Promoting Independence Assessment Form – Carers

The aim of Adult Social Care in Cumbria is to help you have the best quality of life that you can. We therefore want you to have the opportunity to contribute as much as possible in describing what is important to you.

This document is to enable you to describe your needs in relation to your caring role. By needs we mean something that is essential or important rather than something that would be nice to have.

To be able to do this we need to get as complete a picture as possible about your needs, things that impact on your wellbeing and the outcomes you want to achieve. To help us understand clearly we use a series of questions which cover the areas of life which are important to most carers like how you spend your time, getting enough sleep or eating well. There are also questions about things:

·  you can or can’t do;

·  you want to be able to do more or less of;

·  you would like to change or that you want to stay the same.

They have been designed to help us understand which areas of your life are most important to you, telling us how good or bad your life is in your own words. We can then work with you to plan what support might meet your needs and help achieve your outcomes.

This process is called a carers assessment of need. We can complete the form for you using the information we gather during the assessment. Alternatively, you can chose to fill it in yourself, with as much or as little support from us as you want, this process is called ‘supported self-assessment’. If you choose to do a supported self-assessment we would always come back and check with you if we felt that there was not enough information to give a complete and accurate picture of your needs and circumstances. We might also need to verify any information you provide with, for example your Doctor or someone who helps meet your needs as carer – we would only do this if it was relevant and would always ask for your consent before we spoke to anyone else about your assessment.

Name
NHS Number
IAS Number
Address
Contact Details / Telephone: / Email:

Consent

Do you consent to an assessment of need?

Yes No

[For office use only] Unable to consent

Is there anyone who is authorised to help you make decisions, or make decision on your behalf, about your health and welfare?

Yes No

Name
Relationship to you

If Yes:

Is there anyone who is authorised to help you make decisions, or make decisions, on your behalf about your property or finances?

Yes No

Name
Relationship to you

If Yes:

Do you consent for relevant information to be stored and shared as needed?

I consent to relevant information being shared with other people or organisations where there is a need to do so

I consent to relevant information being shared where there is a need to do so except with those people or organisations listed below:

Please do not share with these people or organisations:

I do not consent to relevant information being stored and shared with any other people or organisations

[For office use only] Unable to consent
If the person is unable to consent is there someone who could do this on their behalf? If yes please give details below.
Name
Relationship to the person

In some circumstances the law and our local policy may require us to continue with an assessment or share information without your consent. If these circumstances arise we would always let you know.

Communication Needs

What language do you prefer to communicate in?

If you have any specific requirements to help you communicate please tell us about these here. This might be things like:
·  having documents which are large print, audio, easy read or Braille
·  support from an advocate
·  using a British Sign Language interpreter
·  use of electronic devices e.g. text, e-mail
If your communication needs impact on your wellbeing please tell us about this and, if they do, please explain how significant the impact is. Please also tell us about any change or fluctuation which affects how you communicate. Communication needs means things like: talking, reading, writing, remembering or understanding things.

[For office use only] Unable to communicate

Your Personal Relationships

This means people like family and friends who are important to your life.

Name / Gender / Age / Address / Relationship to you

Professional Involvements

This means people who help you with your care and support on a professional basis, such as a social worker, an occupational therapist, community nurse, doctor. It might also mean some who provides professional support in other ways such as an advocate or someone you pay to manage your finances for you.

Role / Involvement / Organisation, Agency or Team / Name and Job Title / Telephone Number / Start Date:

Employment

Are you:

Employed / Working on a voluntary basis
Self-employed / Retired
Unemployed / Other please give details below:

About the person(s) you care for

Their Name / Address / IAS Number:
(If known)
Person 1
Person 2
Person 3
Person 4

If a person you care for does not live in Cumbria the local authority where they live is responsible for assessment of your caring needs in relation to them and for providing any support if you are eligible for this. However, we will take account of the impact of this in our assessment so please include this in what you tell us.

Needs of the person(s) you care for

Please tell us about any care or support services already arranged for the person(s) you care for:

Type of Service / Provider/Agency / How Often / When
Person 1
Person 2
Person 3
Person 4

Your Caring Role

Thinking about encouragement and support in your caring role, which of the following statements best describes your present situation?

I feel I have encouragement and support
I feel I have some encouragement and support but not enough
I feel I have no encouragement and support
Please tell us about any needs you have in this area of your life. Include things like:
·  how having, or needing, help impacts on how you think and feel about yourself
·  what is most important to you about having help
·  how the way you are encouraged and supported impacts on how you think and feel about yourself. If you don’t have help now think about how having no help makes you feel.
·  what is most important to you about the way people might help you
·  what is good that you would like to stay the same
·  what, if anything you would like to change, the outcomes you want to achieve
If anything has changed or your needs in this area of your life fluctuate tell us about this too.
If you feel that any of the needs described above impact on your wellbeing please tell us here, and if you can, please explain how significant that impact is.
Please give us details of any family, friends, neighbours, or other organisations who support you with this area of your life now or who might be able to do so in the future.
Please describe to us the main ways in which you support the person(s) you look after. Include what is working well for you as a carer now, has done in the past or may help you in the future:
Please describe any support you get with your caring roles from, for example, family, friends, neighbours, or other organisations:

Your Physical Health and Wellbeing

Please tell us about your physical health and wellbeing and how this impacts on your life and your caring role including:
·  any conditions or illnesses that you have
·  how these affect your ability to care for the person(s) you look after
·  any medication or treatment you are receiving
If anything has changed or your needs in this area of your life fluctuate tell us about this too.
If you feel that any of the needs described above impact on your wellbeing please tell us here, and if you can, please explain how significant that impact is.
Please give us details of any family, friends, neighbours, GP / Consultant or other organisations who support you with this area of your life now or who might be able to do so in the future.

Your Mental Health and Emotional Wellbeing

Please tell us about your mental health and emotional wellbeing and how this impacts on your life and your caring role including:
·  any conditions or illnesses that you have
·  how these affect your ability to care for the person(s) you look after
·  any medication or treatment you are receiving
If anything has changed or your needs in this area of your life fluctuate tell us about this too.
If you feel that any of the needs described above impact on your wellbeing please tell us here, and if you can, please explain how significant that impact is.
Please give us details of any family, friends, neighbours, GP / Consultant or other organisations who support you with this area of your life now or who might be able to do so in the future.

Your home – about your surroundings

Which of the following statements best describes how clean and comfortable your home is?

When thinking about how clean and comfortable your home is please think about all of the rooms in your home environment.

My home is as clean and comfortable as I want
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable

If you answered ‘My home is not at all clean or comfortable’ is this having a significant impact on your wellbeing which is likely to result in carer support breakdown?

Yes No

This is about maintaining a habitable home. Please tell us about any needs you have in this area of your life. Include things like:
·  whether your home is sufficiently clean and comfortable.
·  how suited your home environment is to your needs
·  the things that impact on how clean and comfortable your home is including keeping it warm
·  your ability to have maintaining the outside of your home including the garden if you have one
·  what is most important to you about how clean and comfortable your home is
·  what is good that you would like to stay the same
·  what, if anything you would like to change, the outcomes you want to achieve
If anything has changed or your needs in this area of your life fluctuate tell us about this too.
If you feel that any of the needs described above impact on your wellbeing please tell us here, and if you can, please explain how significant that impact is.
Please give us details of any family, friends, neighbours, or other organisations who support you with this area of your life now or who might be able to do so in the future.

Staying Safe

Thinking about your personal safety, which of the statements best describes your present situation?

By ‘personal safety’ we mean feeling safe from fear of abuse, being attacked or other physical harm.

I have no worries about my personal safety
I have some worries about my personal safety
I am extremely worried about my personal safety

If you answered ‘I am extremely worried about my personal safety’ is this having a significant impact on your wellbeing which is likely to result in carer support breakdown?

Yes No

Please tell us about any needs you have in this area of your life. Include things like:
·  what is most important to you about feeling safe
·  is the condition of your home sufficiently clean and maintained to be safe and does it have essential amenities such as water, electricity, gas.
·  what is good that you would like to stay the same, any support you already get to feel as safe as you would like
·  what, if anything you would like to change, the outcomes you want to achieve
If anything has changed or your needs in this area of your life fluctuate tell us about this too.
If you feel that any of the needs described above impact on your wellbeing please tell us here, and if you can, please explain how significant that impact is.
Please give us details of any family, friends, neighbours, or other organisations who support you with this area of your life now or who might be able to do so in the future.

Your nutrition – eating and drinking

Thinking about how much time you have to look after yourself – in terms of getting enough sleep or eating well – which statement best describes your present situation?

I look after myself
Sometimes I can’t look after myself well enough
I feel I am neglecting myself

If you answered ‘I feel I am neglecting myself’ is this having a significant impact on your wellbeing which is likely to result in carer support breakdown?

Yes No

Please tell us about any needs you have in this area of your life. Include things like:
·  what is most important to you about looking after yourself
·  your ability to get meals and drinks at times that suit you
·  your ability to manage and maintain your nutrition
·  what is good that you would like to stay the same, any support you already get to help you look after yourself
·  what, if anything you would like to change and any outcomes you want to achieve
If anything has changed or your needs in this area of your life fluctuate tell us about this too.
If you feel that any of the needs described above impact on your wellbeing please tell us here, and if you can, please explain how significant that impact is.
Please give us details of any family, friends, neighbours, or other organisations who support you with this area of your life now or who might be able to do so in the future.

Your finances and paperwork