to support people in their local communities well before formal services become relevant. In turn, social care assessors will quickly learn which communities have informal support and which don’t, i.e. they will become aware of community assets and deficits. They need systematic ways of feeding this valuable information to commissioners so that a facilitative or commissioning response is enabled in a timely fashion.

As part of the whole systems approach to a culture change embedding asset based thinking and working across all of adult services within the council, staff with business support roles were involved in creative conversations (See appendix 6 for programme overview) with facilitated discussions to enable them to see the part they play in supporting and promoting this fundamental shift. This was seen as an essential component in an approach to dissolve the silos which can be created when different arms of a service focus on their area of specialist concern.

This exercise paid dividends with the commissioning and contracts teams. Schwehr (2014) in her Care Act Clause 5 analysis on http://www.communitycare.co.uk/carebillreadinglist alluded to the observation that for many years, commissioning departments have been undervalued.

‘Years of Case Law have shown that commissioning (in the sense of the word that means contracting and procurement as opposed to deciding on general matters of care management) has been disastrously marginalised as a career path, under-resourced in terms of training and encouraged by management consultants to be separated from the very assessment and care planning function that it was supposed to serve, in the interests of that thing called Value for Money.’

Procurement exercises and tendering arrangements have also led to even greater restrictions in choice with cost imperatives potentially over-riding responsiveness and the diversity of provision available to respond to local need. Whilst value for money is important, the less tangible casualty can be flexibility and actual appropriateness of available provision to fulfill desired service user outcomes. Facilitated discussion with the commissioning and contract teams in Doncaster demonstrated the workforce’s awareness of the need for closer and more responsive relationships with the social work teams at the front line of asset based working. With this relationship closely bonded, commissioners argued that they would be more readily able to ensure the procurement of meaningful services. This will, of course, be dependent of the market place’s willingness to step into the arena. To facilitate this, Doncaster is facilitating provider forums to extend the creative conversation to those who would potentially step into the ring.

Line management

One of the main outcomes of moving to an asset-based assessment process and a co-production competence-based resource allocation system is that social care workers have a lot more responsibility in the field. Their

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http://www.communitycare.co.uk/carebillreadinglist

professional skills in engaging with service users to work with them and their circle of support to assess need and their judgement in risk assessment and risk management is critical to success. The skill and judgement of the social care worker will make a big difference to the allocation of money that people can get. Consistency and appropriateness have to be major training points as indicated above, however, line management has to support the social care workers in the field.

Not only do senior managers have to provide appropriate good quality training to enable social care workers to do their jobs, but they also have to change their own supervisory practice. It matters what decisions have been made, and why the decisions were made. Reviewing cases on a random and outlier basis has to become a regular event, but not on a restricted basis of whether or not the care package needs to change, but on whether or not the most was made of assets and whether or not the overall risk and need judgements were made correctly.

One of the main line management responsibilities is that of financial accountability. Who is responsible for the social care budget? Commissioners often hold the budget responsibility, away for front line social care (though by no means always), and this means control over signing off care plans as commissioners manage their responsibilities. However, if social care workers are making professional decisions about how much money people need, if an inappropriate allocation is made, whether too low or too high, it is not a problem of process, it will be one of competence. Budget control needs to support this. Budget responsibility needs to be with the social care team managers, who need to supervise the social care workers closely on a competency basis.

Creative Conversations and facilitated discussion were built into the culture change programme for managers to be able to explore their own thoughts, feelings, anxieties, and thereafter, strategies for supervising and promoting asset based working. From these sessions, what emerged was the importance for managers to be able to language lucidly and succinctly, the aims, objectives, function and purpose of asset based social work to enable supervision of practice and decision making. Clarity and consistency was recognised as necessary to build confidence in the approach as it enabled the emergence of tangibility for a way of working that could, initially feel somewhat ethereal. Team managers engaged in creative conversations with their teams and also as a peer group to enable the exploration of leadership issues.

Effective and positive approaches to risk assessment and risk management are a central leadership message to end cultures of paternalism and risk averse prescription based practice. This requires professional courage and role clarity. Part of the culture change programme was to promote risk and choice and was informed by the tools for evidencing good decisions devised by RIPFA. These practical approaches were introduced to social work teams and managers to bolster practices that demonstrate how decisions have been made. RIPFA alludes to the fact that good decisions may turn out to be wrong decisions but the evidence lies in the process and analysis. Asset Based social work is more likely than care management approaches to identify relationships and circles of support thus recognising networks for risk enablement.

Conclusion

Personalisation is a broad concept. Its scope is well beyond the initial notion of a self-directed support process. It has resonance with the Care Act which enshrines personal budgets as a core concept of adult social care, and it is a shared priority with health and children’s services. The customer experience is however, at the heart of what personalisation means. Getting their journey right is probably the most important aspect of personalisation. But

13

there are currently some significant problems; all too often bureaucracy and process get in the way of outcomes, choice and control. This paper has focussed on two important elements of this problem, assessments and resource allocation.

The argument advanced in this paper is that assessments, post Care Act, whilst being necessarily deficit based to address FACS, also need to have an asset-based focus that is better able to address prevention and early intervention. Before eligibility is identified, assessors need to identify the strengths people have and the ways in which informal assets can be supported to maintain and develop an individual’s resilience and independence. Once eligibility is established, resources need to be allocated but this does not have to be done in a way which obfuscates the key participants, social work staff and the service users and their family. This is the second point of the paper. Resource allocation can be done at the point of assessment based on the competent judgement of the social care assessor and their skills in working with and alongside the service user and their family members. Both the first point – about a different way of doing assessments and the second point – a co-produced competence based resource allocation process bring with them major challenges, namely the need for changes to culture and practice in adult social care. This constitutes the final area of the paper.

The culture change required to deliver new assessment and resource allocation practices represents a major challenge, and some tools and suggestions have been described as to how this might be achieved. The reason councils might think about developing some of the ideas in this paper, and already being trialed by Doncaster’s project team is that the ideas directly address the concerns of service users, best articulated by this council worker quoted at a recent TLAP self-directed support event in Bristol:

“There are too many stages of assessment, contact and supported self-assessment. Then waiting for a RAS and then support planning and review. Each stage the client gets a visit from a practitioner who goes away writes up a report and a big manila envelope drops onto the doormat of clients. The report/assessment/support plan is often unintelligible to clients as they haven’t written it. Equally when we have asked clients to fill out the paper themselves we’ve had them in tears on the phone because they don’t understand it and it’s too long and daunting. The practitioners don’t spend enough time with the clients to really get to know them and develop person-centred plans.”

Doing different kinds of assessments, focussing on professional competent decisions on resource allocation coproduced with customers and addressing workforce issues addresses the problems with current self-directed support pathways. The new customer pathway reduces a complex black box RAS to a co-produced decision about needs and risk between social care worker and service user, at the time of assessment. There is then only need for a review a few weeks later, to check on sufficiency issues. It removes bureaucracy and process it focusses performance and financial management on to front-line social work, the judgements they make in the field and the evidence for them. But it is the broader approach to assessment which makes the difference and which is a key factor for success, and which readies social care for the new duties in the Care Act. We hope this document helps in some way to provide some useful tools and ideas to move these issues forwards.

AppendicesAppendix 1

14

Assessment of Care and Support Needs

Part 1: – For the Service User

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Community Care Assessment1) How We Will Use The Information On This Form

Please read this section carefully. It explains how we will use and share the information about you that we collect on this form.

Data Protection Act 1998

The information collected on this form about you will be used to assess your need for help, advice, support and care and to manage and plan services which may meet your needs, both now and in the future, to the highest possible standards.

We may need to share your information with other relevant people, departments and agencies, for example your carer(s) or your GP. We will not do this without your consent unless there are legal reasons for this, such as to prevent a crime or to safeguard vulnerable people.

Departments are also required to provide statistics about their performance to the Government. However, your personal details will not be included in these statistics.

This form will be stored securely and kept for up to six years after your last contact with the Department.

You have the right to see information we hold about you at any time.

Consent to share the information on this form

Once this form has been completed, your Social Care or Health Worker will ask you to sign to say that you agree to the information being shared with other relevant people and agencies in accordance with the statement above.

This will include giving your agreement to the information being shared with the Financial Assessment Visiting Team, Housing and Council Tax Benefits, Welfare Rights and The Pension Service. This is for the purpose of considering entitlement to benefits, sharing the results of any benefits claimed and calculating social care charges.

You will be able to withdraw your consent at any time by contacting the following address:

Financial Assessment Visiting Team

Civic Office

Waterdale

social work into practice. This programme commenced with the Creative Conversation, and was then followed by training exploring positive approaches to risk. This course was known as Risk and Choice in Asset Based Social Work. It examined approaches by which social workers and social care assessors could evidence the making of robust decisions. ‘Doing Asset Based Social Work’ examined the role of the social worker at the interface with the state and the individual and considered Doncaster’s new leaner processes for assessing people from an asset based perspective. The next stage will be to embed the RAS into practice.12 For example, ‘People 2 People’ Shropshire Council 2013 http://www.shropshire.gov.uk/adult-social-care/people-2-people/. The NDTI are working with the Council to monitor efficiencies and effectiveness. Details of other social work practice sites are here: http://www.scie.org.uk/workforce/socialworkpractice/pilots.asp

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http://www.scie.org.uk/workforce/socialworkpractice/pilots.asp

http://www.shropshire.gov.uk/adult-social-care/people-2-people/

http://www.shropshire.gov.uk/adult-social-care/people-2-people/

Community Care AssessmentDoncaster,

DN1 3BU

Tel 01302 735336

Your Social Care or Health Worker will discuss with you any information that you do not wish to be shared. You will be able to provide details of this at the end of the form.

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Community Care Assessment2) My Personal Details

Title Mrs First Name Maureen Last Name

Smith

Preferred Name

Address:

Property Name (if applicable)

Property number and road name 24 Station Road

Area Bentley

Town Doncaster

Postcode DN5 2PG

Telephone Number

CareFirst Number P 2 3 4 5 6 7

NHS Number 41043484530

DOB 04 01 34

3) Decision Making

This section is for completion by your Social Care or Health Worker.

Do you consider the Service User lacks the capacity to make decisions in any area relevant to this assessment?

Yes No

If YES, record the specific decisions below and complete form MCA 1 and MCA 2 as appropriate:

Mrs Smith lacks insight in relation to managing household accounts/finances and understanding care needs.

4) My Advance Planning Arrangements

This part is about any arrangements you have made for making decisions on your behalf if there comes a time when you are no longer able to make decisions by yourself.

a) My Property and Affairs

Have you made an Enduring or Lasting Power of Attorney to deal with decisions about your Property and affairs when you are no longer able to make decisions yourself?

Yes No

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Community Care AssessmentIf yes, has the Attorney registered your Enduring or Lasting Power of Attorney?

Yes No

If yes, please give contact details below and please note that a copy will be required:

Title First Name

Last Name

Preferred Name

Address:


Property number and road name

Area

Town

Postcode

Telephone Number

b) My Care and Welfare

Have you made a Lasting Power of Attorney to deal with decisions about your care and welfare when you are no longer able to make decisions yourself?

Yes No

If yes, has the Attorney registered your Lasting Power of Attorney? Yes No

If yes, please give contact details below and please note that a copy will be required:

Title First Name Last Name

Preferred Name

Address:



Area

Town

Postcode

Telephone Number

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Community Care Assessment5) My Money

a) Appointee

Has someone else been appointed to deal with your money? Yes No

Are they your Appointee for your social security benefits? Yes No

If yes, please give contact details below

Title First Name

Last Name

Preferred Name

Address:



Area

Town

Postcode

Telephone Number

b) Court of Protection

Has the Court of Protection appointed a Deputy to deal with your finances?

Yes No

If yes, please give contact details below

Title First Name

Last Name

Preferred Name

Address:



Area

Town

Postcode

Telephone Number

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Community Care Assessment6) A day in my life ……….

Describe a typical day of your life from when you wake up. Think about the things you do every day and whether you do them by yourself or with help and support. For example think about how you:

look after yourself and those you care for (e.g. a child, parent or partner)

manage any health conditions or disabilities and manage your medication

move around your home (both inside and outside)

The things I tend to do every day from when I wake up ……..

Frank wakes me up at 7am and brings me a cup of tea in bed. He helps me to sit up and prompts me to take my tablets. Frank gets my clothes ready and then helps me to get out of bed and takes me to the bathroom. I sit on the toilet while Frank changes my continence pad and then he gives me a flannel and I try to wash myself. Frank helps me with the places that I have missed.

We go back to the bedroom and I sit on the bed and Frank helps me to get dressed. I struggle to fasten buttons, zips and put on my underwear. Frank helps me brush my hair before we go downstairs.

Frank walks in front of me and I hold the banister when we go downstairs. I have two walking sticks; one for upstairs and one for downstairs.

Once down stairs I try and set the table while Frank makes breakfast and then we feed the cats.

We sit at the kitchen table to eat breakfast, sometimes Frank has to help me to butter my toast or put milk on my cereals.

I go to my chair in the lounge and listen to my music while Frank cleans away the breakfast pots.

I frequently need to use the toilet throughout the day, especially in the morning and Frank will always help me. I don’t always get to the toilet on time and so I wear pads.

I tend to spend most of my day in the lounge listening to the radio or watching the telly. I used to love knitting but since my second stroke I struggle to hold the needles.

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Community Care AssessmentThe things I tend to do every day from when I wake up ……..

I used to do all the cooking and household chores but since we retired and my health has deteriorated and Frank now does the majority but I still enjoy helping when I can.

I wait for the daily paper to arrive and when the postman’s been Frank sorts the post while I look at the paper.

We eat our main meal at midday which Frank prepares and cooks while I try and set the table. Frank helps me to cut up my food as I find using a knife difficult and he will give me my tablets.

After dinner Frank washes the dishes and he will potter about the house or in the garden if the weather allows. I will sit and watch him when the weather is fine but I need some help to use the steps to get into the garden.

I have a nap in the afternoon and then we will have tea around 5pm.

We sit together, watch telly and have supper I enjoy watching the soaps. Frank will get the cats in and lock up, we will then go to bed after the news at ten. He walks behind me up the stairs to the bathroom where he helps me undress and wash ready for bed and Frank gives take my bedtime tablets.

7) A typical week of my life ……….

Describe your typical week and the things you tend to do on different days. Also tell us about any days where you do not get the help and support that you told us about for question 5.

My typical week ….

Monday …..

On a Monday we will do all the laundry. I will help Frank to fold the clothes.

Tuesday …..

We used to go into town on a Tuesday for market day but I cannot manage this anymore unless someone picks us up and takes us by car as I can’t use public transport. My Granddaughter will sometimes take us if she gets time, she will also do a bit of cleaning for us.

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Community Care AssessmentMy typical week ….

Wednesday …..

We like to go to the local pub for lunch on a Wednesday as it is over 65’s special and we get a discount. The landlord picks us up at 1pm.

Thursday …..

Frank will go to collect our money from the post office and pay the bills. My next door neighbour Valerie will pop round for an hour for a cuppa and chat whilst Frank is out. I enjoy Valerie coming round I enjoy her company and having someone else to talk to.

Friday …..

I go to memory clinic, I get picked up at 9:30am and am home for tea time.

Saturday …..

My son Michael comes from Sheffield most Saturday mornings with his wife Tracy. Michael takes Frank to do the weekly shopping. Tracy will stay with me and she washes my hair, paints my nails and keeps me company. Michael has recently got a new job and he now has to work Saturdays so will not be able to support Frank with the shopping.

Sunday …..

I used to go to church on a Sunday but it is now too far for me to walk and because Frank does not drive anymore I cannot get there. I do miss going and seeing my old friends.

8) Who is Important to Me?

This part of the form is about who is important to you and who helps to support you. For example:

Family members or friends

Neighbours or people from your local community (e.g. members of local clubs, voluntary organisations or places of worship)

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Community Care Assessment Professionals (e.g. doctors, community nurses, counsellors or support workers)

Paid supporters or helpers (e.g. cleaners or gardeners)

Who is important to me?

Their role or relationship to me

Why they are important to me / how they help to support me

Frank Husband Franks Helps me with everything.

Michael Son He tries to visit every week. He used to be able to help with shopping. We speak on the phone most days.

Tracy Daughter in law Always comes with Michael as she does not drive. She helps me to wash my hair and set it. She will also do a bit of ironing.

Valerie Neighbour / Friend Pops in on a Thursday while Frank is out and if he needs to go to any appointments.

Lucy Granddaughter Comes on Tuesday and sometimes takes us into town and does a bit of cleaning for us.

Memory Clinic NHS I go there on a Friday, meet new people and have my lunch.

9) What’s Important to Me?

Think about the things that are important to you and you want to do but can’t. What’s stopping you from doing these things?

My wish list of the things I would like to do but can’t ….

What’s stopping me from doing the things on my wish list? …..

Going to Church I have no transport

Going to Doncaster Town Shopping on a Tuesday.

I cannot walk long distances or use public transport due to my poor mobility.

Knitting I struggle to hold my needles since I had my stroke.

My hair to look nice and to wear some make up. I cannot do this for myself and Frank has too much to do already. I have always took pride in my appearance.

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Community Care Assessment10) Summary of Assessment

This part of the form is for your health or social care worker to record a summary of the overall assessment.

Assessment conclusion including FACs eligibility, evidence to support FACs eligibility, actions, advice, specialist assessment and signposting discussed.

Brief outline of the current situation

A referral was made by Michael Mrs Smith’s son as he felt Mr Smith was struggling to support his wife. A referral was made into ACT and assessed as having no rehab potential by STEPS therefore was referred to area team.

Mrs Smith is 80yrs old and lives at home with her husband Frank 82yrs. They have lived in the same house for over 30yrs and managed a Green Grocers shop in their local community for many years before retiring. They have one son (Michael) who lives in Sheffield and works fulltime, his wife Tracy does not drive and only visits with Michael. Until recently they visited regularly on a Saturday however due to Michaels job changing he can no longer commit to visiting every week.

Michael and Tracy also have a daughter Lucy who lives in Doncaster and she visits her Grandparents twice a week if possible. Lucy previously took her Grandparents into town on Tuesday but this is becoming increasingly difficult due to Mrs Smith’s reduced mobility and cognitive decline. Lucy will also support Frank with some Household chores.

Mrs Smith was diagnosed with Vascular Dementia following her second stroke in 2012 which left her with left sided weakness and poor mobility and uses a walking stick. This information has been verified by Memory Clinic. At this time she is attending Forrest Gate Memory Service however this is due to finish following 12 weeks assessment. Mrs Smith was diagnosed by GP with Osteoarthritis in 2009 and this affects her posture, knees and hands in particular. Mrs Smith also wears glasses for reading and watching the television. Mrs Smith also wears continence aids that are purchased privately, but awaiting an assessment from Continnence service. This is due to poor mobility which impacts on Mrs Smiths ability to get to the toilet on time even with husbands assistance.

Mrs Smith is prompted to take medication throughout the day for various medical conditions by her husband

Carry out personal care:

Mr Smith provides daily prompts, support and supervision with all aspects of personal and continence care. Due to Mrs Smith’s cognitive decline and Mr Smith's deteriorating health he is struggling to provide the level of 1-1 support that Mrs Smith requires in order to meet her personal hygiene needs and is

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Community Care AssessmentAssessment conclusion including FACs eligibility, evidence to support FACs eligibility, actions, advice, specialist assessment and signposting discussed.

thereby at risk of unintentional self-neglect. Mr and Mrs Smith sleep in the same room and occasionally Mrs Smith requires support to use the toilet during the night due to disorientation and mobility issues.

Preparing and having food and drink:

Mr Smith prepares all food and drinks but encourages and prompts Mrs Smith to make cold drinks and take part in some simple preparation of meals. Mrs Smith requires some foods to be cut up by her husband due to left sided weakness and osteoarthritis.

Household activity / Management:

Mr Smith manages most aspects of daily living however strives to include Mrs Smith in all decision making as much as she is able. Granddaughter supports with some cleaning on a weekly basis and son previously supported with weekly shopping however is not able to continue with this due to personal circumstances. Without this support Mr Smith will find it extremely difficult to complete these tasks.Mrs Smith struggles to access the bathroom/toilet independently due to it being upstairs and decreased mobility as a result of left sided weakness. Mrs Smith also requires assistance to negotiate the steps at the back door and 1-1 support outdoors because of cognitive decline and poor mobility.

Carrying out tasks of being a parent:

No needs

Relationships with family / friends:

Mrs Smith relies on 1-1 support to be taken out. At this time family and friends tend to visit her in her own home and are happy and willing to continue. Once a week Mr and Mrs Smith go to the local pub for lunch with transport provided by the landlord. She has regular telephone contact with her son but due to cognitive impairment she is unable to use the phone independently to maintain family relationships.

Being part of the community:

Currently Mrs Smith attends Forrest Gate Memory Clinic once a week and this is due to end shortly. Mrs Smith has benefited from this service and enjoyed the social stimulation and therefore a suitable alternative needs to be explored.

Mr and Mrs Smith were active members of the local church and since her decline in health and Mr Smith relinquishing his driving licence they have been unable to attend. This is something they would both like to

26


resume.

Mr Smith co-ordinates all medical appointments and attendance and family will support with transportation.

Keeping safe:

Mrs Smith requires support and supervision with the majority of tasks due to cognitive decline and poor mobility. She cannot be left unattended for long periods of time due to a risk of falls and becoming increasingly anxious. Valerie, Neighbour will sit with Mrs Smith to enable Mr Smith to collect pension, pay bills and have a break from his caring role.

Mrs Smith requires prompts for all medication needs throughout the day.

Due to poor mobility Mrs Smith is at a high risk of falls and has fallen twice in the last 3 months. When using the stairs Mr Smith walks in front when descending and behind when ascending, to provide prompts and guidance. However due to continence issues and lack of downstairs facilities this happens several times each day increasing the risk to both Mr and Mrs Smith.

Mrs Smith is unable to access the rear of the property due to high steps.

Mr Smith completes all financial management tasks and household budgeting due to Mrs Smith’s cognitive decline. There is no formal arrangement in place to manage this at present.

Behaviour needs:

No needs

Communication / sensory needs:

Mrs Smith can speak and understand the English language but due to cognitive decline requires clarification and prompts to participate in conversation.

27


Mental well-being / Psychological:

Mrs Smith experiences separation anxiety if she is separated from her Husband for long periods of time. Son and Daughter In Law, neighbour and Granddaughter offer support to stay with Mrs Smith when Mr Smith needs to go out. This reduces anxiety and Mr Smith has a break from his caring role.

Carer support needs:

Mr Smith is the main carer for his Wife. He supports her over a 24 hour period with personal care, toileting needs/hygiene, keeping safe, food and drink, emotional support and daily household tasks. In addition Mr and Mrs Smith’s family and neighbour support throughout the week with shopping, respite sits and transport to appointments. However, Mr Smith is struggling to maintain his level of support due to his own health needs and Mrs Smith’s deterioration. He is becoming more reliant on others to maintain Mrs Smith safely in their home environment. Due to personal and professional circumstances existing support networks are unable to sustain their current levels of support. When this level of support is withdrawn Mr Smith will be at significant risk of carer breakdown.

Medical and Health Conditions (including source of information and medical confirmation)

Medical condtions ascertained from Mr and Mrs Smith at point of assessment.

Confirmation of Vascular dementia diagnoses via Forest Gate Memeory clinic on 01/04/2014.

Confirmation re Osteoarthritis gained via MDT /health database on 01/04/2014.

FACs Eligibility Decision:

Low Moderate Substantial Critical

Social Care Worker’s Evidence to support FACs eligibility decision:

Mrs Smith has been assessed in accordance with the NHS and Community Care Act 1990 and under Fair Access to Care Services 2003. Mrs Smith experiences a substantial risk to her independence, thereby meeting departmental eligibility criteria for community support services.

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In accordance with the Mental Capacity Act 2005 and abiding by the 5 principles of the act on the date of my assessment, it has been determined that although able to participate, Mrs Smith does not have capacity to consent to the assessment process. Mrs Smith does not have capacity to manage financial affairs or understand her level of care needs.

MCA 1 and 2 have been completed.

The assessment identifies Mrs Smith's eligible needs as :

* personal care

* practical aspects of daily living

* being part of the community

* keeping safe

* communication

* psychological

* support for main carer.

* preparing food and drink

* relationships with family and friends

The following needs are met by Mrs Smith's circle of support

* preparing food and drink

* relationships with family and friends

The assessment therefore identifies Mrs Smith as requiring council assistance for the following eligible unmet needs:

* . personal care

* . practical aspects of daily living

* . being part of the community

* . keeping safe

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* . communication

* . psychological

* . support for main carer

Whilst Mr Smith is able to meet some aspects of Mrs Smith's care there will be an inability to carry out the majority of personal care or domestic routines. Mr Smith is at significant risk of carer breakdown if he is not supported in his caring role due to his own deteriorating health.

Mr and Mrs Smith’s family are unable to continue with their existing level of support thereby the majority of social care support systems and relationships cannot or will not be sustained.

As Mrs Smith is unable to live independently due to cognitive and physical decline there is or will be only partial choice or control over vital aspects of the immediate environment.

CHC Checklist Completed Yes No

Is DST required? Yes No

Current Funding Sources: (Please tick as appropriate)

Joint Continuing Healthcare Local Authority

Specify % Split: Other (please state below)

Health % is: % LA % is: %

Fully Funded Continuing Healthcare

11) My Unpaid support

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Community Care AssessmentThis part is about any unpaid support you already receive and will continue to receive, for example from family / friends / neighbours / people within the local community.

Please tick which statement applies

A I get some / all the support from my family, friends, neighbours and others within the community

If you have chosen A, your Assessor will ask your carer(s) to complete Part 2.

Part 2 can be completed with your carer and you at the same time. If caring for you has a substantial or critical impact on your carer or they wish to be assessed separately, then the assessor will offer them a separate carer’s assessment and time to discuss their caring situation in more detail.

B I do not have any family, friends, neighbours and others within the community who are able to support me. I need to have support to meet my needs.

12) Signing This Form

a) My Consent to share the information on this form

Please refer to section one of this form before you complete this section and sign below. Section one explains how we will use the information on this form.

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Consent to share the information on this form

Do you consent to the information on this form being shared at this stage?

Yes No

Is there certain information that you do not wish to be shared?

If yes, provide details below.

Yes No

Requested limitations in information sharing

Please indicate below any limitations requested by the person.

Has the service user been made aware of consent issues detailed under section one of this form?

Yes No

If the Service User is unable to give consent please tick here and specify why below:

Mrs Smith does not have capacity to consent to information sharing.

Mr Smith has given consent re information sharing as Mrs Smith's representative.

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Appendix 2

Need areas----------->1-2need areas

3-4need areas

5-6needs areas

7-8needs areas

9-10needs areas

11-12needs areas

Low risk if outcomes are not achieved(1-7 on Risk Matrix)

A B C D E F

Medium level risk if outcomes are not achieved(8-14 on Risk Matrix)

G H I J K L

High risks if outcomes are not achieved(15-21 on Risk Matrix)

M N O P Q R

Very high risks if outcomes are not achieved(22-28 on Risk Matrix)

S T U V W X

Social Care Worker to use professional judgement to answer the following questions following reference to the Risk Severity and Risk Frequency definitions:1. Number of needs areas (0-12 in groups of two, i.e. 1-2, 3-4 etc., to form the x-

axis number)

2. Risk Severity 1-41: Restricted independence

2: Moderate threats to independence

3: Serious threat to Independence

4: Immediate risk of harm/neglect/crisis

3. Risk Likelihood 1-71: Occasional incidents

2: An incident every month

3: Some incidents a month

4: An incident a week

5: Several incidents a week

6: An incident a day

7: Several incidents a day

Multiply the answer to Q2 (above) by the answer to Q3 (above) to achieve the total score (1-28), to form the y-axis number, banded as set out on the next page:

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Appendix 3

Risk frequency descriptors

When making a judgement of overall Risk Frequency consider the following factors:

Cumulative effect of the risk: What is the cumulative effect of the risk in the context of the circumstances of the case being considered. For example, if the service user is insulin dependent, is unable to manage own medication and family members who provide support visit on an infrequent and irregular basis, the frequency of the risk is likely to be high and is likely to be "several incidents a day." In contrast, if the service user is insulin dependent, is able to manage own medication and family members who provide support do so on a regular and reliable basis, then the frequency of the risk will be less than the previous example.

Risk without funding for support: If the service user currently has paid support in place via an existing personal budget (e.g. a carer funded by social care funding) that is enabling the service user to maintain their independence, consider the risk associated with the unmet needs based on the service user not receiving the funding. The funding currently being received needs to be factored in to the calculation for the RAS to enable the service user to continue to have the support in place.

Falls: Consider the risk of falls. Has the service user fallen recently? How many falls has the service user had recently? How long is the service user left alone? Is a carer present all / the majority of time and if so does this result in reducing the risk of falls? Is a telecare solution in place to help manage the risk of falls?

Risk of neglect: Consider whether the person lives on their own or whether someone else lives in the same property as the person e.g. wife / husband. Are there informal carers or does the person not have anyone to help support them?

Risk severity descriptors

Restricted independence: Reduced ability to maintain daily routines / difficulty in maintaining daily routines. Minimal support needs. E.g. on a weekly basis / 2 or 3 times a week. E.g. a shop call or a respite sit, carer respite once or twice a week.

Moderate threats to independence: Requires some daily support but only once or twice a day. Might require help in a morning and help at night. E.g. personal care, medication prompt, help with daily aspects of living / routines, support to get out, SECs.

Serious threat to Independence: Requires frequent support across the day e.g. more than 2 visits. Maximum support package. Predicatable. Stable packages of support aimed at preventing breakdown. Regular, frequent support, multi-agency solution. E.g. respite care required. Preventing carer breakdown.

Immediate risk of harm/neglect/crisis: Most complex care packages, potentially with 2 carers or high levels of intensive intervention. Multi-ageny solution, highly specific to individual needs. Possibly result of crisis or unpredictable change in needs. Requires support during the night. More vulnerable at night e.g. night sits.

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Appendix 4

Draft Care and Support Plan 1) My Personal Details

Title Full Name Date of Birth:

Address CareFirst Number NHS Number

2) My Support Needs and My Personal Outcomes

My Support Needs My Personal Outcomes / Goals

How this need will be met informally through my circle of support (if relevant)

Eligible for Council assistance?

How this need will be met by my Personal Budget? (if relevant)

Behaviour Needs

35





Being part of the community

Carer Support Needs

Carry Out Personal Care

Carrying out tasks of being a parent

Communication / Sensory Needs

Household Activity / Management

Keeping safe

36





Mental Well Being

Preparing and having food and drink

Relationships with family / friends

Complex health needs

3) BUDGET MANAGEMENT OPTION DECISIONTo be completed by your Social Care or Health Worker. This part of the form is for your social care worker to record the budget management decision option

Budget Management Option

Please tick as appropriate: Direct Payment Managed Account

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Indirect Payment Traditional Service

Reason for Chosen Budget Management OptionSocial care worker summary of judgement around risk to the public purse and the reason for the chosen budget management option indicated above. Make reference to risk assessment/decision support tools used.

4) BUDGET

My starter budget amount (annual): ______________________ My contribution (annual): _______________________

Direct Payment Amount (if relevant): ______________________ Frequency of payments: ______________________(if Direct Payment)

Planned payment/service start date: ______________________

Any further relevant information (this may include: weekly or monthly amount, weekly or monthly contribution, one-off payment information):

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5) SERVICES PROVIDED BY THE COUNCIL

6) INDIRECT PAYMENT (Suitable Person)If you have chosen to receive all or part of your Personal Budget as an ‘Indirect Payment’, below are the details of the person you have chosen to receive your Personal Budget on your behalf.

This person is called the ‘nominated person’ or ‘Direct Payment Recipient’. All correspondence about your Direct Payment will be sent to this person.

Name: Address:

Postcode:

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If some or all of the budget will be taken as Council commissioned services, please note the details here. These details will be used to help set up service arrangements.

Telephone Number:

7) FIRST REVIEW DATE

8) SIGNATURES

Customer signature: _________________________ Suitable Person signature: ________________________

Date: _______________ Date: ______________

Carer signature: _____________________________ Worker signature: ____________________________

Date: _______________ Date: ______________

Team Manager signature: _____________________________

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Date: _______________

9) KEEPING INDEPENDENT

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Appendix 5

Lesson PlanRisk and Choices in Social Care

Trainers: Celia Harbottle

Course programme: 1 day

Topic: Risk and Choices in Social Care

Location: TBC

Learners: 20

Date: TBC Time: 9.30-4.00

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Aims:This one day programme aims to examine positive approaches to risk and choices in asset based social work. It builds on previous programmes which explored FACS and creative conversations about asset based social work. It acknowledges that staff will be well aware of the contents of the course but the day provides the opportunity to explore the issues and their roles in a safe place so that they can reflect on what, culturally needs to change to embed asset based approaches in their practiceObjectives:This will be achieved via consideration and examination of the following:

• The Current Context and the Rights of anyone who comes into contact with Social care services

• The responsibilities of Social workers/social care assessors/care co-ordinators and care managers in upholding service user rights and the responsibilities of provider services, commissioning teams, families and the client themselves.

• Examining the context of social work in asset based approaches to explore accountability in the role

• The policy framework including Care and Support Bill 2012, DoH Independence Risk and Choice and DoH Nothing Ventured, Nothing Gained within the transformation agenda, Putting People First and DMBC’s modernisation agenda

• Examination of the risk relationship between capacity, capability, circumstances and trade off

• The professional role exploring duty of care, negligence and accountability, decision making and confidentiality

• Assessing risk and when a risk management plan is necessary while focusing on the outcomes that would make service user’s lives, better

• Defensible decisions and working in partnership with service users, carers, and other agencies

• When situations are complex – eg. risk enablement, safeguarding and capability issues

Outcome:By the end of the session participants will have been able to explore assessing risk whilst promoting choices to enable service users to achieve the outcomes which would make their lives better and would maximise their assets and strengths in their communities

Links to Previous Session: N/A

44

Time Time spent

Content Facilitator Activity Learner Activity Resources Differentiation

9.30 5 mins Course and Tutor Introduction. Housekeeping/ H&S

Welcome Sign Attendance sheet

PowerPoint 1Laptop/Projector

9.35 5 mins Session Overview and Learning Outcomes

Discuss aims and objectives – programme of session

PowerPoint 2,3,4 Encourage hopes and aspirations for the day

9.40 20 mins Learner Introductions and Identify Prior Learning/experience from asset based conversations and FACS training

Facilitate discussions re prior learning, prior experience, including training and job experience

Introduction – informal Q & A

Listen and encourage all contributions and show genuine value of the experiences shared

10.00 10 minutes

Group Activity to identify knowledge the rights of people who use the services

4 or 5 groups, each to discuss:What is your understanding of the rights of SU incl. statutory and ethical rights

Work in small groups to discuss, including examples (any setting). Record key points on flip chart

Pens/Flipchart paper for each group

10.10 20minutes

Feedback from Group Activity Ask each group to feedbackDiscussion teasing out principles of good practice and statutory rights (plus right to take risks,)

Nominate spokesperson to feedback

Emphasise rights based perspective as the context for FACS and risk assessmentThe right to self- determination and the maintenance of an individual’s strengths

45

10.30 15 mins Responsibilities in upholding/promoting those rights: sw/care manager, provider, commissioners of services, clients and families

Group exercise in which delegates are identify responsibilities across the sector

Encourage delegates reflect on the partnerships between the relationships here

Agree/disagree cards, bluetack

Emphasise responsibility in terms of duty of care

10.45 15 mins

Refreshment break

11.00 45 minutes

Perception of risk across the sector

Group exercise (4/5 per group, each group with a different focus:

What does risk mean to managers? and how do they investigate incidents

What does risk mean to practitioners and what do they understand by the blame culture?

What does risk mean to service users and would their views reflect the concerns of the above

Opportunity to raise queries and openly discuss the issues raised by each group in feedback with the whole group.Consider policy and procedure for guidance on risk assessment

Flip per groupPowerPoint slide

Emphasise professional responsibility, partnership with service users and policy guidance, namely DoH docs Independence, Risk and Choice and Nothing Ventured;Nothing gained

12.30 45 mins Lunch Break

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1.15 30 mins The risk relationship. Explain the framework for consideration which entails: the activity, the capacity and capability of the individual, circumstances and trade off

Questioning and clarification of legislation and DCC policy incl. MCA ’05, FACS guidance and DoH publications

PowerPoint slideHand out

Encourage discussion with regard to looking at this in terms of risk to independence.

1.45 60 mins Evidencing the risks and ways in which they can be managed in an asset based approach to outcomes focused practice

Case discussion of practice situations where risk management plans are necessary

Case study work in pairs to apply the criteria and evidencing defensible decisions

Powerpoint, hand out and case study material

Opportunity to consider the evidence base for decisions.

2.45 15 mins Afternoon break

3.00 20 mins The Professional role Discussion focusing on Duty of Care, Negligence, Accountability, Confidentiality and Decision Making

Consideration of the issues when there are complaints, conflicts and the role of the worker

Powerpoint Opportunity for delegates to share their views and experiences

3.20 30 mins

Defensible decisions, Risk Enablement and decisions that require a wider policy overview such as Safeguarding situations

Evidence base of best practice to make decisions when there are simply unmanageable risks but a duty of care is owed

Consideration of the function and purpose of Consultation and agreement

Powerpoint and handout

Emphasise that collective decision making helping to evidence when there is conflict and/or non/compliance

3.50 10 Recap and summing up Chance to recap the day, Evaluation and Evaluation form and Encourage questions

47

mins evaluate against objectives and identifying any gaps

conclusion Certificates

4.00 Goodbyes

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Additional NotesThe session is informed by the trainer’s up to date knowledge and understanding of policy developments and legal frameworks including the role of the IMCA service, the interface between safeguarding adults and personalisation. DoH publications to support practice are referred to namely Nothing Ventured; Nothing Gained, Independence. Risk and Choice and reference is also made to the DoH Adult Social Care Outcomes Framework (ASCOF) Domain 4 2011/12, The Care and Support White Paper 2012 and TLAP, Local Area Coordination: 2012. DMBC’s policy initiatives are also included

Assessment Methods : Formal & Informal Q & A’s, Case Studies, Discussion , Observation and EvaluationEvaluation of SessionWere learning outcomes met?

Were resources used effectively?

Did learning checks demonstrate that learning has taken place?

Any other comments?

Facilitator signature:

Date:

Appendix 6

Lesson PlanCreative Conversations Exploring Asset Based Social Work

Trainers: Dr Celia Harbottle

Course programme: 1 day

Topic: A course exploring the evidence base and practical skills for a culture shift in Social Work practice

Location: TBC

Learners: 20

Date: TBC Time: 9.30-49

4.00

Aims:This course has been devised to enable social workers to examine the evidence base and current policy context indicating a need for a cultural shift in social care provision underpinned by a re-defining of the social work role. It will explore the need for change and what is meant by asset based social work. It will reflect on pre-existing skills – under used in traditional care management approaches and help workers to identify practical ways of modelling practice to support the outcomes of Putting People First: Choice and Control, Universal Services, Prevention and Social Capital

Objectives:This will be achieved via a range of teaching methods including lecture, discussion, group work and case study material. It will consider:

• The Context – What are the drivers for this: a need to rethink adult social care provision and the role of the social worker in spear-heading a move away from traditional service models to approaches maximising and utilising community capacity.

• The critique – Consideration of the shortfalls created historically in the NHS and CC act 1990 and the emphasis on the social work role as care manager, the mixed economy of traditional provision and the loss of the role of the social worker as the agent of social change.

• The evidence base – Exploring research and policy evolving from Think Local Act Personal, the Centre for Welfare Reform and the DoH including Local Area Co-ordination, Bob Hudson’s and Mansthorpe et al’s analysis of asset based communities, LGA and IDeA analyses of community, neighbourhood and place shaping.

• Consideration of Citizenship – Analysis of what this means and practical approaches to supporting this as a personal and social construct, using systemic theories to inform models of working.

• The picture in Doncaster – ways in which DMBC are supporting this model including the roll out of the emarketplace.

Outcome:By the end of this session, participants will have had the opportunity to explore the need for a culture shift in social work whilst recognising that they have the core skills to make it successfully. They will have considered the wider evidence base for asset based social work and will be able to see its place in DMBC’s way of working

Links to Previous Session: N/A

50

Time Time spent

Content Facilitator Activity Learner Activity Resources Differentiation

9.30 5 mins Course and Tutor Introduction. Housekeeping/ H&S

Welcome Sign Attendance sheet PowerPoint 1Laptop/Projector

9.35 5 mins Session Overview and Learning Outcomes

Discuss aims and objectives – programme of session

PowerPoint Encourage hopes and aspirations for the day

9.40 40 mins Group Activity to explore Alex Fox’s questions: ‘how can we effect a radical change in a care and support system suddenly starved of money?’‘How can we not?’

4 or 5 groups, each to discussboth of these questions and to pool ideas, feedback to wider group

Reflection and discussion

Power point and flipchart

This will encourage delegates to examine the reasons for change for themselves, examining their fears and hopes

10.20 15 mins Lecture: the drivers in the form of CSCI’s critique of the State of Social Care 2006, Cutting the Cake Fairly 2007, Putting People First 2007

Short lecture outlining the early reports highlighting shortfalls in Traditional service provision and the evidence base for change being necessary

powerpoint Context illustrating recognition of the need for change long before the financial crash.

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10.35 25minutes

What is Social Work? Group discussions analysing what the social work role entails.The skills?The legal context?The moral and ethical context?

Encourage open discussion

Consideration of whether social work and care management are one and the same; what social work actually means if it is not being an agency functionary but is regaining its role as an agent of social change.

11.00 15 mins Refreshment break

11.15 60minutes

What is a community?What is Citizenship?What are Universal services?What is an asset based approach?

Lecture, group work and discussion drawing on the discussions from before break considering the literature exploring the context of community as the practice arena for social work.

Powerpoint Local Area Co-ordination descriptors, Hudson’s overview of asset based community work, Mansthorpe et al’s LGA work examining place shaping

12.15 15 minutes Reflection on the current system and contrast with an asset based approach

Lecture and discussion reflecting back on the examples raised at the beginning of the session

Questioning and exploring issues and evidence

powerpoint Brief touch on asset based social work as an introduction to the afternoon’s session

12.30 45 mins Lunch Break

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1.15 5 mins Recap morning’s session Seek any questions from the group

1.20 25 mins Asset based social work as an approach to future practice

Lecture/discussion exploring the strengths based, preventative model that builds capacity in the wider community

Examination of the evidence base

PowerpointDiagram: (Martin’s Onion

Consideration of what is needed: reversing the crises led pattern, building on personal strengths, connections with the community and transformation (changing the whole system)

1.45 45 mins Building on relationships and exploring what makes a good life for individuals

Lecture and discussion exploring personal and social models of citizenship underpinned by research and evidence from the Centre for Welfare Reform

powerpoint Exploring the personal perspective on citizenship to move from deficit based models to strength based approaches

2.30 15 mins Refreshment break

2.45 30 mins Using approaches to help people to identify their assets

Modifying O’Brien’s 5 service accomplishments to analyse personal and social assets:Group work taking the 5 areas analysing assets in accordance with Participation, Presence, Competence, Choice and Respect

This is a bridge from theory pre-dating care management showing that the skills have ALWAYS been a part of social work but have been dormant

Powerpoint and handouts

Using the questions in this framework to practically help social workers to identify the processes they could develop to move towards effective asset based working

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3.15 30 mins DMBC’s current policy and practical developments

The developments demonstrating the re-think in Doncaster including the emarketplace

This is to show Doncaster’s commitment to the culture change

powerpoint Emphasise how the developments enhance asset based social work as a significant move away from traditional services

3.45 15 mins Recap, questions and evaluation

4.00 Close

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Assessment Methods : Formal & Informal Q & A’s, Case Studies, Discussion , Observation and EvaluationEvaluation of SessionWere learning outcomes met?

Were resources used effectively?

Did learning checks demonstrate that learning has taken place?

Any other comments?

Facilitator signature:

Date:

55

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