Promoting Independence Assessment Form

PROMOTING INDEPENDENCE ASSESSMENT FORM

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 care and support needs. By care and support 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 people, like getting enough to eat and drink, being clean and presentable or feeling safe. 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 calledan 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 ‘supportedself-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 providing care and support to help meet your needs – 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?

Would you have substantial difficulties in engaging in the assessment process?

Yes No

If Yes, what difficulties would you have?

Would you like someone with you when we visit, for example an advocate?

Yes No

If Yes please give details below:

Name
Relationship to you
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 yourcommunication 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 meansthingslike: talking, reading, writing, remembering or understanding things.

[For office use only]Unable to communicate

If the person is unable to communicate please give details below.

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:

About you

Please tell us about yourself, for example, your social history, hobbies, interests. Please also consider:

Personal, practical, social and cultural aspects of your life
What are your interests, who are the people in your life who are important to you? Who visits you regularly?
What are your interests and hobbies?
What do you like to do with your time?
Are there any end of life issues you wish to consider?

Your hearing and eyesight

Do you have problems with your eyesight?Yes No

Does this affect your ability to read and /or write?Yes No

Are you Registered Visually Impaired? Yes No

Have you attended a Low Vision Clinic? Yes No

Do you have problems with your hearing? Yes No

If you have problems with your hearing please give details:

Do you have dual sensory loss?Yes No

“A person is regarded as Deafblind if their combined sight and hearing impairment cause difficulties with communication, access to information and mobility. This includes people with a progressive sight and hearing loss.” (Think Dual Sensory, Department of Health, 1995)

Do you have any other sensory loss/Issues?Yes No

e.g. Autism related.

If you have other sensory loss issues please give details:
If you have impairedhearing or eyesight please tell us if this impacts on your wellbeing and, if it does, please explain how significant that impact is. Please also tell us about any change or fluctuation which affects your hearing or eyesight.

Your Physical Health and Wellbeing

Please tell us about your physical health and wellbeing and how this impacts on your life:

any conditions or illnesses that you have
how these affect your life including the ability to care for anyone who 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:

any conditions or illnesses that you have
how these affectyour life including the ability to care for anyone who you look after
any medication or treatment you are receiving

Your Personal Care – Keeping Clean and Presentable

Thinking about keeping clean and presentable in appearance, which of the following statements best describes your situation?

By ‘ keeping clean and presentable’ we mean feeling as personally clean and comfortable as you want to be or, at best, being dressed and groomed in a way that reflects your personal preferences.

I feel clean and am able to present myself the way I like
I feel adequately clean and presentable
I feel less than adequately clean or presentable
I don’t feel at all clean or presentable
Please tell us about any needs you have in this area of your life. Include things like:

your ability to wash yourself and launder your clothes
your ability to dress yourself and be appropriately dressed for instance in relation to the weather to maintain your health

what is most important to you about feeling clean and comfortable
what is good that you would like to stay the same, any support you already get to feel as clean and comfortable as you want
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 Mobility – Getting Around Indoorsand Outside

This is about you being able to make use of home safety. Please tell us about any needs you have in this area of your life. Include things like:

your ability to move around your home safely. Including getting up steps, using kitchen facilities or accessing the bathroom.
your ability to move about outside, including accessing your home e.g. steps leading up to the home.
your ability to getting on and off a chair or toilet, getting in and out of a bed, bath or shower
if you have tripped or fallen or have concerns about trips or falls
the things that impact on how you get around
what is most important to you about your mobility
what is good that you would like to stay the same, any support you already get to help you with this
any equipment, adaptations or assistive technology you have to support you with your mobility. For example, walking frame, rails or handles, community alarms, fire or smoke detectors
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.

Which of the following statements best describes how safe you feel?

By feeling safe we mean how safe you feel both inside and outside the home. This includes fear of abuse, falling or other physical harm.

I feel as safe as I want
Generally I feel adequately safe, but not as safe as I
would like
I feel less than adequately safe
I don’t feel at all safe
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.

Cumbria Fire and Rescue Home Safety Check

The free home fire safety check service operated by Cumbria Fire and Rescue Service is more than just putting up a smoke detector. It’s about assessing general fire risk and providing advice and equipment to the household. We even provide fire retardant bedding, portable sprinkler systems and alarms for people with hearing impairment. It’s about getting the right solution for the right people.

Are you at high risk of fire?

(Consider whether there is a smoker in the house; if the house is cluttered; the source of heating; if there is exposed/old wiring; if someone would need support to exit the house in the event of a fire; if there have been previous fires)

Yes No

Would you like a Home Safety Check from Cumbria Fire and Rescue Service?

Yes No

Please tick any of the boxes relevant to your situation. This will help us to identify if you need additional support in the event of an emergency situation such as extreme cold weather, heat wave or flooding. This will be used in the event of the CCC Emergency Plan being put into action.

Lives alone with no additional social care support / Living in deprived circumstances, house with mould or fuel poor
Lives with others who are also vulnerable with no additional social care support / Very isolated location
Cluttered house / hoarder / Nursed / cared for in bed
Long term chronic medical condition / Oxygen user
Housebound of otherwise low mobility / Over 20 stone (127kg) in weight
No family / friends support within close proximity / None of the above

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 adequately clean and comfortable
My home is not quite clean or comfortable enough
My home is not at all clean or comfortable
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.

Your nutrition – eating and drinking

Thinking about the food and drink you get, which of the following statements best describes your situation?

When thinking about food and drink consider whether you feel your diet is varied and appropriate to your dietary or cultural needs, and whether you get enough food and drink that you enjoy at regular and timely intervals.

I get all the food and drink I like when I want
I get adequate food and drink at OK times
I don’t always get adequate or timely food and drink
I don’t always get adequate or timely food and drink, and I think there is a risk to my health
Please tell us about any needs you have in this area of your life. Include things like:

your ability to access to food and drinks
your ability to prepare food and drink including cooking it
your ability to eat and drink, for example, holding cutlery, cutting up food, chewing or swallowing
any significant unintended weight loss or gain
what is most important to you about the food and drink you get
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.

Your finances and paperwork