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Social Services and Well-Being(Wales) Act

Assessment, eligibility & meeting needs

Guidelines from April2016 for Children’s Services Social

Care Staff Type: Practice Guidelines

Author: CSMT

Authoriser: Director, Social Services

Date for Review: Winter 2017/18

Assessment, eligibility & meeting needs guidelines from April 2016

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ASSESSMENT, ELIGIBILITY & MEETING NEEDS GUIDELINES FROM APRIL 2016 FOR CHILDREN’S SERVICES STAFF IN MERTHYR TYDFIL

TABLE OF CONTENTS

a. Introduction ....................................................................................................2

b. CORE PRINCIPLES .............................................................................................4

c. key legislative duties........................................................................................5

1. Assessing needs duties ..........................................................................................5

2. Determining eligible needs duties .........................................................................6

3. Care and support planning duties..........................................................................8

d. guidelines For Children’ Services staff on Assessment ....................................11

1. Assessment of Children .......................................................................................11

e. Guidelines For Children’s services staff on eligibility ......................................22

1. Determining eligible need ...................................................................................22

f. guidelines for children’s services staff on meeting needs ...............................27

1. Care Planning Process..........................................................................................27

g. References and resources available ...............................................................30

h. Appendix .......................................................................................................31


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INTRODUCTION The Social Services and Well-Being (Wales) Act 2014 (Act) aims to reform and simplify the law relating to the care and support of vulnerable adults and children. It builds on the White Paper ‘Sustainable Social Services for Wales: A Framework for Action’ to modernise the law for care and support in Wales.It introduces new duties for local authorities, local health boards and other public bodies, and covers adults, children and carers.

The Act requires local authorities to make significant changes to current assessment and eligibility practice, with a move away from ‘identifying what social services an individual needs’ to an emphasis on what care and support they require to achieve the personal outcomes that ‘matter to them’. The aim is to streamline assessments through a single process for children, adults and carers while recognising the different requirements of children and adults. Eligibility is not about giving a right to a service; it is about access to care and support to meet personal outcomes. The child or adult has an eligible need for care and support if an assessment establishes that they can only overcome barriers and achieve their personal outcomes if the local authority prepares a care and support plan, or support plan for carers, and ensures that it is delivered. These guidelines focus on MTCBC’s children’s service staff responsibilities in Part 3 and Part 4 of the Act. The assessment and meeting need responsibilities in Parts 3 and 4 of the Act replace Section 17 responsibilities (children in need) in the Children Act 1989.Part 3 defines the circumstances in which MTCBC must assess a person’s needs for care and support, whether they be a child, adult, or carer, and how assessments are carried out. Part 4 describes the national eligibility criteria and how individuals’ needs are to be met. The document provides procedural guidance for MTCBC’s children’s services staff within the following aspects of Part 3 & 4 of the Act:

A process for assessing the needs of a child for care and support, or support in the case of a carer.

A process of assessment that will apply to all people – children, adults and carers.

A process of review and re-assessment that applies to all assessments. How to determine the point at which a child will have an enforceable right to

support from the local authority and the authority has a legal duty to provide or arrange care and support.

How to use the eligibility criteria that will apply to all individuals – children, adults and carers

Sets out the requirements of care and support planning.The document should be read in conjunction with Section 145 of the Social Services and Wellbeing (Wales) Act 2014 (the 2014 Act).


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MTCBC’s children’s services staff should also make reference to the following:1. Part 3 of the codes of practice (assessing the needs of individuals) which

contains guidance on the duties contained in sections 19-29 of the Act and the Care and Support (Assessment) (Wales) Regulations 2015 made under section 30 of the Act (“the assessment regulations”).

2. Part 4 of the codes of practice (meeting needs) which contains guidance under section 32 (determination of eligibility), sections 54 and 55 (care and support plans and support plans), and sections 50, 51, 52 and 53 (direct payments) in Part 4 of the Act on Meeting Needs.

Both codes are critical to the design and delivery of the new system for accessing and delivering care services.In Summary the key changes which apply to assessing and meeting individual needs are: Section 17 (children in need) of the Children Act 1989 is repealed:-.Assessment

and meeting needs is provided for in Part 3 and Part 4 of the Act under section 21: the duty to assess the needs of the child for care and support and section 37: the duty to meet the care and support needs of a child.

A move away from ‘identifying what services an individual needs’ and resource –led pathways to an outcome based approach to assessment, emphasising what care and support the individual requires to achieve the personal outcomes ‘that matter to them’.

Local Authorities must carry out an assessment for any child, adult or carer with an appearance of need for care and support, regardless of whether or not the local authority thinks the individual has eligible needs. Determining their eligibility follows from, and is a product of, the assessment.

Assessments must, as a minimum, record information in line with the national assessment and eligibility tool, which comprises the national minimum core data set (NMDS) – completed by whoever has first contact with the person – and an analysis structured around the five elements of assessment, which require a local authority (or organisation with delegated functions) to:i. assess and have regard to the person’s circumstancesj. have regard to their personal outcomesk. assess and have regard to any barriers to achieving those outcomesl. assess and have regard to any risks to the person if the outcomes are not

achieved m. assess and have regard to the person’s strengths and capabilities

The introduction of national eligibility criteria for children, adults and carers. From the first point of contact social care staff should consider whether

advocacy support is necessary for the child to be able to fully participate in the process.

The Act removes some of the previous restrictions on the use of direct payments which can now be used for any identified need for care and support a local authority is to meet


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CORE PRINCIPLES Assessing individual needs is about working in partnership with children and

families to build on their strengths and understand their needs, to support and enable them to live full lives and maintain their well-being

Supports children to be able to identify what matters to them about their well- being, and to take a full part in decisions about their care.

Supports children’s services staff to exercise their professional judgement working in partnership with people to agree solutions that are in the best interests of the child.

Drives integrated practice that will shape relationships between children;s services staff, and between the families they support

Assessments that focus both on children and families’ needs and on their strengths, and support people to contribute to their own personal well-being outcomes.

Recognises the contribution children and families can make to their own well-being, and their responsibility to do so.

People centred: The child is central to the process. The child and family views and wishes shape the form of engagement with services where this is appropriate.

Promote well-being: Services built on children and families’ strengths andabilities and enable them to maintain an appropriate level of autonomy with the appropriate level of care and support

Outcome based: Work with children and families based on a comprehensive analysis of needs, personal outcomes, risks, and the strengths and capabilities children and families have available to them.

Involving wider family, community and carers: recognise the contribution of the wider community, family and carers can make in providing support to children and families.

Proportionate: the provision of care and support will be appropriate to the child’s or family’s needs.

Use of appropriate language and communication methods: Having all relevant information available in a format that is accessible and understood by the child, including through their own language of need and preferred means of communication appropriate to their age and understanding.

Information accessible through the medium of Welsh and English Clear: work with children and families will be straightforward and

understandable for them. People will be informed of their rights and the process Support will be based on evidence and research about what works. This should

not exclude innovative practice. Sustainable: Services will be based on proven methods, be cost effective and

keep families together where it is safe and appropriate to do so. Performance Measured: the effectiveness of care and support services will be

judged on a combination of child, family and colleague feedback, regular local evaluation with children and families and other stakeholders, and national performance measures that relate to the national outcomes framework.


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KEY LEGISLATIVE DUTIESSection 17 (children in need) of the Children Act 1989 is repealed:-.Assessment and meeting needs is provided for in Part 3 and Part 4 of the Act:

Section 21: the duty to assess the needs of the child for care and support and Section 37: the duty to meet the care and support needs of a child.

1. Assessing needs duties The Act introduces changes to the way in which assessments are provided for all individuals and families and the way in which assessments are provided for the support of carers. The aim is for greater consistency of practice across Wales and more proportionate application of assessments to enable people to receive the help that they need while minimising administrative burdens.MTCBC has a duty to offer an assessment to: 1. Any Child: where it appears to that authority that the child may have needs for care

and support in addition to, or instead of, the care and support provided by the child’s family.For the purpose of the trigger for the duty to assess the needs of a child, a disabled child is presumed to need care and support in addition to, or instead of, the care and support provided by the child’s family (see section 21(7) of the Act).A local authority must assess whether a child has needs for care and support and if so, what those needs are. In carrying out the assessment the local authority must assess the developmental needs of the child, and seek to identify the outcomes that the child wishes to achieve (to the extent it considers appropriate having regard to the child’s age and understanding), and the outcomes that the persons with parental responsibility for the child wish to achieve in relation to the child (to the extent it considers appropriate having regard to the need to promote the child’s wellbeing).There must be an assessment of the extent to which the provision of care and support, preventative services or the provision of information, advice or assistance could contribute to the achievement of those outcomes.The duty applies in relation to children that are ordinarily resident in the area and to other children in the area, regardless of the level of need for care and support and the level of financial resources of the child, or any person with parental responsibility for the child.The assessment itself must be proportionate to need and involve the child and any person with parental responsibility for the child.

2. Any carer where it appears to that authority that the carer may have needs for support: A local authority must assess whether the carer has needs for support (or is likely to do so in the future) and if they do, what those needs are or are likely to be.


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Note: A carer is defined in the Act as a person who provides or intends to provide care for an adult or a disabled child. In general, professional carers who receive payment should not be regarded as carers for the purposes of the Act, nor should people who provide care as voluntary work. However, a local authority can treat a person as a carer even if they would not otherwise be regarded as a carer if they consider that, in the context of the caring relationship, it would be appropriate to do so. A local authority can treat a person as a carer in cases where the caring relationship is not principally a commercial one.

The duty is triggered if it appears to the local authority that a carer may have needs for support. The duty to assess applies regardless of the authority’s view of the level of support the carer needs or the financial resources he or she has or the financial resources of the person needing care.The assessment must include an assessment of the extent to which the carer is able and willing to provide the care and to continue to provide the care, the outcomes the carer wishes to achieve both in terms of themselves and, if a child is the carer, the outcomes the person(s) with parental responsibility for that child wish(es) to achieve for them and the extent to which support, preventative services, or the provision of information, advice or assistance could assist in achieving the identified outcomes. The local authority must involve the carer and where feasible the person for whom the carer provides or intends to provide care in the assessment. The assessment also must have regard to whether the carer works or wishes to work and whether they are participating or wish to participate in education, training or leisure activities. If the carer is a young adult carer aged between 16 and 25 the assessment must include an assessment of any current or future transitions the carer is likely to make into further or higher education, employment or training and have due regard to what the young adult carer wishes to participate in

2. Determining eligible needs duties The local application of the determination of eligibility must support a move away from the deficit model of care (‘what is wrong?’) to an emphasis on strengths, capacity and capabilities (‘what can I do? /how can I get help?’). The approach to determining eligibility must be an outcome-based approach to eligibility that relates closely to the national outcomes framework.The starting point is the meaning of well-being as set out in Part 2 of the Act (Please refer to the MTCBC guidelines on Well-Being Duty for information) and the local authority must determine whether the provision of care and support, or support in the case of a carer, will assist the child to meet their personal outcomes within that framework of well-being. The local authority must be clear about what matters to the child, and what the child and family themselves can do to maximise their own well-being.Local authorities must demonstrate due regard to the United Nations Conventions and Principles listed below when exercising functions in relation to an individual. Guidance


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on the requirements to have due regard are described in the code of practice in relation to Part 2 of the Act.

United Nations Convention on the Rights of the Child United Nations Convention on the Rights of Disabled People

Children and their families must be able to participate fully in the process of determining and meeting their identified care and support needs through a process that is accessible to them.This will include determinations of eligibility for care and support being undertaken through the person’s language of need and preferred means of communication and in a style and manner appropriate to their age, disability and cultural needs.The child must be seen during the assessment. This includes observation of the child and communicating with the child in an age and capacity appropriate manner. The assessment must address the central or most important aspects of the needs of a child and the capacity of his or her parents or caregivers to respond appropriately to these needs within the wider family and community context.MTCBC must assess a childs need for care and support, determine whether any of the needs meet the eligibility criteria or must otherwise be met by the local authority and consider what could be done to meet those needs:

introduce the eligibility criteria against which the needs of all individuals are to be assessed.

Ensure that an automatic right to eligibility for children at risk of abuse or neglect.

An approach to determining eligibility for care and support must recognize the distinction between the local authority’s general duties (as set out in Part 2 of the Act) and the establishment of an enforceable right for the individual to have their needs met by the local authority providing or arranging the provision of care and support (as required by parts 4 of the Act) if the needs meet the eligibility criteria.There is a a requirement that an individual with needs for care and support has a right to the delivery of care and support provided or arranged by the local authority through a care and support plan where those needs cannot be met by themselves alone or with the support of others, or with the assistance of services in the community.The eligibility status is conferred on the individual need not on the person – so where there are needs which can only be met through a care and support plan the person will have the right to have those needs met in this way. This means that some needs may be met through the delivery of a care and support plan even where that person is accessing community based services as part of the route to meeting their personal outcomes

Note: Eligibility is one element of the overall care and support system. The general duties on MTCBC in relation to the provision of the information, advice and assistance service and preventative services as well as the promotion of social enterprises, co-


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operatives, user led services and the third sector are a core part of the overall system. The development of these duties will ensure that more people are enabled to access support easily in their communities.

A person’s changing circumstances can impact on eligibility at any time. A person’s capacities and support mechanisms will vary over time and it is essential that this is recognised when determining the status of a need as an eligible need. A local authority’s approach to meeting people’s needs for care and support must be sufficiently responsive to ensure that an individual has access to the right support to attain their personal outcomes irrespective of their eligibility status. As part of the determination of eligibility, the local authority must also consider the strengths and capabilities of the person themselves and whether the person would benefit from any preventative services; information, advice or assistance; or anything else that may be available in the community. This must be reflected in the assessment process

3. Care and support planning dutiesSection 54 of the Act provides that a local authority must prepare and maintain a care and support plan or a support plan for a person whose needs it is required to meet. The plans must be kept under review. If the local authority believes that a person’s circumstances have changed in a way that affects the plan, it must conduct such assessments and revise the plan in the light of those assessments. A plan must not be closed without a review.

Note: MTCBC may determine that someone has a right to care and support even though that person may refuse to accept it. In these instances you must record why a care and support plan was refused. The eligibility status must be preserved so as to maintain awareness of the person’s needs and enable an appropriate and timely response should the person reconsider their refusal of care and support.

MTCBC must provide and keep under review care and support plans for people who have needs which meet the eligibility criteria and for people where it appears to MTCBC that it is necessary to meet the person’s needs in order to protect the person from abuse or neglect or the risk of abuse or neglect. All reasonable steps should be taken to maximise a person’s ability to communicate their wishes so as to ensure that the care and support plan is in the person’s best interests and is appropriate to their identified needs.MTCBC must provide and keep under review support plans for carers whose needs meet the eligibility criteria. This is in order to promote consistency between plans for carers and to treat carers in the same way as people with needs for care and support. In some instances an assessment may identify that where the person is a carer with support needs the local authority can meet those needs by providing care and support to the person cared for. This may be the case even when there is no duty to meet the


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needs of the person cared for and there is no separate care and support plan for that person.

Note: Many children’s needs can be met without a formal care and support plan. In such instances the information, advice and assistance service or other preventative and community based services such as those from social enterprises, cooperatives, third sector, and user-led services must be clearly signposted.

A record of how these needs will be met without a formal care and support plan must be made on the assessment and eligibility tool.


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Children’s Services Staff Procedures and Guidance

Assessment


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GUIDELINES FOR CHILDREN’ SERVICES STAFF ON ASSESSMENT

1. Assessment of ChildrenThe Act creates a right to an assessment where it appears that the child may have needs for care and support. It is an approach to assessment and care planning that recognises that needs can be met not only through the provision of services but through active support and assistance to enable children and families to meet their own needs. For example, by assisting them to access community supports and local services themselves or supporting people to develop the skills and confidence they need.MTCBC children’s services staff should note the important principles that underpin the approach to assessing children and their families. Assessment must:

Be child centred Be rooted in child development Be holistic in approach Ensure equality of opportunity Involve working with children and their families Build on strengths as well as identify difficulties Include an inter-agency approach to assessment and the provision of services Be a continuing process, not a single event Be carried out in parallel with other action and providing services Be grounded in evidence based knowledge

To be child centred means that the child must be seen and his or her welfare kept in focus throughout the assessment. The significance of seeing and observing the child throughout any assessment cannot be overstated. MTCBC must assess the developmental needs of the child, and seek to identify the personal outcomes that the child wishes to achieve (to the extent appropriate in regard to the child’s age and understanding), as well as the barriers preventing them achieving the outcomes, and what contribution the child and their family or the wider community can make to achieving those outcomes. In the case of the assessment of a child under the age of 16, the assessment should ascertain and have regard to the views, wishes and feelings of the person(s) with parental responsibility for the child in so far as this is reasonably practicable and consistent with promoting the well-being of the child.To support the assessment process for children, MTCBC children’s services staff should gather evidence as informed by the framework for the assessment of children and their families (Part 3 code of practice)It provides an opportunity to broaden the assessment parameters to develop an overview of the child’s experience in the context of family life within a community and may allow more specialist practitioners to evaluate the impact of their specific knowledge and what this means for the child. This sharing of information and bringing


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together understanding across agencies is the benefit of a common assessment approach.

In order to understand and reach sound judgments about a child’s developmental needs, MTCBC children’s services staff must think about many different aspects of their life including physical growth and health, their progress in learning new skills and their attainment in school, their emotional well-being, confidence and increasing independence, developing social skills and relationships with other people. It is important to build a picture of parenting capacity. Families’ history, circumstances and current experience can have a big impact on whether parents and carers feel confident and able to look after their children well and encourage their progress and development.Family and environmental factors can have a significant impact on the well-being children and families. The level of support available from their wider family, social networks and within their neighbourhood can have a positive or negative effect. A child’s wider world includes the environment where the family lives, the school children go to and other resources, as well as families’ level of income. The wider world also includes the extent to which children and families feel included within their communities. Social exclusion can emanate from factors including racial and cultural discrimination.Multi-agency approaches such as the Team Around the Family (TAF) model ensures that a broad range of support can be delivered in ways that suit families, and not solely the child’s circumstances and needs. Multi-agency teams should co-ordinate, target, and tailor provision towards need. The advantages of a tailored approach include the right forms of support being targeted at the problems where they are likely to have greatest impact.With regards to children who are caring, MTCBC children’s services staff must consider whether any of the caring tasks the child is undertaking are inappropriate. Clearly these will vary for different situations and children, but could include carrying out heavy lifting, emotional support, administering medication, and personal care.The timescale for completion of the assessment is a maximum of 42 working days from the point of referral.The graph below provides a diagrammatic overview of the assessment and eligibility process.


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Overview of the assessment and eligibility process

The assessment will often start when a person accesses the ‘Information, Advice and Assistance service, however access to an assessment should not be restricted to being accessible through this service alone.Under this service it is only the provision of information that does not require some sort of assessment. If advice and/or assistance are given an assessment of a person’s needs will have taken place.

Note: The Act provides a useful definition on what constitutes the provision of Information. It will be quality data that provides support to a person to help them make an informed choice about their well-being. What constitutes the provision of information?: - This will include information about how the care system works, the availability of preventative well-being services,

I think I may need care and support

I think someone I know may need care and support

Contact the…

Information, Advice and Assistance Service.Signpost to preventative services OR start an assessment

If needs are not eligible meet through preventative well-being services

Advocacy:If people need help to participate in this process ensure assistance or advocacy is available

Urgent need and safeguardingAssessments must not delay the meeting of urgent needs. If people need protection then apply safeguarding procedures:

Specialist assessmentsIf other specialist assessments need to be undertaken, do so concurrently and build in as required

AssessmentDoes the person have needs

for care and support?

Assessment Identify whether each need can be met through signposting to preventative services or met in another way OR whether a care and support plan is required.

If the identified need can be met through signposting the need will NOT be eligible.

If the identified need can only be met through a Care and Support Plan the identified need will be eligible.

If needs are eligible develop a Care and Support Plan to meet needs

Preventative Well-being ServicesRange of services and support available in the community, some of which may be chargeable.

Care and Support PlanDeliver care and support to meet identified needs.Plan will include reference to any other needs being met outside the care and support plan if applicable.

Review /Re-assessment

Care and support plan will be reviewed at

agreed point.Re-assessment will be

undertaken If circumstances change


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financial information, information on direct payments, information on charges, and other matters that would enable someone to plan how to meet their care and support needs, or support needs if they were a carer

Responsibilities & remit for staff providing an information serviceMTCBC staff should record information about the nature of the enquiry and which type of service the enquirer was signposted or referred to for their own management information purposes and to feed into the population needs assessments. The collation and recording of personal data is not needed at this stage. In this way the person accessing the service for information could remain anonymous for recording purposes.However, it is good practice to capture information about the nature of the enquiry or which type of service the enquirer was signposted or referred to. This will both feed into the population needs assessment and provide performance information to help improve the management of the service.If a child and family requires advice or assistance then a proportionate assessment will be required (please see below for a definition and explanation on proportionate assessments).An assessment can be undertaken by a single member of staff where that member of staff would not need additional specialist advice or assessments to determine eligibility.Assessments must, as a minimum record the assessment in line with the national assessment and eligibility tool and is set out below.Before undertaking any assessment, MTCBC children’s services staff must consider whether or not the child whose care and support needs are being assessed would benefit from the support or presence of a carer, family member, friend or independent advocate. (Please refer to the MTCBC Advocacy guidelines for more information)The national assessment and eligibility tool comprises the following:

The national minimum core data set (NMDS) An analysis structured around five elements of the assessment; including

setting out the outcomes which have been identified The actions to be taken by MTCBC and other partners or persons to help the

child and family achieve those outcomes (including actions to be taken by the child or family)

A statement of how MTCBC children’s services assesses the identified action will contribute to the achievement of the personal outcome or otherwise meet needs identified by the assessment. This applies to those needs which are to be met through the provision of care and support and those met through community based or preventative services, the provision of information, advice and assistance, or by any other means.

National Minimum Core Data Set


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The Act places a duty on local authorities to work together with local health boards and NHS trusts to ensure that local, regional and specialist assessment templates meet the national minimum core data set (NMDS) criteria and are used by all partners across the local area as part of any assessment which leads to the provision of advice, assistance, or a care and support plan. When carrying out an assessment MTCBC children’s services staff should record as much of the basic personal data for the NMDS as is appropriate for the circumstances. The NMDS only needs to be completed in its entirety if the child’s care and support needs are eligible and a care and / or support plan is required.MTCBC must work with partners to have a system in place to ensure that, as a minimum, personal information in the NMDS for any child or family is shared safely and appropriately between partners. Where appropriate, this will include following the Wales Accord for Sharing Personal Information (WASPI) and ensuring compliance with the Data Protection Act 1998.

Note: The NMDS should enable MTCBC staff to quickly identify and reference other health, care and support, and well-being assessments that have been provided to the child and / or family. The NMDS data has been integrated into the Proportionate Assessment

The 5 elements of assessmentAll assessments must, as a minimum, comprise of the NMDS and use an analysis of the 5 elements of assessment structured into a conversation, which require MTCBC staff to:

Assess and have regard to the person’s circumstances Have regard to their personal outcomes Assess and have regard to any barriers to achieving those outcomes Assess and have regard to any risks to the person if the outcomes are not

achieved Assess and have regard to the person’s strengths and capabilities.

The attached document contains example/explanations on each of the 5 elements of the assessment This is not an exhaustive list and it will be for MTCBC staff and managers to identify that the individual has a need for care, support or both care and support.

guidance on 5 elements.docx

The process of assessment requires that MTCBC children’s services staff must have discussions with children and their families to identify “What matters to them” and the personal outcomes they wish to achieve and what contribution the child and their family can make to achieving those outcomes. This may involve the friends, family or professionals advocating on the individual’s behalf.


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These personal outcomes should reflect the national well-being outcomes, as defined in Part 2 of the Act and in the definition of well-being in section 2 of the Act. (Please refer to the MTCBC guidelines on Well-Being Duty for more Information)Through this, the assessment must identify what solutions a family needs and how they will be delivered. It must be a partnership approach between the family and the MTCBC practitioner with a shared understanding of the outcomesAll five of the elements listed above must be taken into account in the assessment, and from this, a judgement reached about whether each of the identified needs is one that must be met by the provision of care and support, a need which is an eligible need.More comprehensive assessments may sometimes involve several stages or discussions to establish a full understanding of the child’s care and support needs and the outcomes they wish to achieve These may also involve seeking the views of other professionals via a multi-agency approach, but where the other professionals’ involvement does not constitute an assessment.

Note: If a more specialist assessment is required it is likely that the needs are more urgent in nature. As a result MTCBC children’s services staff must ensure that there is minimal delay in completing a specialist assessment so that a care and support plan can be progressed quickly and should consider whether it is appropriate to put interim support in place.

Proportionate Assessments Proportionality means that the assessment is only as intrusive as it needs to be to establish an accurate picture of the needs of the child and their family, regardless of whatever method of assessment is used – i.e. supported self-assessment, face-to-face assessment or other. This will involve:

Both hearing and understanding the initial presenting problem Not taking this at ‘face value’ Ensuring any underlying needs are also explored and understood.

Needs may well differ in their breadth and depth, meaning:

Additional exploration of underlying needs may be required A child may have needs which require more consideration only within some

aspects of their lives Children and families with a clear understanding of those needs and/or the care

and support system may require less intensive assessment than someone who has recently developed needs and has less clarity about their needs and the care and support system.

The aim of carrying out assessment proportionately is to ensure that assessment is not overly burdensome and recognises the child’s and their family’s own knowledge and capacity.The process of assessment must be designed around the requirements of the child whose care and support needs are being assessed; this includes the environment


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where the assessment takes place, the documentation used and the methods of communication employed.The assessment process must recognise the concept of language need and you should ensure that the Active Offer principle (See References and Resources Section) is embedded in practice. This means that MTCBC should be proactive in its approach and the child and parent should be asked which language they would prefer at the beginning of the process. The requirement for an assessment to be in the medium of Welsh should not delay the process.Proportionality is not about whether the assessment is short or long; the key factor is to tailor assessments to the individual situation based on a conversation that encompasses all of the 5 elements of assessment and moves away from approaches that are overly administrative / process driven. It may be necessary to adjust approaches being taken to assessment in any given case as events unfold. The process of assessment must recognise the reality of fluctuating conditions and capacity and be responsive to changing circumstances. In practice, this recognition of fluctuating conditions may require that the child’s circumstances are considered over such period as is necessary to establish an accurate indication of the level of care and support needs. However, this must not lead to a delay in support.An appropriate assessment might include a pause in the assessment process to provide or facilitate supports from the community or preventative services and then to determine the affect they might have.What Matters ConversationsIn carrying out an assessment, local authorities must work with children and families to identify what matters to them. People will wish to achieve different aspects of well-being, dependent on their circumstances, and these make up personal outcomes. MTCBC must consider the personal outcomes that a child wishes to achieve and those a person with parental responsibility wish to achieve, the resources available, and how we may support them to achieve these. Central to this will be to understand the barriers that a child may face in achieving their personal outcomes.Children should be supported to identify what matters to them by a range of practitioners and other people involved with them including their family and friends. Engaging effectively in a ‘what matters to me’ conversation requires MTCBC staff to: listen rather than tell; see the child as a resourceful young person; and empower the child and work with them not the presenting behaviour.Children and their family must be supported to be fully engaged in identifying what preventative measures could assist them to achieve their well-being and in planning their delivery. These can be from within their own and their communities’ resources. Where a child is not able to express their views, wishes or feelings, local authorities must ensure the child is supported to do so. If it is not possible for family or friends to provide this assistance and there is no wider support available, local authorities must ensure the individual is supported by an independent professional advocate at no cost to the individual


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Support for staff in identifying individual barriers to participating in the assessment process The Act defines four ways in which children and adults could experience barriers that impair them from fully engaging and participating in the key care and support processes:

understanding relevant information retaining information using or weighing up the information communicating their views, wishes and feelings

This could be any combination of intellectual, physical, emotional, psychological or sensory factors, and some of the questions which you need to consider are whether the child or family are able to:

answer the questions you need to ask make clear that they understand who you are and what your role make clear to you that they understand their situation tell you how they feel about their situation show you that they understand what you have told them recall information or decisions that were shared in any previous meeting fully describe the options available to them describe the possible outcomes of any choices they make describe their preferences to you

If a person is experiencing barriers with any one of the areas of understanding, retaining, or weighing information or communicating their views wishes and feelings then that would indicate that they need more support to be able to fully participate. However, you need to establish whether the person’s immediate situation is particularly unusual or stressful, or whether the barrier is substantial enough to have an impact on their participation.You need to ensure that the barrier is not caused by external factors that can be addressed. You should do so by resolving these wherever possible. So, for example, you need to make sure that your communication methods offer the person good opportunities to participate and that any information you share with them is presented in an appropriate format.You need to make sure that you are making the judgement on the basis of the person’s true responses. So, for example, you need to be clear that they are not inappropriately influenced or interpreted by other people, and that their responses are not affected by fears or threats. An important way of getting the information you need to make your judgement is by engaging directly with the person themselves, using appropriate communication methods dependent on their age and understanding, but there are other sources of information which can help you to get a rounded picture such as speaking with family and other people who know the person well or checking any child records or reports. Safeguarding and Protecting


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A key part of the assessment must be to establish whether there is reasonable cause to suspect that a child is at risk.If there is reasonable cause to suspect that a child is at risk and it has not already done so, you must raise immediately with the team manager who to decide to initiate child protection proceedings and make inquiries into the circumstances of that child under Section 47 of the Children Act 1989. Where these inquiries indicate the need, MTCBC must decide what action, if any, it may need to take to safeguard and promote the child’s welfare. The investigation will form an in-depth assessment of the nature of the child’s needs and the capacity of his or her parents to meet those needs within the wider family and community context. (refer to MTCBC’s safeguarding policy?)Reviews of AssessmentsMTCBC must review an assessment where there has been a significant change in the child’s or family’s circumstances. Where the previous assessment has not fully addressed the child’s care and support needs, or when there are new needs due to a change in circumstances then a review of an assessment must be undertaken. Where this is not the case there is no duty to review.

Note: This is not the same as reviewing the care and support plan, which is a process by which you and the child and family consider how effective the care and support plan has been in supporting the family to meet their identified outcomes.

The judgement on whether the change is significant should be made with reference to the 5 elements of assessment. This can include a new barrier, a new risk or a resource has been lostThe transition from child to adult constitutes a significant change in circumstances and so creates a right to a re-assessment of needs The aim is to re-establish whether and to what extent the provision of care and support, preventative services and / or information, advice and assistance can contribute to the achievement of the child’s newly identified outcomes or otherwise meet identified needs. The child, family or those acting on their behalf, has the right to request a re-assessment of their needs at any time. Re-assessments must be acted upon quickly and without delay.MTCBC’S Team Managers must consider whether a different assessor to the staff member who undertook the initial assessment should undertake the re-assessment. This will be particularly relevant when an individual has requested a re-assessment because they are not satisfied with the outcome of the original assessment.Refusal of an assessmentAn individual who possibly has needs for care and support or a carer may refuse to have an assessment because, for instance, they do not feel that they need it or they may not want local authority support. If someone refuses an assessment and has capacity they are entitled to choose to do so. Good practice in such circumstances might include maintaining a relationship with the person, supporting them to consider


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the implications of their choice and to understand other choices, and monitoring the person’s capacity to make decisions.

Note: This is not the case for carers i.e. if an adult carer or a carer aged 16 or 17 refuses an assessment then the duty to assess does not apply.

However, there are some circumstances in which a refusal to accept an assessment by an adult, child or the child’s parents must be overridden, these exceptions are

1. When an adult lacks capacity and it would be in his or her best interest2. Experiencing or at risk from abuse or neglect

A child aged 16 or 17 is presumed to be able to make an informed decision, but in the case of children under 16, there is no presumption in law that they have capacity. In order for a refusal by a child under 16 to discharge the local authority’s duty to carry out an assessment, the local authority must be satisfied that the child is able to make an informed decision. MTCBC must carry out an assessment of a child who lacks capacity to make the decision to refuse the assessment and an assessment would be in his or her best interests. The decision to refuse an assessment must also be overridden if the local authority suspects the child is experiencing or is at risk of abuse, neglect or other kinds of harm.If anyone with parental responsibility for a child under 16 refuses an assessment for that child then the duty on the local authority to assess does not apply except where the local authority:

suspects the child is experiencing or is at risk of abuse, neglect or other kinds of harm

is satisfied that the parent lacks the capacity to decide is satisfied that the child can make an informed decision and disagrees with the

parent’s viewIn the case of children under the age of 16, a refusal by a child who is considered capable of making an informed decision must be overridden if MTCBC suspects the child is experiencing or is at risk of abuse, neglect or other kinds of harm.A child or parent who refuses an assessment is entitled to change their mind and MTCBC must then carry out an assessment. Also, if the child’s needs, or person with parental responsibility’s needs, or circumstances change, MTCBC must again offer to carry out an assessment but is not obliged to do so if the child refuses (unless one of the exceptions applies).


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Children’s Services StaffProcedures and Guidance

Eligibility

GUIDELINES FOR CHILDREN’S SERVICES STAFF ON ELIGIBILITY

1. Determining eligible needThe assessment is the key process for determining eligibility.


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After an assessment has been carried out, MTCBC staff must decide whether the child family or carer has eligible needs. A judgement must be made about whether the assessed need is eligible for help with securing services through a care and support plan based on the national criteria in the Care and Support (Eligibility) (Wales) Regulations 2015. (Attached in Annex 1)

The assessment should establish whether the child’s needs are such that the needs cannot be met through: services and supports available in the community which areaccessible to them without the need for a care and support plan; care and supportcoordinated by themselves, their family or carer, or others; or by any other means.Determining eligibility is not about giving a right to any one service, but about guaranteeing access to care and support where without it the child is unlikely to achieve their personal outcomes. The eligibility status is conferred on the need not on the child – so children and families may have some needs which can be met through accessing community services and other needs which can only be met through the provision of services through a care and support plan.There is a presumption that a disabled child has needs for care and support in addition to, or instead of, the care and support provided by the child’s own family (Section 21(7) of the Act) 1a. Eligibility criteria for care and supportThe Care and Support (Eligibility) (Wales) Regulations 2015 set out national eligibility criteria for care and support for children, adults and carers.There are four separate conditions which must all be met for the child’s assessed need to be eligible.The first condition relates to the child’s circumstances and is met if the need arises from the circumstances which are specified in the regulations: physical or mental ill-health; age; disability; dependence on alcohol or drugs; or or other similar circumstancesOR if the need is unmet it is likely to have an adverse effect on the child’s development.

The second condition is met if the need relates to one or more of the outcomesspecified in the regulations:

ability to carry out self-care or domestic routines; ability to communicate; protection from abuse or neglect; involvement in work, education, learning or in leisure activities; maintenance or development of family or other significant personal relationships;


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development and maintenance of social relationships and involvement in the community; or

achieving developmental goals.

The third condition is met if the need is such that neither the child, the child’s parents nor other persons in a parental role are able to meet, either alone or together, or with the support of willing others or with assistance of services in the community to which the child, the parents or other persons in a parental role have access.

The fourth condition is met if the child is unlikely to achieve one or more of theirpersonal outcomes unless the local authority provides or arranges care and support to meet the need in accordance with a care and support plan or it enables the need to be met by making direct payments.

National Eligibility criteria for carersThere are four separate conditions which must all be met for the carer’s assessed needto be eligible.

The first condition relates to the carer’s circumstances and is met if the need is one that arises as a result of providing care for either a disabled child or an adult who has needs arising from circumstances which are specified in the regulations and shown on the left hand side of the slide:

physical or mental ill-health; age; disability; dependence on alcohol or drugs; or other similar circumstances.

The second condition is met if the need relates to one or more of the outcomes specified in the regulations and shown on the right hand side of the slide:

ability to carry out self-care or domestic routines; ability to communicate; protection from abuse or neglect; involvement in work, education, learning or in leisure activities; maintenance or development of family or other significant personal relationships; development and maintenance of social relationships and involvement in the

community; or in the case of an adult carer, fulfilment of caring responsibilities for a child; in the case of a child carer, achieving developmental goals.

The third condition is met if the need is such that the carer is not able to meet that needalone, with the support of others who are able and willing to provide that support, or with


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the assistance of services which the carer has access to..

The fourth condition is met if the carer is unlikely to achieve one or more of their personal outcomes unless i) the local authority provides or arranges support to the carer to meet the carer’s need, or ii) the local authority provides or arranges care and support to the person for whom the carer provides care, in order to meet the carer’s need, or iii) it enables the need to be met by making direct payments. SafeguardingWhere there is reasonable cause to suspect that a child is at risk there is no need to consider or determine eligibility for care and support. Where the assessment produces reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child's welfare under Section 47 of the Children Act 1989. The investigation will form an in-depth assessment of the nature of the child’s needs and the capacity of his or her parents to meet those needs within the wider family and community context.There is a new duty for all relevant partners of a local authority to report an adult or a child at risk if they have reasonable cause to suspect the adult or child is at risk. The relevant partners are police, other local authorities, probation, local health boards and NHS trusts.The determination of eligibility must not be applied where to do so may prevent or delayMTCBC from making a response designed to protect and safeguard the childconcerned.(refer to MTCBC’s safeguarding policy?)

Ineligible needsIf a child is not considered to have eligible needs, the decision should be set out in writing with underpinning explanations.

Information and advice should be provided on what support the child and family may be able to access in the community or what preventative measures could be taken to support the family.

This also applies where only some of the child’s needs are considered ineligible while their other needs may be eligible.

Discretionary powersDiscretionary powers enable a local authority to meet the care and support needs of an individual irrespective of the eligibility determination. These powers also enable a local authority to respond to urgent need, or to act to protect a person without the need for first completing an assessment or determining eligibility. They enable MTCBC to decide to meet needs that do not meet the eligibility criteria if they wish to do so. For example: if an ineligible need is seen to have a significant impact on the child’s well-being.


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Children’s Services Staff Procedures and Guidance

Meeting Needs

GUIDELINES FOR CHILDREN’S SERVICES STAFF ON MEETING NEEDS

1. Care Planning ProcessThe overarching duties of the Act must be followed when developing plans, which should be person-centred, promote well-being and be outcome-based. It is also


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important that they are clear and concise and use appropriate language, communication methods and are in an accessible format so that the child and family can participate in their planning and understand their plan.MTCBC must provide and keep under review care and support plans for children who have needs which meet the eligibility criteria and for children where it appears to MTCBC that it is necessary to meet the child’s needs in order to protect a child from harm or the risk of harm.

Note: Where the duties to a child fall under Part 6 of the Act (Looked After and Accommodated Children) a Part 6 care and support plan must be developed and reviewed in line with the requirements of the Regulations made under that part of the Act. (See the MTCBC looked after children’s guidelines for more information)

The Care and Support Plan must be developed in partnership with the child and family to ensure there is an agreed understanding on how the needs will be met and personal outcomes achieved.Where MTCBC is required to prepare and maintain a care and support plan or a support plan, a named care and support plan co-coordinator must be assigned to co-ordinate the preparation, completion, review, delivery and revision of the planThe name of the care and support plan co-ordinator must be recorded on the core data set (NMDS). In many cases the care and support plan co-ordinator will be the same MTCBC member of staff who undertook the assessment.The role of the co-ordinator will include monitoring the delivery of the services and support delivered through the plan where it is agreed that this is required. The responsibilities of this role will include:

1) To draw in additional specialists as required2) To act as a focus for communication for different social care and health staff and

the child and family3) To make sure that information is recorded correctly and that the care and support

plan is made available to the child and family4) To ensure that any problems or difficulties in the co-ordination or completion of a

review are resolved.5) Is aware of other plans in place for the child to avoid duplication, omissions or

confusion.

Note: It is advised that the appropriate levels of qualification for undertaking care and support planning activities include:

Either a registered social work / social care professional holding a professional qualification at level 5 or above

Or a person holding a social care qualification at level 4 or above, which includes knowledge and skills undertaking person centred assessment, under the supervision of a registered social work / social care professional.

The care and support plan should be copied in full to the child and family, as long as this is not detrimental to the child’s well-being and all providers contributing to the


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care and support plan. This should be a full and holistic care plan outlining the outcomes they are working towards and the roles and actions to agreed timescales of all involved, including the child, family and informal supports, in helping to achieve those outcomes. It will be the responsibility of the MTCBC children’s services member of staff who developed the plan with the child and family (including any formal or informal advocacy support) to ensure there is a clear and concise confirmation of the agreed actions, and who will undertake them within the plan. Content of the Care and Support Plans must cover the following:

The specific, achievable, child focused outcomes which have been identified in relation to the child to whom the plan relates

The actions to be taken by the local authority and other persons to help the child achieve those outcomes

The needs that will be met through the delivery of care and support How progress towards achieving those outcomes will be monitored and

measured The date of the next review of the care and support plan. The roles and responsibilities of the child, parents, carers, other family

members, MTCBC children’s sevices staff and other practitoners The resources (including financial resources) required from each party.

Note: charging for children’s services has not been enacted, hence the charging policy and financial assessments do not apply for services to children and families.

Where some or all of the child’s needs are to be met by making direct payments, a care and support plan and a support plan must also contain a description of:

The needs which are to be met by direct payments The amount and frequency of the direct payments.

(Refer to MTCBC’s Direct Payments Policy for more information) ?Care and Support Plans must contain a clear date, which should be agreed with the family, by which the plan will be reviewed. In the case of a child the date of review must not exceed 6 monthsThe completed care and support plan should be signed off by the team manager

There is also an overlapping duty in respect of assessments for adoption support services under the Adoption and Children Act 2002 and the associated Regulations and Guidance. The duty to prepare an adoption support plan is enhanced by the provisions of this Act. Where, following the assessment, MTCBC is satisfied that the conditions and eligibility for a care and support plan are met MTCBC must prepare a care and support plan in line with these Regulations and code of practice. Eligibility and entitlement to adoption support services remains as outlined in the Adoption and Children Act 2002, the associated Regulations and Guidance.Reviewing care and support plans


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Care and support plans need to be kept under review to understand whether the provision of that care and support is meeting the identified needs of the child, and to consider if their needs have changed and if a re-assessment is required. The agreed date for the review of the plan must be set out in the plan.

When reviewing a care and support plan MTCBC’s children’s services staff should ensure that the following is included in the review:

Consider the extent to which the delivery of the plan is meeting assessed needs and how it has helped the child and family to achieve their outcomes

Determine what support is needed in future, and confirm, amend or end the services involved.

The review arrangements must ensure that the child and parent and advocate is an active participant in the review.

When carrying out a review you must also involve the child in the most meaningful way for them, and the parent or person with parental responsibility for the childIn all cases, where appropriate and with consideration of the wishes and feelings of the child you should also involve:

Any person whom the child or parent asks MTCBC to involve Other practitioners/ professionals who have undertaken or will need to

undertake a related assessment Other practitioners/ professionals with expertise in the circumstances or needs

of the child concernedThis will include an advocate where required to enable the child to engage and participate fully in the care and support planning process.

All care and support plans must have a review date. This date must be agreed or set at the inception of the care and support plan and each subsequent review. A care and support plan must be reviewed within such period as is agreed between MTCBC and the person to whom the plan relates. Review dates for a child’s care and support plan must not exceed 6 monthsIf it appears that the care and support plan is not meeting the assessed needs then a review must be undertaken irrespective of the agreed review date. This may be at the request of the child, persons with parental responsibility, or any person authorised to act on their behalf.Where the plan contains details of direct payments, any review of the direct payments must involve a review of the care and support plan. Where someone is in receipt of direct payments and the review of the care and support plan results in a change to the care and support plan there must be a review of the direct payments.Closing a care and support plan

Following the review, the team manager must consider whether to confirm, revise or close the plan. If it is decided to confirm the plan, the decision and the reasons for the decision must be recorded.


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Where it is planned that services will no longer be provided the review must include a closure statement covering reasons for closure; an evaluation of the extent to which the outcomes were achieved; and confirmation that the child or family has appropriate information, advice or assistance and / or access to community based preventative services to meet their needs. The closure statement must be recorded.on the system?A care and support plan must not be closed while a young person is known to the Youth Offending Service.

REFERENCES AND RESOURCES AVAILABLE1 Social Services and Well-Being (Wales) Act 2014 National Outcomes Framework

national outcomes framework.pdf

2 Technical Briefing: Part 3, Sections 19, 21 and 24 – Duty to assess an individual’s need for care and support, and a carer’s need for support3 Technical Briefing: Part 4, Section 32 – Determination of eligibility and consideration of what to do to meet needs

4 Technical Briefing: Part 4, Section 54 – Duty to prepare and maintain a care and support plan

5.WASPI –The Wales Accord of the Sharing of Personal Information FrameworkSpecific MTCBC docs?

APPENDIX1) Care and support (Assessment) (Wales) Regulations 2015

assessment regs.pdf

2) Care and support (Eligibility) (Wales) Regulations 2015

elgibility regs.pdf

http://gov.wales/docs/phhs/publications/151125pt3needsen.pdf

http://gov.wales/docs/phhs/publications/151125pt3needsen.pdf

http://gov.wales/docs/phhs/publications/151125pt4eligibilityen.pdf

http://gov.wales/docs/phhs/publications/151125pt4eligibilityen.pdf

http://gov.wales/docs/phhs/publications/151125pt4careen.pdf

http://gov.wales/docs/phhs/publications/151125pt4careen.pdf


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3) Care and support (Care Planning) (Wales) Regulations 2015

care planning regs.pdf

4) Care and support (Direct Payments) (Wales) Regulations 2015

direct payments regs.pdf

meeting needs assessment, eligibility & (wales) act social ... paper 3.pdfbodies, and covers...

Documents