Purpose of this form
Part 1 - Community Care Assessment Details
Part 2 - Other Assessment Requirements and Eligibility
Part 3 -Primary Client Grouo
Part 4 - Assessment Outcome
Part 5 - Setting Up the Client's Care Plan
Part 6 - Monitoring and Review
Part 7 - Disability Registration
Part 8 - Changes to CareFirst Details
Part 9 - Care Plan / Service Details
Purpose of this form
This form is used to record the details of a Community Care Assessment event, including who it is allocated to, the assessment activities, the outcome of the assessment process, the care plan and the service package details. It is also used to capture any new or amended case details for input to CareFirst.
Only those options displayed on the form are legitimate options for system input. This is to ensure that reporting is maintained accurately and consistently.
Who can use the Community Care Assessment Process Form?
The SS1(P) is used by Referral Co-ordinators, Practice Managers and workers to allocate and record the assessment process, and is input by Referral Co-ordinators or Business Resources staff.
If the assessment process is fully completed via the Level 1 / Contact Assessment, the person receiving the referral and completing the Level 1 / Contact Assessment (such as a Referral Co-ordinator) should complete all necessary sections on the SS1(P) so that the assessment can be recorded along with any care plan and service details.
If further assessment work is required, a Practice Manager will allocate the required activities either to a worker or to a Waiting List on the SS1(P). This is input on CareFirst and then passed to the worker (or held if on the waiting list) for completion.
How to use the Assessment Process Form
It is not always necessary to complete the entire form, only those parts that apply to the current situation.
If the case file is included with the documentation, the SS1(P) should remain attached to the front until all work has been completed and input to the system.
Level of Assessment (Activity)
The form lists all the available assessment activity options. The person receiving the referral and completing the Level 1 / Contact Assessment should complete the Level 1 activity details/line.
If further assessment is required following the Level 1 / Contact Assessment, the Practice Manager needs to allocate the required activity on the appropriate line.
| Allocated to | Write the name / system number of the assigned worker |
| Date allocated | Date the piece of work was requested. A new activity may be requested at any time throughout the assessment process External Mobility Assessment' is only used when an assessment has already taken place by a health worker, such as a hospital OT or Physiotherapist, which identifies the need for social care equipment only. This activity is allocated to the responsible Team. |
| Date required | The date by which the activity is to be completed. This will activate the 'traffic light' information on a worker's desktop, where any Assessment activity assigned to them will show a Green, Black (becoming due) or Red (overdue). This date must take into account risk, referral priority and quality standard requirements. Once input, this date must never be changed (see Waiting List activity on the following page). |
| Input by | This is for Business Resources to initial and date to indicate that the activity has been opened. |
| Completed / Abandoned and Date | The worker allocated to undertake the activity completes this to confirm that the assessment has been completed (C) or abandoned (A) and the date. |
| Input by | This is for Business Resources to initial and date to indicate that the system has been updated. |
Note: The Community Care Assessment event should be allocated on CareFirst to the worker undertaking the main assessment activity.
The assessment outcome can be completed once the appropriate Level 1 / Contact Assessment, Level 2 / Overview assessment or Level 3 activity has been completed (or abandoned), if the outcome is to Provide Ongoing Services. In this circumstance, it is not necessary to wait for a specialist assessment to be completed before moving onto completing Parts 2 and 3. If the outcome of the main assessment work is either Provide a One Off Service or Close / NFA and there is an outstanding specialist assessment do not complete Parts 4, 5 or 6, unless the main assessment's outcome is Provide Ongoing Services.
Waiting List Activity
Open a Waiting List activity if there is no appropriate worker available to carry out the type of assessment required. A Waiting List activity is allocated to the designated Practice Manager who holds the team's waiting list.
When a Waiting List activity becomes due, or an appropriate worker is available, the Waiting List activity is marked as C (Completed). In the Activities section, allocate the type of assessment needed to the available worker on the appropriate line.
Note:If a Waiting List activity is no longer needed (because the client no longer needs - or wants - to be assessed), mark the Waiting List activity as 'Abandoned'.
In exceptional circumstances, a Waiting List activity's required by date can be extended. Note this in the same 'Date required' space on the SS1(P) using a different colour pen. The responsible Manager should initial this. Also indicate the CareFirst input in a different colour. A Waiting List activity is the only Activity that may be amended in this way.
Specialist Assessments
Workers completing a specialist assessment who operate from the same office as the person responsible for the main assessment can share the same SS1(P). A separate SS1(P) can be used by any "off site" workers.
Case files should remain within the relevant Care Management team office. The SS1(P) should remain attached to the front of the case file (on site) or stay together with copies of any assessment documentation (off site) until all work has been authorised and input to the system.
Note:There must be discussion and agreement between the workers completing the Level 1, 2 or 3 assessment and other specialist assessments about who will be responsible for completing the Care Plan (this will usually be the worker undertaking the main assessment activity). If the worker completing a specialist assessment makes care plan or service recommendations to the worker responsible for the main assessment, the details must be added to the relevant SS1(P) and outlined on an SS2(a) or SS6.
Assessment Activity Reassigned
Complete the 'Assessment Activity reassigned to' when an assessment activity needs to be re-allocated to a different worker. Pass the SS1(P) to Business Resources to update the system before passing it to the new worker.
When the main assessment process has been completed, if there is a need for the case to be personally care managed, record the PCM worker's name.
If a joint assessment has been completed, the details of the carer (including Name, Title, Address, Contact Telephone Number, Age or Date or Birth) must be recorded in Part 8 (Any Other Changes). Business Resources staff will tick the 'Done' box when the carer has been recorded as a 'Party' to the client's assessment.
If a separate carer assessment is required (or has been completed), complete an SS91 Carer Contact Form. If the worker has completed the separate Carers assessment, also complete an SS1(APC) Adult Protection / Carer Process Form to record the carer's assessment. Tick into the 'Done' box to confirm the necessary form(s) have been completed.
Adult Protection Assessment
The worker completing the form must tick the appropriate box ('Yes' or 'No') to indicate if there are any Adult Protection concerns.
If 'Yes', complete an SS1(SAP) (or an SS1 for a Learning Disability client) so that a new referral for the adult protection concerns can be recorded. If the worker has completed the adult protection assessment work, also complete an SS1(P)APC, so that an Adult Protection Assessment event can be recorded. Tick into the 'Done' box to confirm the necessary form(s) have been completed.
Eligibility
The worker completing the FACS Eligibility Checklist (SS14) must add their name and the date the assessment was completed on the SS1(P). Business Resources staff will use these details and the actual SS14 Checklist to record Eligibility Criteria on CareFirst.
Notes
Clients who have previously been assessed may already have a Primary Client Group recorded. Check CareFirst to identify if the client has already got a Primary Client Group, as the box ticked on the SS1(P) will be used to add a Primary Client Group, or to update the system.
The client's Primary Client Group does not have to be completed if the Community Care Assessment outcome is 'Cancelled' (the assessment was not completed as it was abandoned or terminated), and there is insufficient information to form a judgement about the correct Primary Client Group.
A Secondary Client Group can be recorded if required. The worker needs to write the appropriate category details and their name, as the assessing worker.
| Provide One Off Service | For example - for Equipment / Adaptation |
| Provide Ongoing Services | For example - Domiciliary Care, Day Care, Meals, Residential/ Nursing Care (including respite), and for PCM cases - Professional Services |
| Close / NFA | Where there are no ongoing services, for example, following assessment only for disability registration, provision of advice / information only, or referral to another agency |
| Cancelled | Where the assessment process has not been completed (has been abandoned), either because further assessment was declined, a change in circumstances (such as, client going into hospital or moving away), or due to death |
Record the assessment completed or abandoned date, and the overall priority (as assessed by FACS)
The outcome of the Set Up Care Plan event is either:
| Monitoring | Ongoing services are planned and/or provisioned |
| Close /NFA | Service provision has not commenced, and will not go ahead (for example, has been declined by the client |
| Cancelled | No service has actually been received by the client, due to either death or a change in circumstances. Record the care planning process completion date, or the date when this was abandoned |
If Monitor Personal Care Management (PCM) is selected, the named care manager must be identified. For the remaining Help Desk options (Monitor CC and Monitor SCM), annotate the responsible team. Business Resources staff will record the event's start date and provisional priority on CareFirst using the same details as the Set Up Care Plan outcome.
Time Limited Services Check or Review Activity
A Time Limited Services (TLS) activity must be set up when the client has been assessed as requiring non-residential services following discharge from hospital. This type of activity can also be used following general assessment for non-residential services by a Locality team where services are only required for a maximum of six weeks.
The 'Date requested' is the same date as the start of the Monitoring event, and the 'Date required' is up to a maximum of six weeks.
For all other clients, the Review Date identifies when the client's first review (not a monitoring check) will take place. This cannot be more than 52 weeks on from the Monitor start date.
Indicate who the review should be allocated to (this can be a named worker or a team) and whether the review will be a Desktop or Face to Face review. (Refer to separate guidance for the criteria for these two review types.)
Note:Any client in a Monitoring event must have either a Time Limited Service check or a Review activity added.
The worker who completed the assessment should add their name and tick the appropriate box.
A Secondary Disability Registration can be recorded if appropriate. The worker needs to write the appropriate category details and their name, as the assessing worker.
Note: If the client has been known to / assessed previously by Social Services, they may already have a disability registration recorded on CareFirst.
Risk Assessment
The only risks being recorded on CareFirst are those that are High or Moderate and have a bearing on the safety of staff/service providers when visiting the client and/or their home.
Any risks reported at the referral or Contact Assessment / Level 1 stage must be confirmed or removed following an assessment of need. The relevant risk is ticked, plus a ‘C’ or an ‘N’ to show whether this is confirmation of - or a newly identified - risk, or an ‘R’ if the risk is being removed (either due to error or as it is no longer valid). Also, record the date this decision was reached and what document (Risk Assessment Form / Management Plan) it is evidenced on.
Any Other Changes or Additional Admin Tasks Required
The assessing worker should add any other changes to the client's personal or case details identified during the assessment process in this section, with each change's effective date.
This includes details such as new telephone / contact numbers; important family members or other contacts (for example, emergency contact / spare key holder), actual date of birth, recording religion, actual or change of GP. If the client is moving into long term residential or nursing care, the placement address details should be noted here so that the client's address can be updated on the system.
Carer details (following a joint Carers assessment) should also be noted here.
It is the responsibility of all staff to ensure that accurate records are maintained.
| Care Plan Start Date | On CareFirst, this is the same as the Community Care Assessment start date. Using this date ensures that any services arranged immediately (following the Level 1 assessment) can be recorded |
| Tick one box to indicate the Care Plan Goal: | |
| Support to Remain at Home Safely | If the client is going to have services such as Domiciliary, Day Care, Meals, Equipment or an Adaptation or respite care (residential or nursing |
| Provide Rehab or Reablement | If a client is going to a unit for rehab or reablement |
| Provide 24hr care in Alternate Setting | If the client is going into long term residential or nursing care |
| Copied to the Client? | Tick the 'Yes' box to indicate that a copy of the care plan has been (or will be) provided to the client (or their representative). If the care plan is not going to be provided to the client (or their representative), tick the 'No' box and add a short note why. |
| Responsibility for the Care Plan | Tick the relevant box to indicate who will be responsible for the Care Plan. This reflects the case type. Use Team for Help Desk (CC), the Personal Care Manager or Self (Client) for Self Care Management cases |
Service Details
The services to be provided are chosen from a restricted list of services on CareFirst. Add the overall
service type, such as:
| Equipment / Adaptations | Respite Residential/Nursing Care |
| Day Care | Short Term Residential/Reablement |
| Domiciliary Care | Professional Services |
| Meals | Transport |
| Residential/Nursing Care |
For Equipment / Adaptation or Professional Services, add on the SS1(P) the type of equipment
or adaptation or professional service provided (as these are input by Business Resources staff from
this form).
Direct Payments is noted on the form as one of the service types. If Direct Payments is not appropriate
for the client, annotate N/A (not applicable) against it. If the client is eligible for but declined Direct
Payments, tick the 'Service Declined' box so that this can be recorded on CareFirst.
Note: Direct Payments is not the only service that can be recorded as declined, but this service type is picked up for reporting purposes.
For all other service types, add on the SS1(P) the overall service description (for example, Day Care or Domiciliary). The full service details (the provider or the number of units) are not required.(These are input via from the Service Contract Forms - SS618 / SS619 - by Finance Staff.)
The Proposed Start Date is the date the service is due or intended to start.
The Fully Provisioned date is:
Authorisation
The SS1(P) does not need to be authorised prior to final computer input.
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