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Section 3: Personalising the outcomes
In this section you will learn more about what FACS 2010 says about:
- who has the right to assessment
- first response
- assessment
- support planning
- reviews
- transitions
- providing ongoing support.
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Section 3: Personalising the outcomes
Outcomes-based operation is central to FACS.
Personalising the outcomes for individuals and carers is critical to setting, reviewing and achieving outcomes that meet the needs of adults seeking and using services. At each point in the assessment and review process the focus should be on the ensuring that the outcomes are personalised and achievable and are revised in the context of changing needs and circumstances.
Click on the items below this topic in more detail.
Section 3.1
Who has the right to assessment?
Explore the options below to learn more about who has the right to assessment.
When you are ready, click on the last link to read the implications for practice.
Section 3.1
Adults seeking services
FACS 2010 expects that social care assessments should be available to all individuals using or seeking to use services (to which they are referred to or to which they refer themselves) because they:
- have substantial, critical or fluctuating needs; or
- have moderate or low social care needs that could be met through accessing information and advice, universal services, or through local support groups or in the private or voluntary sector.
- are on the edge of having eligible social care needs, but where this may be prevented or delayed through signposting to universal services, information or advocacy, local community or user-led groups.
Section 3.1
Carers
Since 2000 carers have had the right to a separate assessment of their needs and risks to the caring function, but carers are not always aware that they have this right. A holistic approach means that carers' own needs could in future be looked as part of a whole family assessment.
Section 3.1
Emergencies and crises
For those who request or are referred for social care support in emergencies and crises, an immediate response should be followed up by a fuller assessment later.
Section 3.1
Who has the right to assessment?
Person-centred assessment should be available, regardless of age, circumstances or nature of needs, to any person who approaches, or is referred to, the local authority for help. When determining who has a right to assessment, whatever their means, staff will need to:
- respond in appropriate ways to a wider range of adults with a diversity of presenting needs.
- access relevant up-to-date information about local resources and universal services to support and signpost adults seeking and using services.
Section 3.2: First contact
The first contact with adults using or seeking social care support, or with their relatives or carers, is recognised as critical to establishing an effective relationship within which staff and the individual, family and/or carer can explore and begin to identify needs and agree appropriate outcomes.
Local authorities vary in their referral/intake arrangements, and the initial contact may be with a professional, an intake worker, a call centre worker or receptionist.
Section 3.2: first contact
Evidence from CSCI inspectors [link to refs page] was that people's needs and those of carers are often insufficiently explored at this stage, and that people are screened out too early or not given adequate signposting to other sources of support.
The quality of the first response influences people's willingness to make contact with the adult services in future.
A positive experience can make the difference between people renewing contact when a situation begins to deteriorate or waiting until crisis point is reached and more intensive support is required.
When you are ready, select 'Implications for practice' to find out more.
Section 3.2: first contact
Implications for practice
For all of us, first impressions are important. They affect how we feel about a person or and organisation, whether we perceive them as helpful, and how we respond to them. With this in mind, staff at all levels involved in receiving referrals and making initial contact should:
Section 3.3: Assessment
Click on the case studies below to find out more about needs of assessment.
Assessment needs to:
Section 3.3: Assessment
Assessment needs to: Be a collaborative, holistic and transparent process
An effective collaborative, holistic, transparent process means ensuring that adults using, or seeking support - and carers - are able to:
- gain a better understanding of the purpose of assessment and its implications for their situation
- actively participate in the process
- identify and articulate the outcomes they wish to achieve
- identify, and express preferences among, the options available to meet those outcomes and support their independence and well-being in whatever capacity
- understand the basis on which decisions are reached.
Section 3.3: Assessment
Assessment needs to: Use a whole systems approach
Using a whole systems approach involves working with other agencies such as children's services, mental health or learning disability services, the NHS, housing providers, employment and training services. Where there are complex needs a joint assessment ensures that the different aspects of the individual's or carer's lives are addressed and resources can be provided by those agencies to promote the adult's or carer's well-being and reduce the need for social care support.
Section 3.3: Assessment
Assessment needs to: put adults and carers in control
FACS 2010 expects adults using or seeking services and carers who request, or are referred for, an assessment to retain as much control as possible over their own lives and the way they define and meet their social care needs.
Section 3.3: Implications for Practice
Assessment is not something professionals do to people seeking support and their carers. It is a process people, their carers and staff need to engage in, sharing information and ideas, working in partnership. Staff undertaking assessments should:
- work in partnership with people and their carers at all stages of the assessment process.
- apply the principles of personalisation to:
- maximise people's control over their lives, and prioritise the outcomes they value
- recognise individuals' and carers' expert contribution to assessment
- explore solutions that lie within the adult's own network or through local community resources
- signpost or provide information and advice on support from universal services, other agencies and community resources.
- draw on the results of self-assessment to inform the assessment process
- ensure that the scope of the assessment process is proportionate to the need and fit for purpose
- collect sufficient evidence to make a sound judgement about eligibility within the FACS bandings and criteria, agree outcomes, identify and manage risks and address any safeguarding issues.
Section 3.4: Support planning
Support planning should focus on the full range of sources of support available to the adults seeking or using services.
Select from the links below to read more
Section 3.4
Information
Planning should cover the full range of sources of support, including:
- preventative and early intervention.
- the provision of direct or commissioned services.
- self-directed support.
- a combination of support from personal support networks, family, community or specialist groups, and funded services.
Section 3.4
Personalised budgets and direct payments
The majority of adults eligible for social care support will be in control of that support using one of the following:
- Personal Budgets
- Direct payments
This will enable them to use the funding to meet their needs in ways that best suit them. Where adults' needs are so complex, and/or there are significant risks to their safety or that of others, self-directed support may be not possible. The level of co-ordination required between different agencies and professionals may be too much for an individual or his or her carers to manage alone.
Section 3.4
Maximising control
The council must ensure that adults with special needs can participate as fully as possible in planning how their needs will be met, using interpreters, translators, advocates or supporters as required.
Councils should ensure that the choices made by adults and carers are respected and supported whenever possible, and be clear about risks and how they can be managed.
Section 3.4
When control is limited
Adults' right to control over their lives is limited only when the Five Mental Capacity Act Statutory Principles are met. These are:
- A person must be assumed to have capacity unless it is established that they lack capacity.
- A person is not to be treated as unable to make a decision unless all the practicable steps to help him or her to do so have been taken without success.
- A person is not to be treated as unable to make a decisions merely because he or she makes an unwise decision.
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made in his or her best interests.
- Before an act is done, or a decision is made, careful consideration has to be given to ensuring that it is the least the restrictive option and will minimise as far as possible limitations on the individual's rights and freedom of action.
Section 3.4
Recording
Councils should provide a written record of the support plan in an accessible format to the individual and, where agreed, to a carer. It should include:
- eligible needs identified during assessment.
- agreed outcomes and support to meet those outcomes.
- risk assessment and any actions to be taken to manage identified risks.
- contingency plans to manage emergency changes.
- any financial contributions the individual is assessed to pay.
- support which carers and others are willing and able to provide.
- support provided to address carers' needs identified through the carers' assessment.
- a review date.
Section 3.4: Implications for practice
Support planning
When planning support with individuals and carers, staff seeking to promote control and choice for people will need to address issues of participation, procedure and recording.
- 1. Involve individuals and their social networks in developing support plans by:
- promoting their capacity to use direct payments and personal budgets, and to contribute to the record of their own support plan.
- ensuring they receive and understand information, before support is arranged, about the basis for financial assessment and any charges / contributions.
- enabling individuals with limited capacity to participate as fully as possible in decisions about their lives.
- providing information, advice, advocacy and/or brokerage, to help them plan their own support.
- 2. Follow procedures to implement the law, the council's procedures, service coordination arrangements and multi agency agreements when an individual's right to control has been limited.
- 3. Ensure records of the support plan are in accessible formats and language, and:
- are person-centred and based on agreed and shared outcomes, assessments of risk and arrangements to manage them.
- identify areas of disagreement or conflict about needs, risks and how to address them, together with any anticipated difficulties this might cause when carrying out the plan.
- clarify resources, highlight responsibilities, identify when and how problems will be handled, and set out what to do in emergencies.
Section 3.5: Review
Explore the links below to read more about reviews:
Section 3.5
The must-dos
Section 3.5
Taking account of carer needs
If carers are receiving support, they can ask to have a review separate from that of the adult using services.
Section 3.5
The questions to ask
Section 3.5
Special needs and circumstances
Any special needs, including assistance with communication, should be met to ensure people can participate in, and contribute to, the review as fully as possible.
Section 3.5
Keeping the records straight
A written record of the results of these considerations should be kept and shared with the service user and with agreed other workers.
Section 3.5: Implications for practice
Review
The review should cover key aspects of the person's circumstances and the working of the support plan, including changes to outcomes, needs, risks, requirements, finances and coordination arrangements, and scope for widening the contributions the individual is making to family/community life.
Staff undertaking reviews must:
Section 3.6: Transitions
When young people with continuing social care needs reach adulthood and transfer to adult services, they should have the opportunity to live as independently as possible and receive the support they need to achieve this.
Young people should not be disadvantaged by their move from children's to adults' services support.
The responsibilities to the young person and their family of other agencies, including the NHS, housing, education, training, employment and benefits, need to be identified and coordinated, to help the young person navigate the transition process.
Section 3.6: Transitions
The impact on parents or carers of any changes in support that occur as a result of the transition to adults services should be identified and addressed.
For young people with complex needs, transition planning requires particularly close partnership working between directors of Children's Services (DCS) and directors of Adult Social Services (DASS), and the involvement of young people and their families in this process, in order to achieve positive outcomes.
When you are ready, select 'Implications for practice' to find out more.
Section 3.6:
Implications for practice: Transitions
To implement FACS 2010 guidance, staff should be able to:
- put the young person at the centre and promote their involvement at all stages of the transition process.
- implement agreements between children's and adults' services, and joint multi-agency arrangements for effective transitions.
- ensure planning begins early and at the agreed points prior to the date of transition, and take into account the impact on parents or carers of any changes in the young person's support.
- support the young person and their family to identify and access the support available from universal and other services.
- take account of the person's and family's medium and long-term needs and recognise that transition arrangements may need to continue over a period of years.
Section 3.7
Providing ongoing support
Select from the links below to find out more about providing ongoing support. This includes mental health and learning disability.
Section 3.7: Adults with long-term needs
Disabled adults and those with sensory, mental health, substance misuse or learning disability needs, or combinations of these, may require continuing health care services from the NHS and/or on-going support from councils. The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care sets out the criteria for different levels of NHS-funded nursing and care.
Section 3.7: Supporting carers
Carers' support for people with long-term conditions can be key to their staying independent and continuing to live in the community. Carers retain the right to an assessment if the individual is receiving NHS-funded Continuing and Nursing Care, and, if eligible, to support with their caring role and help to maintain family and work commitments.
Section 3.7: Timely support
Appropriate and timely support for people with long-term conditions can help maintain their independence and reduce unnecessary hospital or care home admissions.
Section 3.7: Re-ablement and intermediate care
Reablement and intermediate care can prevent hospital admission or transfer from hospital direct to long-term care, or reduce the need for ongoing home care support .
Section 3.7: Responsibility of NHS
The responsibility for providing ongoing support to those with continuing needs rests with both the NHS and the council. When support is provided by the NHS and adult services, effective partnership arrangements will need to ensure that the adult or carer receives integrated and seamless support.
Section 3.7: Implications for practice
Disabled adults and those with sensory, mental health, substance misuse or learning disability needs, or combinations of these, may require continuing care services from the NHS and/or on-going support from councils. When working with people who have long-term or fluctuating needs, staff should to be able to:
- promote their involvement, and where appropriate their support networks, and report on and address any identified barriers.
- ensure that the approach, including when working with other agencies, is person focused, and takes account of medium and long-term needs and their potential impact on the identification and achievement of agreed outcomes.
- work within the council's agreements with the NHS on continuing health care, and with agencies more widely on multi-agency working.
- be alert to new approaches to maximise independence and control offered through pilots (e.g. personal health budgets, Common Assessment Framework when applicable) and other initiatives.
- identify and report any concerns about, or indications of, safeguarding issues.
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