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• Assessment in health and social care

Assessment of support needs in health and social care

At certain times in life people may need support related to health, disability or mental health. For older people this may happen when health matters cause a person difficulty in looking after themselves in the home or getting out and about, or where there is change in family support.

Often people's needs overlap and at times they may have their needs assessed by several agencies, which can become confusing. So for older people, from 2005, all councils and NHS trusts have been required to gather initial information in a standard person centred way, seek the persons views on their desired outcomes, and have a process in place to make this available across agencies with the consent from the person. This is called the "single assessment process" (SAP).

What is the Coventry approach?

In Coventry as part of implementation a standard form is used across all older people's services for referrals between services- an "Interagency Referral/Contact".

In addition at a point where it is clear a person will have a longer term need for a service, each nurse, therapist or social worker completes a standard overview assessment and, additional to the agencies' own records, offer it to the person in a standard orange folder - a "person held record".

The person held record is held by the older person themselves. It has space for the nursing and intermediate care records during any periods they are involved, for summary documents such as Care Plans, Reviews and communication sheets for other significant events to be recorded.

When they visit, professionals are expected to seek consent to view the available information from the folder and build on it, thus avoiding unnecessary questions. Patients are also advised to take the folder to hospital appointments and allow new services access to the information.

Alternative arrangements are in place if the person is concerned about holding the summary record, or they are unable to safeguard it.

At an early stage we will be seeking to know what outcomes you seek from services. Practitioners concerned then work out which support may be available from which agencies.

Can I assess my own needs, or refer myself or my relative?

If you are contacting us for advice or assessment and are over age of 65 staff will generally undertake a "contact assessment" based on the "Interagency Referral/Contact". Your views of the issues are essential, and you can help by giving us information on a "Word" form available through this page, as a combined referral and assessment. (If the person is in hospital discuss first with ward staff)

We will then work out how to help through advice or support or further assessment . If more complex services are needed, specialist assessments are undertaken such as those by occupational therapists and health staff.

What if my primary need is a health one?

In most situations ongoing nursing needs are met through the District Nursing service. If your need is primarily a healthcare one or you are advised your support could be through a nursing home, you should also have assessments from Coventry NHS Primary Care Trust staff. They will discuss your needs with you and also work out if they can give financial assistance.

Your Community Nurse will initiate this, or if they are not involved, you or your social worker/care manager can approach the Continuing Healthcare and Adult Assessment Team (CHAAT) and ask for assessments relating to Continuing Health Care and Residential Nursing care Contribution (RNCC). The CHAAT team number is 024 7684 4111.

How is ongoing support managed and reviewed?

We look for recovery and change, and many people recover their ability to look after themselves with the right kind of support. Sometimes people need care services for a period of time.

When we plan care with you we co-ordinate the different services going in for a person to meet the overall objective.
 
We monitor and set up reviews as routine and in response when needs change, working with partners under the Single Assessment process, and, if they have mental health needs, the “Care Programme Approach”.  In this role staff are called care manager, or "care co-ordinator", if they coordinate arrangements between agencies.

If you have a care package through the council, a team is identified with case management responsibility, and staff undertake Reviews at minimum intervals of 12 months to ensure that needs are still being addressed and arrangements are best in place to meet outcomes. In any difficulty you should direct your enquiry to that office.

What is the future for the single assessment process?

In the longer term, adults will be asked for consent for information on their needs to be recorded on secure systems in social care and the NHS. In several years time Connecting for Health - the NHS's National Programme for Information Technology  will support it being securely available between health and social care systems, with the patient's consent. This will also ensure better coordination of services for people with complex needs.

It is expected that people will be able to access their own records electronically, or have paper summaries sent to them at regular intervals. More details on the Process are available through the leaflet below.

Contact Details

Downloadable documents

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•  Introduction to Single Assessment Process in Coventry  (192 kb)