Guidance Notes for the Monitoring and/or Assessment Summary form (SS6)(Revised Nov ’05)

Contents

Purpose of this Form
When to use the Form
When should this Form Not Be Used
Completing the Process Sections
Part 1 - Time Limited Services Check
Part 2 - Adult Protection Review or (Separate) Carer Review
Part 3 - Changes to Case Details

Purpose of this form

Use this form for:

• A means of succinct summary to inform the service user, carer, service provider and / or other professionals about the outcome of an assessment or re-assessment of need (including eligibility, needs, risk level).
• A summary / record of an additional or specialist assessment (appropriate additional / specialist assessment documentation should be completed where possible).
• Care Plan monitoring and / or minor adjustment in between agreed review periods.
• Recording the outcome of a Time Limited Services check (when non-residential services are set up for a period of up to six weeks).
• For the planned transfer of cases from Personal Care Management (PCM) to the Help Desk.
• Recording a review of cases with a Carer Monitor event or Adult Protection Monitor event (or abandoning this, if monitoring or review is no longer required).

When to use the Form?

Assessment Summary

• When an assessment of need has taken place and a summary is required by the service user / carer / advocate (including a summary of eligible needs).
• When an assessment has taken place but there will be no service provision from Social Services, for example, where the service user does not meet the eligibility criteria, does not wish to pay for our services, or another agency can provide a service more effectively.
• When an assessment for a new client has resulted in a one-off service provision, for example, the issue of a single piece of equipment, and it would not be appropriate to send the service user a copy of the full assessment.  The assessment may be summarised (including eligibility), and the appropriate contract (SS618 / JES order) issued.
• For recording the outcome and agreed action following a specialist assessment (when there is no other appropriate documentation to record the assessment outcome).

For Monitoring

• When monitoring is required for an existing care managed case between agreed review periods.

Note:  When recording the outcome of general monitoring work on the front of the SS6, the worker must clearly indicate any changes to the client's personal, case or service details that need to be input onto CareFirst.  This will help Business Resources staff to update the system easily.

• When a PCM case is planned to transfer to Help Desk (following a recent assessment or review).  On the transfer date, if there are no changes of circumstances, record the transfer instructions on the front of the SS6 form.  The PCM worker must note clearly that the case is for transfer to the responsible Team, the new type of case management required (either Care Coordination or Self Care Management) and the effective date of transfer.  Business Resources staff will use these details to update CareFirst.  

The front of the form and the Process Sections on the back of the form must only be completed:

• When a monitoring check of Time Limited Services has happened, or need to be abandoned.
• When a review has happened for a Carer in an open Carer Monitor event.  

Note:   Use a Review Guide (SS3), plus any other forms necessary, for recording the carers review.

• When a review has happened for a case in an Adult Protection Monitor event.
• To close a Carer Monitor event or an Adult Protection Monitor event if this type of monitoring is no longer required.     

When completing the front of the form, the monitoring observations should be recorded, including differences of view of the service user, carer(s), and/or other professionals as necessary, and any actions noted clearly in the Agreed Action box.  If minor adjustments are made to services these should also be clearly noted.

Use the process sections on the reverse of the form when the Time Limited Services check (Part 1) or Care Plan Review activity (for a Carer or Adult Protection Review - Part 2) has been completed (or abandoned).  

Changes to Case Details (Part 3) is generic for either the check or review situations.  

When should this form not be used?

• When contact is made regarding an existing care managed cases (with a Monitoring event - SCM, CC or PCM) and the nature of the contact indicates a re-assessment of needs:
• For cases managed by the Help Desk (SCM and CC), this is recorded as a re-referral on a Referral Form (SS1) (for Learning Disability teams) or a Contact Assessment / Reassessment Form (SAP1 / SAP1(a)) and a CareFirst Referral Checklist SS1(SAP)) (for Adult teams).  Input as an Initial Contact / Referral with an Outcome of Review on CareFirst.  Next, use a Review Process Form (SS3(P)).  
• For PCM cases, the details should be recorded on a Message Form (SS4(a)) and passed to the personal care manager to decide what action is required.  

Additional Notes:

This form should not be used instead of a Review Form (SS3).  

This form should not be used instead of Your Care Plan (SS2), in part or whole.

Completing the Process Sections

Part 1:  Time Limited Services Check

Notes:  

For a case where there are only "time limited services", if there has been no contact with or from the client regarding their time limited services (and no monitoring check is necessary), when all services have ended as planned complete Part 1 on an SS3(P) Review Process form to close the case.  The end date of the Monitoring event should be the end date of the last service.  

For an existing care managed case with ongoing services and "time limited services", the SS6 will need to be completed as described in further detail below.

If the time limited services check identifies new concerns or needs unrelated to those originally assessed, do not complete the process sections on the back of the SS6.  Follow the Review process for reassessment.  (Use an SS1(SAP) CareFirst Referral Checklist to record the re-referral, and an SS3(P) Review Process form.)

The worker completing the time limited services check must complete their name and tick the appropriate box to record whether this activity has been completed (or abandoned), and the date.

Input Note:  If the activity had originally been allocated to a team, reassign the activity to the worker on CareFirst before 'completing' or 'abandoning' the activity on the system.  (See the separate guidance - CareFirst Guidance Note 003 - on how to reassign activities.)

For a completed or abandoned check activity, the case either needs to close (if there are only time limited services and all are due to end as planned), or another Time Limited Services check or review activity set up.  

• For an existing care managed case, if an extension of the existing time limited services is required (to a maximum of another six week period):
  • Tick the Time Limited Service check box, allocate the next check activity to a worker or team as appropriate and set the next check date (to a maximum of six weeks from the completed check activity).
• For an existing care managed case, if the client is eligible to continue with the services as an ongoing care management client:
• The worker must complete a new FACS Eligibility Checklist (SS14) and care plan, recording the client's new desired outcomes and how they are to be achieved.  

Input Note:  The new FACS eligibility and a new/revised care plan are not input on CareFirst.

• Do not indicate a next review activity, as there will already be one set up on CareFirst.
• For a case that only had time limited services, tick the appropriate box (Desktop or Face to Face) to indicate what type of Review will be needed next.  (Refer to separate guidance for criteria for these two review types.)  Allocate the activity to a named worker (for Personally Care Managed cases) or to a team.  The next review date cannot be more than 52 weeks on from the Monitoring event start date.
• If the time limited services are to end as planned:
• For an existing care managed case, if a time limited services check activity has been completed, tick into the Completed box and record the date the check was undertaken.  If a check activity was not required (and the services have ended as planned) tick the Abandoned box and date.  A next check or review activity is not required (as the case already has an existing Review activity associated with the ongoing services).  
• Where the client only had time limited services, tick into the Completed box and record the date the check was undertaken.  The Monitor event cannot be closed until all services have ended.  Complete the Monitor event Outcome as Close/NFA and indicate the appropriate Reason (Services not required; Not eligible for services; Due to death).  The end date is the date all services have ended and record an overall priority.
• From the Time Limited Services monitoring, if the case is to transfer from one locality team to another or from one type of care management to another:
• Complete the Monitor event Outcome box with the Outcome of Transfer and indicate the appropriate Reason (Change of Case Type; Change of Team).  The Review Completed date is the same as the completed Time Limited Service check activity, and the priority is the overall priority (as assessed by FACS).  Tick into the appropriate Monitor box to indicate the next type of Monitor event required (either Monitor CC or Monitor SCM) and note to which Team this is to be allocated.  

Any changes to case details or any new or ending services must be recorded in Part 3 - Changes to case details.

Part 2:  Adult Protection Review or (Separate) Carer Review

The worker completing the Care Plan Review activity must complete their name, tick the appropriate box to record the type of review (Carer or Adult Protection) and whether it has been completed (or abandoned), and the date.

Input Note:  If the activity had originally been allocated to a team, reassign the activity to the worker on CareFirst before 'completing' or 'abandoning' the activity on the system. (See the separate guidance - CareFirst Guidance Note 003 - on how to reassign activities.)

Following a completed review, if the case needs ongoing monitoring (due to ongoing adult protection issues/concerns, or for a carer - because they are to continue to receive ongoing services), a next Care Plan Review activity is required.  If ongoing monitoring is not required, the Monitor event must be closed.

If there are circumstances where the case does not need either ongoing monitoring or review, close the Monitor event.

• Following a completed Carer Review
• If the carer is to continue to receive services, the worker must indicate if a FACS Eligibility Checklist (SS14) has been completed, their name and the date the review was completed.  Business Resources staff will use these details and the actual SS14 Checklist to record Eligibility Criteria on CareFirst.  Tick the Care Plan Review box, record the next review date (up to 52 weeks on from the completed review date), and allocate to the team.  Any changes to case details or new/ended services must be recorded in Part 3 - Changes to Case Details.
• If the carer is not going to continue to receive services, the worker must indicate if a FACS Eligibility Checklist (SS14) has been completed, their name and the date the review was completed. Business Resources staff will use these details and the actual SS14 Checklist to record Eligibility Criteria on CareFirst.  Complete the Monitor event Outcome box as Close/NFA and indicate the appropriate Reason (Services not Required; Not Eligible for Services; Due to Death).  The Monitor event end date is the same as the completed review, and an overall priority.  
• Following a completed Adult Protection Review
• If the case still needs an Adult Protection Monitor event, a next Care Plan Review activity is required.  Tick the Care Plan Review box, record the next review date (up to 26 weeks from the completed review), and allocate to a named worker.  
• If the case does not need ongoing monitoring of this type, complete the Monitor event Outcome box as Close/NFA, and indicate the appropriate Reason (Services not Required).  The Monitor event end date is the same as the completed review, and an overall priority.

Part 3:  Changes to Case Details

The only Risks recorded on CareFirst are those that are High or Moderate and have a bearing on the safety of staff / service providers when visiting the person and / or their home.

If new risks are identified, or risks are no longer valid (or are now of a low level) these must be updated on the system.  Tick the relevant risk box, indicate with an ‘N’ if it is a newly identified risk, or an ‘R’ if the risk is being removed.  Also record the date this decision was reached and what document (Risk Assessment Form / Management Plan) evidences this Risk / removal of Risk.

Any other changes to case or personal details need to be recorded in the Any Other Changes to CareFirst Details box.  It is the responsibility of all staff to ensure that accurate records are maintained, and therefore any known changes must be listed, and the date the new information / changes are effective from.

Following a Time Limited Services check or a Carer Review, if there are any changes to service types (for example, services ending), complete the New / Ended Service details box.  Changes in the level of provision or the provider will be recorded on an Individual Service Contract Form (or Amendment form), and will be input by Finance staff.  

Note:  Business Resources staff will input / end service agreements on the system for Equipment/Adaptation and Adult Professional Services.  

When it is used for an Adult Protection case, the SS6 should be authorised prior to final computer input.

Business Resources staff should initial and date to confirm all required information has been input and the system updated, and to confirm if a copy of the summary (front of the form) has been sent to the service user / carer / provider / other as necessary.