East Dunbartonshirecouncilsocial Work Services

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EAST DUNBARTONSHIRECOUNCILSOCIAL WORK SERVICES

ASSESSMENT AND CARE MANAGEMENT PROCEDURES

June2010

CONTENTS

Page Number

Introduction 3

Objectives 4

Process 4

Standards 6

Access & Information 8

Determining the level of response to referrals 9

Assessments 10

Priority/Risk Matrix 11

Carer Assessment 17

Care Planning 18

Implementing the Care Plan 19

Monitoring & Reviewing 20

Advocacy 21

Information Sharing 21

Evaluation 22

Closure of cases 22

Recording 23

Supervision of staff 23

Review of procedures 24

INTRODUCTION

These procedures aim to assist practitioners and their managers in improving outcomes for customers and carers by clarifying processes and approaches around assessment and care management. They are relevant to work with all adult care groups and aim to provide consistency of practice in areas such as timescales for delivering services and deciding on priorities.

This framework should be read in conjunction with a number of other local policies and procedures governing practice including:

• Social Work Adult Protection Procedures (updated 2009)
• Multi-Agency Adult Protection Procedures (updated 2009)
• Adults with Incapacity Procedures (2003)
• Guidance on Free Personal Care (updated 2009)
• Access to Services & Resources (2003)
• Direct Payment Procedures (updated 2009)
• Charging for Non-Residential Services Policy (2009)

as well as all relevant legislation relating to adults at risk or in need of services.

OBJECTIVES

The mainaims of these procedures are as follows:

• to provide a clear framework and guidance for practitioners

• to adopt standards within the assessment and care management process which allow for measurement of performance and provide clear expectations for customers and carers

• to incorporate the national eligibility criteria (September 2009) into local procedures to provide an explicit matrix for the consistent prioritisation of need across care groups based on personal outcomes and well-being as well as risk

These procedures also acknowledge the importance of practice around assessment and care management of the following:

• the role and supporting of carers

• use of advocacy

• feedback from service users

• good case recording

• effective supervision of staff

• improved multi-agency working and information-sharing

PROCESS

The core tasks within the assessment and care management process are summarised within the following chart (Scottish Government 2009):

STANDARDS

Practitioners and managers will work to the following standards which are detailed within this document in terms of how standards can be met and performance on them measured:

Standard 1
Contact with East Dunbartonshire community care services will be convenient and ‘user friendly’ , including good quality accessible information about services.
Standard 2
Referrals received by East Dunbartonshire Council will be screened, prioritised and responded to within the following timescales:
-screening within 3 working days
-written acknowledgement to referrer within 5 working days
Standard 3
All new customers will receive an assessment appropriate to their level of need and risk and within the timescales set out in the Priority/Risk Matrix on pages 11-14.
Standard 4
All identified carers have their views recorded and taken account of as part of the
customer’s assessment unless the carer explicitly declines.
Standard 5
All identified carers are offered the opportunity to have a separate assessment of their own needs in order to support them in continuing in their caring role.
Standard 6
A Care Plan will be developed within 4 weeks for each individual with an assessed
need outlining agreed objectives and interventions/actions.
Standard 7
The care manager will adopt a personalised and outcomes-based approach to meeting needs wherever possible with matching to existing services being only one of a range of options.
Standard 8
Practitioners and managers will comply with waiting times as required by national or local policies.
Standard 9
Services to meet assessed needs will be delivered at the earliest opportunity and
within agreed ‘time intervals’ subject to the priorities laid out in Council policies.
Standard 10
Case reviews will be held within 4 weeks of any placement and otherwise
as a minimum annually and involve the participation of the customer and all relevant people.
Standard 11
Where a customer or carer requires assistance in expressing or having represented
their views the Council will offer and commission an independent advocacy worker.
Standard 12
Information about the customer is either sought from or disclosed to other parties wherever possible with the explicit consent of the customer or there is clear justification for doing so without consent.
Standard 13
All interventions will be evaluated with regard to outcomes and customers and/or carers will be an integral part of such evaluation both at an individual and service-wide level.
Standard 14
Safeguards will be followed to ensure that no case is closed without explicit reasons and a consideration of current needs and risks.
Standard 15
The recording of all activity and intervention at all stages from referral to closure will be clear, comprehensive and accurate.
Standard 16
All staff undertaking assessment and care management activity will receive regular supervision from a designated manager in line with the departmental policy on supervision.
Standard 17
These procedures will be reviewed at least annually to ensure that they remain relevant and up-to-date.

ACCESS AND INFORMATION

Standard 1
Contact with East Dunbartonshire community care services will be convenient and ‘user friendly’, including good quality accessible information about services.
Performance Criteria
Information is published which informs potential customers how to access services and
what to expect regarding their nature and quality, including opportunities for self-directed
support.
Information is clear around service responsibilities including signposting to other relevant agencies.
Clear information about eligibility criteria, assessment priorities and assessment processes, including timescales for response.
Clear information around charging policies.
Includes ‘access to files’ advice to allow customers to request information held about them.
Includes clear guidance around making a complaint.
Information published in various formats – including for people with a learning disability or a visual impairment - and in ‘plain English’.
Information available in locations likely to be used by people who may require to use
social work services.
Service/information provided wherever possible in customer’s preferred language or arrangements made for communication via interpreter, signing etc.

DETERMINING THE LEVEL OF RESPONSE TO REFERRALS

Standard 2
Referrals received by East Dunbartonshire Council will be screened, prioritised and responded to within the timescales set out below.
Performance Criteria
All referrals – whether received by letter, email, telephone or fax – will be screened within
3 working days in order to
-establish the appropriateness of the referral for Social Work
-redirect the referral/referrer if required
-prioritise the referral in terms of initial response
A written acknowledgement will be sent to the referrer within 5 working daysof the referral.
This will be the responsibility of the team to whom the referral is passed following screening (otherwise it falls to the screening team if the case is not passed on within 5 days).
The referral/referrer will if appropriate (and in relation to the best interests of the customer)
be redirected promptly to another agency. Wherever possible this will be done directly by
the screening worker rather than asking the referrer to contact the other agency.
Action (or no action) following screening will be based on the Priority/Risk Matrix (see pages
11-14) in terms of timescale for response i.e. Critical Risk/Substantial Risk/Moderate Risk/
Low Risk/No Risk.
N.B. Priority status may need to be changed at any point depending on circumstances and
any new information.
Where a referral is passed to another team for further action this will be fully recorded on
Carefirst indicating if case is new or open to another team.
In cases of Critical or Substantial Risk there will be personal or telephone contact between
the referring and receiving managers (which can be followed up but not initiated by email).
Following agreement between managers a referral on to another team by Adult Intake will
be done using the Screening Tool which contains core information on the customer and circumstances. In all other transactions the referring-on team must provide this either via an existing assessment or by completing the Screening Tool.

ASSESSMENTS

Standard 3
All new customers will receive an assessment appropriate to their level of need and risk and within the timescales set out in the Priority/Risk Matrix on pages 11-14.
Performance Criteria
The assessor will be knowledgeable about, and competent within, the assessment process.
Customer (or carer where appropriate) is given target date for allocation (and informed of any further delay) and reasons for exceeding agreed timescale is recorded.
The opportunities for the customer to fully participate in the assessment process will
be maximised, including evidence of their views and expectations
The outcome of the assessment emphasises the strengths, abilities and aspirations of the customer as well as needs and difficulties.
There is evidence of consultation with other significant people known to or involved with the customer informing the analysis of needs and risks.
The type and level of assessment will be agreed with the customer, including the
appropriateness of carrying out or referring on for specialist assessments.
The customer will receive a summary of the assessment, including identified needs.
Date of allocation for assessment and target date for completion are recorded by the
allocating manager.
Date of actual completion of the assessment and details of assessed needs are recorded on Carefirst and the assessment countersignedby the line manager.
Action following completion of the assessment is agreed between the worker and manager
and recorded including agreed outcomes/objectives.

PRIORITY/RISK MATRIX

These procedures also make use of the four categories of risk within the National Eligibility

Framework to determine timescales within which assessments should be commenced as outlined in the tables on pages

Critical risk Indicates that there are major risks to an individual’s independent

living or health and well-being likely to call for immediate or imminent

intervention and/or provision of social care services.

Substantial risk Indicates there are significant risks to an individual’s independence

or health and well-being likely to call for immediate or imminent

intervention and/or provision of social care services.

Moderate risk Indicates there are some risks to an individual’s independence or

health and well-being. These may call for the provision of some

social care services managed and prioritised on an ongoing basis or

they may simply be manageable over the foreseeable future without

service provision with appropriate arrangement for review.

Low risk Indicates there may be some quality of life issues but low risks to an

individual’s independence or health and well-being with very limited,

if any, requirement for the provision of social care services. There

may be some need for alternative support or advice and appropriate

arrangements for review over the foreseeable future or longer term.

Risks relating to neglect or physical or mental health / Timescale to commence assessment / Timescale for completion of assessment
Critical / Serious harm or neglect has occurred or is strongly suspected and customer needs protective intervention by social care services / Major health problems which cause life threatening harm or danger to customer or others / Day of
referral / Initial assessment on same day – where required full assessment within 25 working days of referral
Substantial / Harm or neglect has occurred or is strongly suspected / Significant health problems which cause significant risks of harm or danger to customer or others / Within 2 working days / Initial assessment within 2 working days– where required full assessment within 25 working days of referral
Moderate / Adult at risk needs to raise their awareness to potential risks of harm / Some health problems indicating some risk to independence and/or intermittent distress – potential to maintain health with minimum interventions / Within 12 weeks / Within 25 working days of commencing the assessment
Low / Preventative measures including reminders to minimise potential risk of harm / Few health problems indicating low risk to independence – potential to maintain health with minimum interventions / Within 16 weeks / Within 25 working days of commencing the assessment
Risks relating to personal care/domestic Timescale Timescale for
routines/home environment to commence completion of
assessment assessment
Critical / Unable to do vital or most aspects of personal care causing major harm or danger to customer or others or major risks to independence / Unable to manage the most vital or most aspects of domestic routines causing major harm or danger to customer or others or major risks to independence / Extensive/complete loss of choice and control over vital aspects of home environment causing major harm or danger to customer or others or there are major risks to independence / Day of
referral / Initial assessment on same day – where required full assessment within 25 working days of referral
Substantial / Unable to do many aspects of personal care causing significant risk of danger or harm to customer or others or there are significant risks to independence / Unable to manage many aspects of domestic routines causing significant risk or harm or danger to customer or others or significant risk to independence / Substantial loss of choice and control managing home environment causing a significant risk of harm or danger to customer or others or significant risk to independence / Within 2 working days / Initial assessment within 2 working days – where required full assessment within 25 working days of referral
Moderate / Unable to do some aspects of personal care indicating some risk to independence / Able to manage some aspects of domestic activities indicating some risk to independence / Able to manage some aspects of home environment leaving some risk to independence / Within 12 weeks / Within 25 working days of commencing the assessment
Low / Difficulty with one or two aspects of personal care, domestic routines and/or home environment indicating little risk to independence / Able to manage most aspects of basic domestic activities / Able to manage most basic aspects of home environment / Within 16 weeks / Within 25 working days of commencing the assessment
Timescale to Timescale to
Risks relating to participation in community life commence complete
assessment assessment
Critical / Unable to sustain involvement in vital aspects of work/education/learning causing serious loss of independence / Unable to sustain involvement in vital or most aspects of family/social roles and responsibilities and social contact causing severe loss of independence / Within 25 working days / Initial assessment within 25 working days – where required full assessment within a further 25 working days
Substantial / Unable to sustain involvement in many aspects of work/education/learning causing a significant risk to losing independence / Unable to sustain involvement in many aspects of family/social roles and responsibilities and social contact causing significant distress and/or risk to independence / Within 12 weeks / Initial assessment within 12 weeks – where required full assessment within a further 25 working days
Moderate / Unable to manage several aspects of involvement in work/education/learning and this will in the foreseeable future pose a risk to independence / Able to manage some aspects of family/social roles and responsibilities and social contact that poses some risk to independence / Within 16 weeks / Within 25 working days of commencing the assessment
Low / Has difficulty undertaking one or two aspects of work/education/family and/or social networks indicating little risk to independence / Able to manage most aspects of family/social roles and responsibilities and social contact indicating little risk to independence / Within 16 weeks / Within 25 working days of commencing the assessment

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Timescale to Timescale to
Risks relating to carers commence complete
assessment assessment
Critical / Carer has major physical and/or mental health difficulties due to the impact of carer role causing life threatening harm or danger to themselves or others / Complete breakdown in the relationship between carer and customer and carer is unable to continue caring or has difficulty sustaining vital or most aspects of the caring role / Carer is unable to manage vital or most aspects of their caring/family/work/domestic or social roles and responsibilities / Day of
referral / Initial assessment on same day – where required full assessment within 25 working days
Substantial / Carer has significant physical and/or mental health difficulties due to the impact of carer role causing significant harm or danger to themselves or others / Significant breakdown in the relationship between customer and carer and carer is unable to sustain many aspects of the role / Carer is unable to manage many aspects of their caring/family/work/domestic or social roles and responsibilities / Within 2 working days / Initial assessment within 2 working days – where required full assessment within 25 working days
Moderate / Carer able to manage some aspects of the caring/family
domestic/social roles – potential risk to breakdown of their own health identified / Relationship between customer and carer maintained although at times under strain limiting some aspects of the caring role / Carer is able to manage some aspects of their caring/family/work/domestic
social roles and responsibilities / Within 25 working days / Within 25 working days of commencing the assessment
Low / Carer able to manage most aspects – has difficulty undertaking one or two aspects of caring/domestic role but with low risk to carer or customer / Relationship maintained between carer and customer by limiting aspects of caring role / Carer is able to manage most aspects of their caring/family/work/domestic
social roles and responsibilities / Within 12 weeks / Within 25 working days of commencing the assessment

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CARER ASSESSMENT

Standard 4
All identified carers have their views recorded and taken account of as part of the
customer’s assessment unless the carer explicitly declines.
Performance Criteria
The carer’s views are clearly recorded in customers’ assessments and demonstrably contribute
to care planning.
The outcome of the customer’s assessment emphasises the strengths, abilities and aspirations
of the carer as well as any support needs.
Standard 5
All identified carers are offered the opportunity to have a separate assessment of their
own needs in order to support them in continuing their caring role.
Performance Criteria
The response of the carer to the offer of a carer assessment is clearly recorded.
The opportunities for the carer to participate fully in the carer assessment are maximised,
including evidence of his or her views and expectations.
The outcome of the carer assessment emphasises the strengths, abilities and aspirations of the
carer as well as any support needs.
The carer will be provided with a copy of the carer assessment.
Actions agreed between the assessor and carer are clearly recorded, including agreed
outcomes/objectives.
Carers are provided with information on sources of support, including local carer groups.

CARE PLANNING