IT’S YOUR LIFE - TAKE CONTROL!

Hertfordshire County Council

Adult Care Services

Self Directed Support and Personal Budgets

NEEDS ASSESSMENT

Surname: / For Office use: IRIS No
First Name:
Address: / Post code:
Date of
Birth: / Gender:
For office use
Care Manager: / Please print name:
If not completed with service user please give reasons:

The information you provide on this Needs Assessment will be used to assess your need for social care help and support. Your information will be held securely and confidentially on a computer and on file in accordance with the principles of the Data Protection Act 1998. This information may be shared with other social care professionals in order to provide the support you need.

ETHNICITY

Please complete this table by indicating with a “” We only use this information to monitor our services.

White / Asian or British Asian
White British / Indian
White Irish / Pakistani
Any other white background / Bangladeshi
Mixed Background / Any other Asian background
Mixed Caribbean / Black or Black British
Mixed African / Caribbean
Mixed Asian / African
Any other mixed background / Any other black background
Chinese, British Chinese or Other
Chinese
Any other ethnic group

Question 1a: Your family carers or friends

We need to understand whether any family members or friends support you, with your care needs, and are willing/able to continue. This might include helping you get up and dressed, cooking meals, shopping or helping you with your money.

Do any family members or friends help you with your care needs?

YES NO (Go to question 2)

This part is for your family or carer to fill in. What does supporting you mean for your family carer? What is their life like as the current role is undertaken?

Please tick one box below that best describes you. / Carer’s
View
A / I am able and willing to continue in my current caring role.
B / I have or will have some difficulty in carrying out my day-to-day caring role.
C / I am not able to continue in my caring role.

You may have found it difficult to tick one of these statements and would prefer to discuss the impact of your caring role privately. If this is the case please tick here and we will contact you separately to score this page.

I would prefer to discuss the impact of my role privately Yes

  • Is there any additional information you would like to give about yourself, or level of help this person needs?

ASSESSMENT INFORMATION (Worker to complete)

Question 1b: Carer’s Assessment(N/A )

This part is for your family or carer to fill in. It is important that we understand how much support you have from family and friends.

Please ask your carer to complete these questions:

Please tick ‘Yes’ or ‘No’

Have you had a Carer’s Assessment? / Yes / No
Would you like a Carer’s Assessment or a review of your Carer’s Assessment? / Yes / No
Would you like an introduction to your local carer’s organisation? / Yes / No
Additional comments about family carer or the support they provide.

Question 2: Meeting My Personal Care Needs(N/A )

This part is about looking after you and the support you may/may not need

(Things like washing, dressing and going to the toilet)

Please tick one box below that best describes you. / My View / Carer’s
View / Worker’s View / Final Agreement
A / I do not require help to meet my personal care needs.
B / I occasionally need help or encouragement with personal
C / I need a lot of support with personal care during the day / CS1
D / I need a lot of support with personal care during the day and night / CS1
E / I need two people to support with personal care / CS1
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)

Question 3:My Meals (N/A )

This part is about –eating, drinking and food preparation

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I do not need help in this area / already provided (e.g. meals on wheels).
B / I need guidance about preparing meals. / CM1-CS1
C / I need assistance and supervision with cooking, preparing meals and/or eating my food / CC1
D / I would like support to do these things independently in the future. / CC1
E / I need all/most of my meals prepared for me and/or total assistance to eat my meals / CC1
How much help can your family and friends continue to give you help? / 1. I don’t need help / already provided
2. I get some help
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Are meals already provided (e.g. meals on wheels) / Yes / No

Question 4: My Domestic Tasks(N/A )

This part is about day to day life; things like, shopping, cleaning, doing the laundry, managing money and paying bills.

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I don’t need help with these things / already provided (e.g. cleaner).
B / I need occasional help (less than weekly) to do these things / CM1- CS1
C / I often (weekly) need help with these things / CS1
D / I would like support to help me do these things independently in the future. / CS1
How much help can your family and friends continue to give you help? / 1. I don’t need help / already provided
2. I get some help.
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is a referral to Money Advice Unit needed? / Yes / No

Question 5: My Physical & Mental Health(N/A )

(Well-Being and Recovery)

This part refers to support you may need to manage your physical or mental health condition (e.g. diabetes, heart or respiratory failure, stroke, epilepsy, depression, anxiety state, bereavement, dementia, etc).

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I am well and don’t need any support
B / I need a little help from others to make sure I stay well.
For example I require occasional reminders regarding medication or assistance to get medical help.
C / I need some help from professionals to make sure I stay well as there is some concern about my health needs. I see them at least once every three months and may need assistance to administer medication or get medical help. / AC2
D / I need some help from professionals to make sure I stay well as there is real concern about my health needs. I see them at least once a month, and/or need assistance to administer medication on a daily basis. / AC1
E / My health is very unstable and I need help from professionals to ensure I stay well as there is a real concern about my complex health needs. I see them at least once every two weeks, and/or need assistance to administer medication on a daily basis. / AC1
AC2
How much help can your family and friends continue to give you help? / 1. I don’t need help
2. I get some help
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is a specialist mental health assessment needed? / Yes / No
Is a continuing care assessment needed? / Yes / No
Is a mental healthcare coordination assessment needed? / Yes / No

Question 6: Getting Out and About(N/A )

This part is about doing things in your community, like using local shops, the library, going to a luncheon club or the community centre, church or other place of worship, visiting neighbours, or being involved in local organisations. It also looks at being with friends.

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I don’t need support / already provided ( e.g. day time activity, community group or club)
B / I need some support todo things in my community and/or maintain friendships and social contacts. / DS2
C / I need regular support to maintain my friendships and social contacts. / DS2/DC2
D / I am unable to do things in my community and maintain my friendships and social contacts without constant help or supervision. / DC2/DC3
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is transport / travel training required? e.g. bus pass, escort, taxi / Yes / No

Question 7: Work and Learning(N/A )

This part is about having a job and learning new things.

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I have no difficulty accessing work/learning or
, I am not interested in doing any further work, learning or leisure activities.
B / I can only access work or learning opportunities with frequent support. / DS1
C / I can only access work or learning opportunities with total support. / DC1/DS1
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is a referral to Work Solutions needed? / Yes / No

Question 8: Making Decisions About My Life(N/A )

This part is about who decides important things in your life – things like where you live, who supports you, who decides how your money is spent.

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I can make decisions without help.
B / I occasionally need some support and advice to make important decisions. / BS1
C / I decide some things. But I don’t have as much say as I would like in the important decisions about my life and I need some support. / BS1
D / Other people make decisions about my life. I need the support of someone to advocate on my behalf and help me gain control of my life. / BC1
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is an additional mental capacity assessment needed? / Yes / No

Question 9: Staying Safe from Harm(N/A )

This part is about keeping safe. This could be when you’re out in the community or at home. Staying safe is about different things for different people.

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I don’t need help to stay safe
B / On a daily basis I manage well although there have been occasions when someone or some equipment to assist me would give me or others reassurance.
C / Sometimes I need help to stay safe. People worry a bit about my safety. I need someone to contact me at least once a week.
D / I need help much of the time to stay safeduring the day. People worry about my safety. (I need somebody to be in daily contact). / AS3,CS1
E / I need help and support to stay safe all of the time. People worry a lot about my safety. I need someone to be available at night. / AC1,AC3,
AS3
F / I need an exceptional amount of support including supervision and monitoring to stay safe. I require somebody to be awake throughout the night or 2 people to support me / AC1
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I need more help.
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is a risk assessment needed? / Yes / No
Is a safeguarding referral needed? / Yes / No

Question 10: Managing MyBehaviour(N/A )

This part is about whether your behaviour may affect or be a risk to other people and whether you need any support to manage this.

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I do not need any support with this.
B / I need occasional support to help me manage my behaviour / DS1,DS2 DS3,AS3
C / I need some support in this area because occasionally my behaviour might present a risk to others. there is a risk that I could hurt myself and/or other people. ????
I regularly need support to help me manage my behaviour / AC2/AC3
DC1/DC2
D / I always need support to help me manage my behaviour ???? / AC1
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I need more help..
What would YOU like to be different or better; what do YOU want to achieve?
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION (Worker to complete)
Is a risk assessment needed? / Yes / No

Question 11: My Role as a Parent and/or Carer (N/A )

This part is about the support you need to care for someone else e.g. child,parent, partner

Please tick one box below that best describes you. / My View / Carers
View / Worker’s View / Final Agreement
A / I am not a parent/carer and/or I don’t need any support to fulfil my parenting/caring role
B / I need occasional support with my parenting/caring role / DS2
C / I need support during the day with my parenting/caring role / DS2/DC2
D / I need support during the day and night with my parenting/caring role / DC2/DC3
E / I always need constant support with my parenting/caring role / DC2/DC3
How much help can your family and friends continue to give you help? / 1. I don’t need help.
2. I get some help.
3. I get no help.
What would YOU like to be different or better; what do YOU want to achieve?
3
WHAT I WANT TO ACHIEVE
ASSESSMENT INFORMATION
Is a carer’s assessment needed? / Yes / No

AGREED SUPPORT/ACTION PLAN

QUESTION / AGREED NEED / SCORE (FOR OFFICE USE)
Q1Family Carers and Friends / PULL THROUGH ANSWER TEXT
Q2 Meeting Your Personal Care Needs / PULL THROUGH ANSWER TEXT
Q3 Your Meals / PULL THROUGH ANSWER TEXT
Q4Practical Aspects of Daily Living / PULL THROUGH ANSWER TEXT
Q5Your Physical & Mental Health; Well-Being and Recovery / PULL THROUGH ANSWER TEXT
Q6 Community and Family Inclusion / PULL THROUGH ANSWER TEXT
Q7 Work & Learning / PULL THROUGH ANSWER TEXT
Q8 Making Decisions About Your Life / PULL THROUGH ANSWER TEXT
Q9 Staying Safe From Harm / PULL THROUGH ANSWER TEXT
Q10 Managing Your Actions / PULL THROUGH ANSWER TEXT
Q11 Your Role as a Parent and/or Carer / PULL THROUGH ANSWER TEXT
TOTAL

I confirm the information that I have given in this questionnaire is correct

I agree that this assessment

May be shared as needed to support my care / Yes / Yes but with limitations / No
Details of any limitations:

My SignatureCarer Signature (if applicable)

Advocate Signature (if applicable)Worker Signature

Date:

1

Version 7.1 August 2009