Taking Control and Having a Choice

Your Supported

Self-Assessment

Taking Control and Having a Choice

This questionnaire is designed to help you to think about what is important in your life and how you manage. Your answers will be discussed in full with you and will form your assessment under the Care Act 2014. Following this a decision will be reached regarding your eligibility for care and support.

Completion Instructions

You will be contacted by a member of staff from Liverpool’s Adult Social and Health Service who will make arrangements to visit and help you to complete this form. They will always carry ID so please ask to see this. However you may want to start thinking about the questions by reading the statements and ticking the box in ‘Your View’ next to the one which you feel best matches your situation. Please use the space ‘Your Notes’ to describe your current situation and what is important to you.

Personal Details:

Name
Address
Date of Birth

Agreed Consent Notice for Assessment Document

To ensure that Liverpool City Council maintains the highest standards it may be necessary to share information with other council departments and our authorised partners in Health Services.

Please indicate:

Do you consent to this? / Yes / No
Is consent being given by an authorised agent on behalf of the Service User? / Yes / No

Authorised Agents Details

NAME………………………………………………………………

ADDRESS …………………………………………………………….

RELATIONSHIP TO SERVICE USER ……………………………….

Your information will be kept secure at all times and in accordance with the Data Protection Act 1998.

Should you wish to know what information is held about you please contact us by letter;

The Information Manager, Room 221, Municipal Buildings, Dale Street, Liverpool, L69 2DH

Or email:

Do you have any physical or mental illness or impairment? / Yes / No
Please provide details:

COMMUNICATION

This part is about communicating with other people. It includes understanding others and making yourself understood. You may have difficulties because of language, environment, illness or impairment.

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I can communicate with people without the need for support. I can understand what people are saying and they can understand me. / ¨ / ¨
1. / I find it difficult to communicate with people sometimes (e.g. noisy places, poor light) because I have poor eyesight / poor hearing or difficulty in speaking / understanding. / ¨ / ¨
2. / I cannot communicate with others without communication aids or equipment or without someone to help me understand. / ¨ / ¨
3. / I cannot communicate with others without support from somebody to help me: a communication partner or an interpreter or someone who knows me well and can use my method of non-verbal communication. / ¨ / ¨

Informal Support

Your View / Assessor’s View
How much support is your family / friends or other persons willing to provide to support you in this area? / No support / ¨
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¨
¨
¨ / ¨
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¨
¨
¨
Some support
Lots of support
Full support
Unable to continue with current level of support

Your Notes: Is there anything you would like to tell us about your communication needs?

Assessor’s Notes

MAKING IMPORTANT DECISIONS IN YOUR LIFE

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

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I do not need help to make decisions and choices as I can do this independently. / ¨ / ¨
1. / I am able to make decisions and choices about my life with some support and advice. / ¨ / ¨
2. / I am able to make choices but need a lot of support to make important decisions about my life. / ¨ / ¨
3. / Other people make all the decisions in my life. I need a lot of support to make any choices. / ¨ / ¨
4. / Someone has power of attorney and makes decisions on my behalf. / ¨ / ¨

Informal Support

Your View / Assessor’s View
How much support is your family / friends or other persons willing to provide to support you in this area? / No support / ¨
¨
¨
¨
¨ / ¨
¨
¨
¨
¨
Some support
Lots of support
Full support
Unable to continue with current level of support

Your Notes: Is there anything you would like to tell us about making important decisions in your life?

Assessor’s Notes

PHYSICAL AND MENTAL WELLBEING

This part refers to managing a physical or mental health condition.

A) This part refers to professional health care support you need to manage a physical or mental health condition. By professional health care we mean support from your GP, nurse, community matron, community psychiatric nurse, outreach worker, substance misuse worker or other health professional.

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I don’t have any physical or mental health problems which require professional support. / ¨ / ¨
1. / I occasionally need professional support to stay healthy and manage my health conditions. / ¨ / ¨
2. / I need professional support at least once a month to stay healthy and manage my health conditions. / ¨ / ¨
3. / I need professional support at least once a week to stay healthy and manage my health conditions. / ¨ / ¨
4. / I need professional support on a daily basis to stay healthy and manage my health conditions. / ¨ / ¨

Informal Support

Your Notes: Please outline any health conditions or aspects of your lifestyle that you would like us to know about?

Assessor’s Notes

B) Mobility

This part refers to how you get around, how you mobilise and if you require/use any aids to get around.

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I have no problems with my mobility inside and outside of my home. / ¨ / ¨
1. / I can walk independently with the use of aids ie Zimmer or Delta frame. / ¨ / ¨
2. / I am a wheelchair user. / ¨ / ¨
3. / I am not able to mobilise independently and require assistance at all times. / ¨ / ¨

Informal Support

Your Notes: Is there anything you would like to tell us about your mobility needs?

Assessor’s Notes

C) Managing your medication

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I do not take any medication. / ¨ / ¨
1. / I take medication but I do not need any support with taking / applying it. / ¨ / ¨
2. / I can take my own medication but I sometimes need prompting and / or reminding to take / apply my medication. / ¨ / ¨
3. / I need physical help to take / apply my medication or direct supervision. / ¨ / ¨

Informal Support

Your Notes: Is there anything you would like to tell us about your medication needs?

Assessor’s Notes

D) About your Behaviour

This part is about your behaviour which may include hurting yourself or neglecting yourself, things you do that may upset or hurt other people.

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I have no behavioural issues. / ¨ / ¨
1. / I sometimes do things which could upset others but is not harmful or dangerous. / ¨ / ¨
2. / I occasionally do things which could be harmful or dangerous (once or twice a month) but I do not need support every day. There is some risk of harm to either yourself or others. / ¨ / ¨
3. / I regularly do things which could be harmful or dangerous (once or twice a week). There is some risk of harm to either yourself or others. / ¨ / ¨
4. / I often (daily) do things which could be harmful or dangerous. There is a very real risk of harm to either yourself or others. I need somebody with me at all times. / ¨ / ¨

Informal Support

Your Notes: Is there anything you would like to tell us about your behaviour?

Assessor’s Notes: Please consider Risk section on Page 45.

MEETING PERSONAL CARE NEEDS

This section is about looking after yourself / your personal appearance.

A) During the day

This could be things like getting up out of bed, dressing, going to the toilet, strip wash or shower, prompting or encouragement to look after yourself. Help to change position during the day.

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I am able to manage my personal care needs. / ¨ / ¨
1. / I need help once or twice a week with personal care. / ¨ / ¨
2. / I need help once or twice a day with personal care – or someone to remind me. / ¨ / ¨
3. / I need help 3-4 times a day with my personal care or someone to prompt me. / ¨ / ¨
4. / I need someone to take care of my personal care needs for me. / ¨ / ¨

Informal Support

Your Notes: Is there anything you would like to tell us about your daytime personal care needs?

Assessor’s Notes

B) During the night

This could include you needing help at night to get up out of bed to go to the toilet, change bedding, help you into bed if you have disturbed nights and help to change position in bed during the night.

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I do not need help during the night. I am able to get help if I need to. / ¨ / ¨
1. / I need help occasionally (once or twice a month). / ¨ / ¨
2. / I need help sometimes (once a week). / ¨ / ¨
3. / I need help at least once every night. / ¨ / ¨
4. / I need frequent help with personal care or to make sure I’m safe or well during the night. / ¨ / ¨

Informal Support

Your Notes: Is there anything you would like to tell us about your nighttime personal care needs?

Assessor’s Notes

MEALS AND NUTRITION

This part is about help you may need to ensure you are well nourished, able to eat and drink properly to stay healthy. You may need help to prepare your meal and drinks and prompting or encouragement to eat or manage your feeding.

A) Eating and Drinking

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I can manage to eat and drink without help. / ¨ / ¨
1. / I can manage to eat and drink if someone is there to supervise. / ¨ / ¨
2. / I cannot eat or drink without someone to help me. / ¨ / ¨
3. / I need assistance with my PEG Feed or other form of enteral feeding. / ¨ / ¨

Informal Support

Your Notes: Is there anything you would like to tell us about your eating and drinking needs?

Assessor’s Notes

B) Making snacks, hot meals and drinks

Please tick one box you think best describes your needs / Your View / Assessor’s View
0. / I can manage to make a snack, hot meal or drink on my own. / ¨ / ¨
1. / I can manage to make a snack or drink but need help with making a hot meal. / ¨ / ¨
2. / I need someone to help me make a snack, hot meal or drink or to prompt / supervise me. / ¨ / ¨
3. / I need someone to make a snack, drink or hot meal for me. / ¨ / ¨

Informal Support