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Practice example: Fluctuating needs

Published: March 2015
Last reviewed/updated: October 2022


Mr X is an elderly man living alone in a one-bedroom flat on the ground floor in sheltered accommodation. He has a small but supportive family network, and a good network in the sheltered accommodation community.

Mr X has multiple sclerosis and support from the local authority, but the condition has a significant impact on his life, despite the care he receives from his care and support plan.

As a result of his multiple sclerosis, Mr X has mobility issues, relying on a walking frame and rollator to get around, which he successfully manages for the majority of the time. With some difficulty and support from his family he manages to get to the local shops to buy food, which he can prepare and eat himself. He is house-proud, and mostly maintains his flat to the standard he was used to when his partner was alive, as well as managing his personal care.

Mr X is tired by the effort of looking after himself, but with the support his family are able to provide he is generally able to cope. His family, a daughter and son, live locally and have full-time work commitments and young families, which limits the amount of support they can provide. This means they practise a rota system to ensure he receives their care and support on a regular basis.

Mr X suffers occasional severe relapses in his condition. During these times he is almost totally immobilised, unable to sit up, get out of bed or care for himself, occasionally totally losing the sight in his left eye. These episodes are rare, never occurring more than two or three times a year, but when they do Mr X needs round-the-clock support, for periods of between one and three weeks. His family do their best to support him in these events but they are finding it increasingly difficult to provide this level of care on the occasions when his condition and needs are most extreme.

Mr X has recently experienced a fluctuation in his needs. This went on for longer than previously and his family were concerned about his safety as they found it difficult to cope. Mr X discussed his anxiety during this period with his daughter and son, and with the warden in the sheltered accommodation. They told him of their concern for his safety and the warden suggested he approach the local authority. Mr X requested an assessment of his needs and asked for support as he was worried about his safety if his condition fluctuated in the future and the distress this would cause his children.

Preparing for an assessment

When preparing to make an assessment it is useful to ask yourself the following questions in relation to the legal duties for the Care Act 2014.

  • What needs to be taken into account to ensure the assessment is appropriate and proportionate?
  • How will you ensure a strengths-based approach has been applied?
  • How do answers to the first two questions above affect the way this assessment is conducted?
  • Who will be involved with the assessment?
  • Does the assessor need to have specific training and expertise?
  • In preparing for the assessment, what additional issues or obstacles need to be considered (if any) – and how can they be dealt with?
  • Have you considered the individual’s needs over an appropriate period of time to ensure that they have all been accounted for?
  • What questions do you need to consider to get a holistic picture of Mr X’s needs over time?
  • What other information do you need, and where do you get this?
  • What is the impact on the whole family? Should there be a carer’s assessment?
  • What information and advice would be helpful?
  • What preventative measures (to prevent, delay or reduce needs) will you consider?
  • What else might you need to think about with regards to this example?

Ensuring the assessment is proportionate and appropriate


  • Severity and extent of needs. Mr X has physical health needs, which impact on most of the eligibility outcomes. For the most part he is able to cope, with the support from his family, however, the level to which his needs fluctuate means that there are periods when this is not the case (two or three times a year). The assessor therefore needs to establish the full extent of this variation and involves the staff at Mr X’s sheltered accommodation to get a view on the day-to-day impact this has on him.
  • Person’s wishes, preferences and desired outcomes. Mr X is lucid, articulate and very aware of his condition, surroundings and circumstances. He is able to express his needs very clearly when he is feeling reasonably well. He does not need any additional support to be able to express himself in regards to his desired outcomes and preferences during such periods. However, when his needs deteriorate he is not fully aware of the risk to himself, the amount of support he needs from his family and the impact and distress that this places on them. Although Mr X has the capacity to fully be involved in the assessment, it is important that the views of others are taken into account during periods when his capacity is reduced.  
  • Potential fluctuation of person’s needs. Mr X’s physical needs fluctuate. In the past this fluctuation has been managed by his family and the support provided under his existing care plan. Now, however, the demands of his children’s jobs and their own young families mean they are no longer able to provide round the clock support and this leaves Mr X vulnerable. The assessor seeks advice from Mr X’s GP and associated health care professionals to ascertain when, how and to what extent Mr X’s health needs are likely to fluctuate and how this might get worse over time. This will involve the assessor considering Mr X’s condition over a suitable period, taking account of the experience of his condition over the years and the assessor’s own experience of dealing with people with similar conditions in similar circumstances. The views and experiences of Mr X, his family and the staff at the sheltered accommodation should also be carefully considered.
  • Other information and assessments. Although Mr X is not currently receiving care and support from his local authority, he is already known to other parts of the authority and to health care services. The assessor gathers – with Mr X’s consent – all existing information from the housing department, the warden, the GP, the district nurse, physiotherapist and occupational therapist. This information is then examined to establish what is relevant in order to produce sufficient and appropriate background information to obtain an overall picture of Mr X’s needs.
  • Relevance of assessment questions for this case. Mr X has the appearance of needs across most – if not all – of the eligibility outcome areas. His circumstances have changed due to the fluctuation in his needs over time and the changes in the ability of his family to provide the level of care he requires. The assessor needs to consider Mr X’s needs when he is in a period of stability and what his needs are when he deteriorates. They will also consider what might be done to prevent/delay the periods of fluctuation: are there ways of identifying when he is going to fluctuate? Is his care plan flexible enough to meet his needs when they do fluctuate, as well as when they are reduced during periods of stability? The assessor will, therefore, discuss the information with Mr X and his family to identify his needs and desired outcomes during fluctuation and stability, and the best way to meet these. 


  • Proportionate: as above.
  • Communication needs. Mr X does not need any additional support for communication and he is capable of understanding questions, processing information and providing answers himself. He does, however, need support from his family to describe his needs when they fluctuate as he is not fully aware of these at the time.
  • Means. A face–to-face assessment seems to be the most suitable method for Mr X to allow the assessor to obtain a clear view of the fluctuations in his needs.
  • Location and timing. Mr X prefers the assessment to take place in his own home, as it is where he is most comfortable. It is agreed that the assessment will be carried out as soon as possible when Mr X is in a stable condition. The care and support plan can be reviewed after a period when Mr X’s needs have fluctuated to ensure it is appropriate.
  • Capacity and level of understanding. Mr X does not need a mental capacity assessment or an independent advocate. The assessor agrees with Mr X that at least one member of his family will be present at each of the visits for the assessment.
  • Involvement. Mr X’s family are involved in his care and support and will therefore be involved in the assessment. Mr X asks that one of them is present at each of the visits to explain his needs during periods of fluctuation.
  • Holistic. The assessor will gather information about Mr X’s needs through the assessment and, with his agreement, from his family, the warden and other relevant professionals. The assessor must ensure that the information gathered is over an appropriate period of time to get an overall picture of Mr X’s needs.   .
  • Process. Mr X will be sent the assessment materials in advance, along with information about the assessment and the process involved. Agreement will be reached on the best time to carry out the assessment and who will be consulted.

Determining eligibility

  1. Do the needs for care and support arise from a physical or mental impairment or illness?
  2. Do these needs mean the adult is unable to achieve two or more of the listed outcomes?
  3. As a consequence of being unable to achieve the outcomes, is there, or is there is likely to be, a significant impact on the adult’s wellbeing?


Determination. Following a face-to-face assessment over a four-month period, Mr X’s needs were found to be eligible.

Condition 1. Mr X’s needs arise from a physical impairment.

Condition 2. As a result, he is unable to achieve two or more of the following outcomes: managing and maintaining nutrition; managing personal hygiene; managing toilet needs; and being appropriately clothed.

Condition 3. This is having a significant impact on Mr X’s wellbeing, in particular with respect to his physical wellbeing and control over day-to-day life.

Next steps

How the adult’s eligible needs might be met

Mr X’s needs are very likely to continue to fluctuate. Taking into account that he is in a severe situation, and that his family are unlikely to be able to provide the required support, the assessor ensures that his care plan is flexible enough to meet his needs when his condition is stable and when it fluctuates, and this is kept under regular review.

The assessor will seek professional advice from Mr X’s GP and other health care professionals in regular contact with him to ascertain the likelihood of Mr X’s needs fluctuating in the future and to get an idea of any previous fluctuating pattern. In addition, the assessor recommends Mr X is supported in a request to his GP or consultant for a medication review to ensure his pain is being managed effectively.

During the four months of the assessment, an urgent needs package is arranged, allowing consideration of Mr X’s needs in the right context and over a suitable time period.

The eligibility determination is made based on the time when Mr X’s level of needs is greatest – however, this does not mean that his personal budget or care and support plan will be at fixed levels.

Reflection points

  • How do the outcomes concur with your assessment of this situation?
  • What else did you think about?
  • What else might apply/be relevant in your authority?
  • What might you do differently?
  • What have you learned?