Preparing to Establish Needs (Hospital Discharge)

1. Consent, Refusal and Engagement Difficulties

Where the person does not consent to the assessment

Any assessment can only be carried out if the person it relates to has given their consent unless:

1. The person lacks capacity to refuse the assessment and you are satisfied that carrying out the assessment would be in their best interests; or
2. The person is experiencing, or is at risk of, abuse or neglect.

As long as neither of the above criteria applies you do not have to carry out the assessment. You should:

1. Confirm to the person that the assessment is not being carried out on the basis that they have refused it;
2. Provide any information and advice about adult Care and Support as appropriate and relevant;
3. Provide any information and advice that will reduce, delay or prevent the need for Care and Support;
4. Let the person know they have the right to an assessment at any point in the future on the appearance of need alone;
5. Provide information about how the person can request an assessment in the future; and
6. Where there is a need to monitor the situation, agree how this will happen; and
7. Where the situation is to be monitored, explain that the Local Authority will offer the person another assessment at any point that it feels this would be beneficial to them.

Where the person who has refused an assessment has a carer the duty to assess the carer's needs still applies, unless the carer also refuses the assessment.

If no monitoring activity has been agreed you should:

1. Make a proportionate record of the person's refusal and the action you have taken;
2. Notify the person who requested the assessment (if this was not the person); and
3. Proceed to close the case.

Make sure it is only your own involvement that ends when the Local Authority is to remain involved in some way, for example:

1. Appointeeship.
2. Deputyship
3. Carers support
4. Tenancy in extra sheltered housing.

Click here to access the process for ending your involvement and closing a case.

Consent and Capacity

If there are concerns that the person may lack capacity to consent to the assessment then a proportionate mental capacity assessment must be carried out to determine whether this is the case. This can be carried out by a person other than the assessor if they have the necessary skills to do so.

If the person has capacity to consent following the mental capacity assessment their consent must be obtained before carrying out the assessment.

If the person lacks capacity to consent following the mental capacity assessment then a Best Interest Decision must be made to confirm that carrying out the assessment will be in their Best Interests. This decision should be made by the assessor as the decision whether to assess or not rests with them.

Click here to access the Mental Capacity Act 2005 Resource and Practice Toolkit, which contains guidance about assessing capacity and making best interest decisions.

Support can also be sought from team members, champions and the Mental Capacity Act Lead.

Note: All formal mental capacity assessments must be signed off by a manager.

Assessment when the person has substantial difficulty engaging

If a person does not lack capacity but does have substantial difficulty being involved in any Care and Support process you must take all reasonable steps to ensure their involvement.

You must:

1. Ensure that you have provided information in an accessible way, or that the person has an appropriate person to support them to understand it;
2. Arrange to carry out the assessment in an appropriate format so that it is accessible. This is likely to be face to face, unless the person's difficulty arises when engaging in face to face communication;
3. Consider whether the person has an appropriate person to support their involvement and, if not, whether the advocacy duty applies.

Click here to access the advocacy procedures, including how to establish whether a person needs an advocate and how to make a referral.

Refusal of an assessment by the Local Authority

If any assessment is refused by the Local Authority you must confirm this in writing and explain to the person:

1. The reason the assessment has been refused;
2. Information and advice about what can be done to prevent or reduce the development of needs for Care and Support in the future; and
3. What to do if their needs change in the future.

The only ground upon which the Local Authority can lawfully refuse any adult an assessment is where there is no appearance of need. It does not matter whether the appearance of need is likely to prove eligible after any assessment. As such, it is unlikely that many people who request an assessment will be refused.

If you do feel that an assessment is not appropriate you should discuss this with a manager before refusing it as you must be sure that the decision to refuse is legally sound.

Notifying others that an assessment has been refused

You should notify the person who requested the assessment so that they can make any arrangements to discuss other options with the person.

Refused access to a person requiring an assessment

Sometimes another person will obstruct you from carrying out an assessment with a person who has Care and Support needs. This can happen at any point from initial contact, to arranging an assessment, to carrying out an assessment. You should establish whether:

1. The person with Care and Support needs has asked the person to obstruct the assessment, and if so whether they have capacity to refuse the assessment (this can only be achieved through direct contact with the person with Care and Support needs);
2. The person obstructing the assessment is doing so out of concern for the person with Care and Support needs (for example would the assessment process cause anxiety);
3. The person with Care and Support needs is at risk of abuse or neglect.

Wherever possible you should provide information and advice relating to adult Care and Support and the assessment process to the person obstructing the assessment, to support them to understand the benefits and engage in the process.

If the person continues to obstruct the assessment, and you are not able to establish from the person with Care and Support needs that this is at their request you must take action to ensure the assessment is carried out. By obstructing the assessment process the person is:

1. Putting the person with Care and Support needs at risk through lack of support;
2. Preventing the Local Authority from fulfilling its duties under the Care Act to assess and meet eligible needs.

An assessment in this situation can be carried out based on the information available and through consultation with others. The advocacy duty should be considered and it is likely that a referral would be appropriate to ensure that the person's involvement in the process is maximised.

Any information gathered must be enhanced at such time when the person is involved, and all information sharing should give regard to confidentiality.

Click here to access the local Data Protection policy.

Depending on the circumstances consideration should also be given to raising an adult safeguarding concern.

Click here to access the safeguarding adults procedures, including how to recognise abuse and neglect, how to raise a concern and how to record safeguarding information.

Assessment when the person is at risk of abuse or neglect

Under the Care Act you have a duty to carry out the assessment if the person is at risk of abuse or neglect. This is regardless of whether they consent to it or not.

Where the person does not consent but there is a duty to assess you should:

1. Explain to the person that you have a duty to assess;
2. Support and encourage the person to be involved in the assessment; and
3. Carry out the assessment to the best of your abilities while ensuring their involvement as much as possible.

2. Gathering, Understanding and Using Available Information

What the Care Act says

The Care Act is clear that you should not ask the person (or anybody that you consult with for the purpose of assessment) to repeat information that has already been made available to you unless there is a valid reason for doing so. For example, if you have not understood the information and want to clarify the meaning behind it then it may be appropriate to ask for it to be repeated, summarised or clarified.

Before continuing or beginning to carry out any kind of assessment you should take some time to read through the information that is already available for the purposes of:

1. Understanding it; and
2. Thinking about how it should inform the assessment process.

Sources of existing information

Existing sources of information may be available via:

1. Referral forms;
2. Recordings of any contact made;
3. Letters, texts and emails;
4. A confidential conversation with a colleague or manager who is familiar with the person;
5. Reports from professionals (for example a Speech and Language Therapist, Psychologist or Teacher);
6. Records relating to current or historical safeguarding enquiries or concerns;
7. Existing or historical mental capacity assessments; or
8. Existing or historical assessment reports, review reports or Care and Support Plans.

All information gathering and sharing should be carried out with regard to the Caldicott Principles and local information sharing policies.

Use the tri.x Resources tab to access further information about the Caldicott Principles in the glossary.

Click here to access the local Data Protection policy.

Other sources of information available

It may be appropriate and necessary for you to undertake an element of research in order to improve your own knowledge or awareness of a particular issue or health condition:

1. By speaking with a colleague who possesses skills and knowledge in a particular area;
2. By reading particular guidance or written resources about a particular medical condition;
3. By accessing a reputable website for information and advice (for example Parkinson's UK, the British Institute for Learning Disabilities or MIND).

Click here for details of some national organisations offering a specific information and advice helpline.

Click here for a wider range of useful national contacts for adult Care and Support.

Consultation with the Person

You may need to speak to the person in advance of arranging their assessment in order to gather or clarify any information.

Gathering Information and Consulting with Others

3. Arranging the Assessment and Preparing the Person

Legally you must have regard to the following when arranging an assessment:

1. The person's views and wishes about when and how the assessment is carried out, including who they would like to support them;
2. The impact of any delay in assessment on their individual Wellbeing; and
3. Whether any information and advice can be given to them that will prevent, delay or reduce the need for Care and Support.

When to arrange the assessment

The Care Act statutory guidance states that 'an assessment should be carried out over an appropriate and reasonable timeframe taking into account the urgency of the needs or situation and consideration of any fluctuating needs'.

The timing of the assessment should be agreed with the person and anyone else who is to be involved in it.

You should also take into account the following:

1. The level of risk;
2. The level of need;
3. Current support in place and the sustainability/effectiveness of this;
4. The urgency;
5. The likelihood of deterioration;
6. The potential for fluctuation;
7. Any clear indication of timeframe provided within any referral or recorded contact (i.e. any approaching discharge dates); and
8. Whether the person will need the support of an independent advocate and the time it may take to arrange this.

How to arrange the assessment

The method of communication should reflect that requested by the person and any specific communication needs they may have. For the purposes of the Care Act communication about the assessment is subject to the same requirements as the provision of information and advice, and the duty to make it accessible therefore applies equally.

Click here to read more about how to provide information in an accessible way under the Care Act.

What should be considered when arranging the assessment

The most important thing you must consider when arranging the assessment is how you will ensure the involvement of the person. Some of the things you should think about include:

1. Whether the person will require independent advocacy;
2. Whether the person will find any assessment process to be emotionally difficult and what can be done to reduce their anxiety;
3. The information the person (or their carer) may need to prepare for the assessment;
4. Whether the person requires any support with communication (for example, will any assessment tool need to be adapted, will an interpreter be required or does a Speech and Language Therapist need to be involved);
5. Whether the person would like for anyone in particular to be involved in any assessment;
6. Which environment would be best to meet in (if a meeting is to be arranged); and
7. Whether the assessment needs to consider any physical needs the person has for medication, rest or personal care.

When arranging the assessment you should also identify other people who may need to be a part of it. For example, a health professional or a service provider may need to be involved.

If the person lacks capacity

If the person lacks capacity you should make arrangements with an appropriate person. Where available this should be a person legally authorised to represent them (for example a Court appointed Deputy or a Lasting Power of Attorney) or an independent advocate.

Preparing the Person for Assessment

Under the Care Act you must provide information to the person about the assessment process (or their representative if they lack capacity) as early as possible. This will help ensure their involvement in the assessment and any subsequent Care and Support processes. Wherever practical this should be provided before the assessment process begins.

Any information should be provided in an accessible way for the person who will be receiving it.

The information that should be provided is as follows:

1. Information about what can be expected during the assessment process;
2. The format that the assessment will take;
3. The indicative timeframe for assessment (when will it begin and how long is it likely to take);
4. The complaints process; and
5. Information about possible access to independent advocacy.

You should also provide a list of any questions that you intend to ask of the person during the assessment. This will help them to prepare for the assessment and to think about their Wellbeing, the impact of their needs on this and what outcomes they want to achieve.

Information about finances

You should inform the person (or their representative if they lack capacity) that if, following assessment the Local Authority meets any eligible needs a financial assessment will take place and that the outcome of this will determine whether they will need to make a financial contribution to the cost of any support, services or equipment arranged.

Financial assessment is often a key point of anxiety for people and it is important that you are able to provide good information and advice (either directly or by supporting the person to access it from an appropriate person or source).

For further detail about specific information about financial assessment that must be given under the Care Act click here.

Click here to see the answers to some frequently asked questions around financial assessment.

Click here to access the financial assessment procedures, including how and when to provide information and advice about financial assessment, how and when to request a financial assessment and what to do if a person refuses a financial assessment.

4. Using Independent Advocacy

If the need for independent advocacy has not already been established at contact or referral then this should become clear when either arranging the assessment or providing information about it. As soon as this is established you must consider whether the duty to make independent advocacy applies and, if so make the necessary arrangements.

5. Preparing Others for Involvement

In all cases

In some cases the only person who will need to be involved in any assessment will be the person with Care and Support needs. In other cases more people will need to be involved because:

1. The person has a carer (carer's must be involved in the person's assessment);
2. The person has asked you to involve another person;
3. The person has consented to the involvement of another person;
4. The person will be using independent advocacy;
5. The person lacks capacity and a decision has been made in their best interests to involve another person; or
6. The assessment is being carried out because of the risk of abuse and neglect and there is a need to involve others.

It is important that everyone who is to be involved in an assessment is aware of:

1. The purpose of the assessment;
2. The process of assessment; and
3. Their role in any assessment.

The needs of others involved in an assessment should also be considered, but this should not be at the detriment of maximising the person's own involvement.

If a person has a role in the assessment process but is not able to physically attend any planned meeting it is possible under the Care Act to consult with them separately and still include their views in any assessment and decision making processes.

Preparing carers and family members

The Care Act is clear that a whole family approach to assessment should be taken wherever possible. This means that you should:

1. Establish who relevant family members are; and
2. Arrange for them to be involved in the assessment (if the person consents or lacks capacity and it is in their best interests to do so).

Relevant family members include anyone living with the person, including older adults and any children. It can also include family members who are not living with the person, but who are still involved or interested in the person's wellbeing.

Family members may have particular questions and require additional information to the general guidance above, which could include:

1. Information relating to financial assessment;
2. Information about mental capacity and best interests;
3. Information about a Lasting Power of Attorney;
4. Information about Appointeeship;
5. Information about Deprivation of Liberty Safeguards; and
6. Information about carers assessment.

Where the person has not consented for a carer to be involved

Under the Care Act carers have to be a part of the cared for person's assessment, even if the cared for person does not want them to be. This is because the Local Authority needs to:

1. Understand the person's needs, how they are currently being met and whether this is appropriate and sustainable; and
2. Identify and support carers.

When a person has not consented to the carer being a part of the assessment you should:

1. Advise the person that you have a duty to involve the carer;
2. Explain the benefits of the carer being involved; and
3. Agree the most appropriate way to involve the carer (for example a separate meeting with the carer).

If the person has requested particular information not relating to needs is withheld from the carer, and they have capacity to do so normal confidentiality rules apply unless doing so would put the person at risk of abuse or neglect.

6. Deciding the Nature of the Assessment

The different assessments available

The Hospital Discharge Social Work team can complete either:

1. An needs assessment to determine eligibility under the Care Act; or
2. A Discharge to Assess assessment (LIFE Service Assessment and Care Planning Form).

Combining a needs assessment with a carers assessment

A needs assessment can be carried out under the Care Act as a combined assessment at the same time as any carers assessment, so long as:

1. It is deemed appropriate to do so (for example both parties involvement can still be maximised and there is no conflict between the parties);
2. Both the person and the carer agree to a combined assessment process; or
3. The person with care and support needs lacks capacity to agree but a best interest decision is made to carry out a combined assessment;
4. Both parties consent to sharing information with each other for the purpose of combined assessment; or
5. The person with care and support needs lacks capacity to consent but a best interest decision is made to that effect.

Click here to access the procedures for carrying out a carer's assessment, which you should use to enhance these procedures when assessing the needs of a carer during any combined assessment process.

How to decide the nature of assessment

When making a decision about the nature of assessment you must have regard to:

1. The wishes and preferences of the person;
2. The outcome the person seeks from the assessment; and
3. The severity and overall extent of the person's needs.

Discharge to Assess

If a LIFE Service Assessment and Care Planning Form is to be completed you should follow the relevant procedures in the Life Team section of this site. Click here to access them.

7. Tools to Establish Needs

Using a tool to support the process of establishing needs or formal assessment can be useful for all involved. If you are going to use a tool you should endeavour to provide this to the person (or whoever will be supporting them) before the assessment is scheduled to take place.

8. Joint Work

Often there is a clear benefit to a joint assessment with a health colleague involved in making discharge arrangements. The Care Act permits the Local Authority to make any arrangements it deems appropriate in order to facilitate joint working with others.

The duty to co-operate

Where the Local Authority requests another party to work jointly in some way to benefit the person with Care and Support needs that party has a duty to co-operate with the request (unless by doing so they will be prevented from carrying out their own duties under the Care Act or other legislation).

For further information about the duty to co-operate under the Care Act click here.

How to request joint work or assessment

Any decision to request joint work should be made with the person (or their representative). Where the person is unable to provide consent to joint work decisions should be made in their best interests.

Joint work requests should be made in the manner preferred by the relevant health colleague. This may or may not take the form of a referral.

The request should explain clearly the nature of the joint work required and any specific skills, knowledge and competence requirements of the practitioner to support allocation.

Responding to a request for joint work

If you have been asked to work jointly with a health colleague you should contact the person you will be working jointly with to confirm your involvement and discuss the most effective way to work together. The things you should establish include:

1. The work they are doing/will be doing/have done and whether they have any information that you need to know or can use to avoid duplication;
2. Whether there are opportunities to coordinate systems and processes and, if so how this will be managed;
3. What the expectations are in terms of joint-working (for example will you be expected to carry out a joint assessment, meet with the person together, produce joint records or just consult and share information);
4. What the anticipated outcome of the joint work is (for example joint funding of support, on-going joint-work to monitor);
5. What does the person with care and support needs know about the joint-work to be carried out (and if they don't know who and how should this be explained);
6. Who will be the primary contact for the person (or their representative) to go to with any queries; and
7. Who will be responsible for communicating progress and decisions to the person.

Further practice guidance about effective joint working can be found in the joint-work procedure by clicking here.

Specialist joint work or assessment

Some areas of joint work are specialist or non-frequent in nature. The procedures for these pieces of work can be found in the Specialist and Universal Procedures section of this manual. The following are examples of the specialist and non-frequent procedures that can be found there:

1. NHS Continuing Healthcare assessments;
2. Continuity of Care;
3. Cross Border Placement.

9. Preparing in an Urgent Situation

Sometimes the timeframe within which to arrange an assessment is not conducive to all of the considered planning and preparation as outlined in this procedure. For example, there may always not be the time to research and make the best use of available information or to consult with others before arranging to meet with the person. However, even when the timeframe is short it is of paramount importance that you still:

1. Take all available steps to ensure the involvement of the person in any assessment;
2. Consider consent and mental capacity;
3. Provide independent advocacy where there is a statutory duty to do so;
4. Prepare the person as much as possible;
5. Identify what existing information is important and understand it; and
6. Know what you have not been able to do and ensure that at the earliest opportunity you make arrangements to do so (for example to consult with another professional or read a particular report).

If the need to meet needs is urgent you may need to arrange interim services to ensure that urgent needs are met during the assessment process. If this is the case you can access the procedures for arranging urgent or interim support and services by clicking here.