Determination of eligibility under the Care Act

The eligibility determination follows an assessment and cannot be undertaken until the Care Act assessment is completed.

The national eligibility criteria has three conditions and, as a social care practitioner, you will need to address each of the conditions in order, using the information gathered during the assessment to evidence your answers.

If you are supporting an adult, the conditions are:

1. The adult’s needs arise from, or are related to, a physical or mental impairment or illness.
2. As a result of the adult’s needs, the adult is unable to achieve two or more of the specified outcomes (which are described in the guidance below).
3. As a consequence of being unable to achieve these outcomes there is, or there is likely to be, a significant impact on the adult’s wellbeing.

If you are supporting a carer, the conditions are:

1. The needs arise as a consequence of providing necessary care for an adult
2. The effect of the carer’s needs is that any of the below apply to the carer
   1. the carer’s physical or mental health is, or is at risk of, deteriorating and/or
   2. the carer is unable to achieve any of the specified outcomes.
3. As a consequence, there is, or there is likely to be, a significant impact on the carer’s wellbeing

For the individual (adult or carer) to have eligible needs you will have to evidence an affirmative response to each of the conditions represented in the two sets of questions below.

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

1. Do the needs arise because the carer is providing necessary care and support?
2. Is the carer’s physical or mental health affected or at risk of deteriorating, or is the carer unable to achieve any of the listed outcomes?
3. As a consequence of that fact is there, or is there likely to be, a significant impact on the carer’s well-being?

The local authority’s duties in relation to determination of eligibility are exactly the same for individuals that are self-funders.

This is the first condition to determine eligibility for care and support. You do not need a formal diagnosis of an illness or impairment.

As a social care practitioner, you must be able to satisfy yourself – and have the necessary evidence in the assessment – that the individual is living with either a physical, mental, sensory, learning or cognitive disability or illness, substance misuse or brain injury that leads to them having the needs you have identified in your assessment. It does not need to be a long-term impairment or illness.

You as a social care practitioner must be able to satisfy yourself – and have the necessary evidence in the assessment – that the individual is providing necessary support. This means that the adult can’t do without support what the carer is doing for/with them.

You do not need evidence to indicate that the amount of unpaid support provided is significant or related to a practical task; it could be emotional support. The amount of time, or regularity or type of care and support provided, does not matter at this stage.

Condition two refers to the eligibility outcomes.

It may be that the individual only has one need that makes them unable to achieve two or more of the specified outcomes.

As a social care practitioner, you will need to demonstrate how an individual is able or unable to achieve each of the specified outcomes and have the necessary evidence in the assessment, and to ensure that a need in relation to that outcome has been identified in the assessment.

For example: If an individual is not interested in pursuing any work, education or volunteering opportunities and this is clearly recorded in the assessment, you won’t need to demonstrate whether they are able or unable to achieve ‘accessing and engaging in work, training, education or volunteering’. However, if they are interested, even if you think they are able to do it, you will have to demonstrate that they are actually able to do it.

Adult – an adult is to be regarded as being unable to achieve an outcome if the adult is:

• unable to achieve the outcome without assistance.
  • For example, this would include where an adult would be unable to do so even when assistance is provided. It also includes where the adult may need prompting. For example, some adults may be physically able to wash but need reminding of the importance of personal hygiene.
• able to achieve the outcome without assistance but doing so causes the adult significant pain, distress or anxiety
  • For example, an older person with severe arthritis may be able to prepare a meal but doing so will leave them in severe pain and unable to eat the meal.
• able to achieve the outcome without assistance, but doing so endangers or is likely to endanger the health or safety of the adult, or of others.
  • For example, if the health or safety of another member of the family, including any child, could be endangered when an adult attempts to complete a task or an activity without relevant support.
• able to achieve the outcome without assistance but takes significantly longer than would normally be expected.
  • For example, an adult with a physical disability can dress themselves in the morning, but it takes them a long time to do this, leaves them exhausted and prevents them from achieving other outcomes.

Read more about Adult eligbility criteria.

You will need to specify which outcomes the individual is unable to achieve and in which way they are unable to achieve them, as noted above.

If an individual expresses that they ‘find it difficult’ or ‘are struggling’, it does not necessarily mean that they are unable to achieve the outcome being explored. Therefore, it is important that you clarify what they mean by finding it difficult or struggling. It could indicate that they are unable to achieve but without more information it would not be possible to determine.

Carer – a carer is to be regarded as being unable to achieve an outcome if the carer:

• is unable to achieve it without assistance; for example, is unable to go to a place of employment without having another person be with the adult.
• is able to achieve it without assistance but doing so causes the carer significant pain, distress or anxiety; for example, is able to go shopping but has anxiety about what is happening with the adult while they are out of the house.
• is able to achieve it without assistance but doing so endangers, or is likely to endanger, the health or safety of the carer, or of others; for example, would be able to do the school run but in doing so the adult is at risk of harm while the carer is not in the house.

Read more about Carer eligibility criteria.

Two people can have a similar level of needs or type of needs, but these needs may have very different impact on their wellbeing due to different priorities, personalities, personal and network resources and/or personal outcomes.

The following are examples of what ‘significant impact’ could mean:

• Significant impact could be a consequence of a single effect: the inability to achieve two or more outcomes affects at least one of the areas of the individual’s wellbeing in a significant way.
• Significant impact could be a consequence of a cumulative effect: the individual may have needs across several of the eligibility outcomes, perhaps at a relatively low level, but as these needs affect them in various areas of their life, the overall impact on their wellbeing is significant.
  • For example, an adult is struggling to manage and maintain their nutrition, personal hygiene and toilet needs and their standards are reducing due to low social interaction and decreasing mobility around the home. The adult could consequently be very close to becoming unable to meet most of the outcomes. It could be argued that the adult does not meet condition 3 of the eligibility criteria for adults with care and support needs, due to the level of needs being relatively low. However, taking a holistic view of the level of impact of the individual’s mobility needs, and the accumulation of a number of the ‘low/medium’ levels of needs, this could add up to a ‘significant impact’ on the adult’s wellbeing. However, without having in the assessment clear evidence of what the adult understands as wellbeing – their priorities around the nine wellbeing areas – you will it find impossible to evidence impact on the individual’s wellbeing.
• As a consequence of a domino effect: currently the individual may have needs in relation to few eligibility outcomes, but it can be anticipated that in the near future other outcomes will be affected, causing a significant impact on their wellbeing.
  • An individual could have identified/assessed needs around their difficulty to maintain relationships with their family and in making use of facilities or services in the local community, but currently does not have any problems with managing and maintaining their nutrition, personal hygiene, toilet needs or a habitable home environment. However, the individual is depressed, affecting their ability to interact socially. As a result, their emotional situation is decreasing further, to the extent that it is clear that in the near future they also will not be able to manage or maintain nutrition, personal hygiene, toilet needs or a habitable home. In this example, the impact on the individual’s wellbeing is significant.

If an individual says that they are ‘frustrated’ or ‘struggling’, it does not necessarily mean that there is a significant impact, so clarifying what they mean and how it impacts their individual wellbeing as described at the time of the assessment will support you in responding and evidencing your answer to condition three of the eligibility criteria.

It is important you do not determine significant impact based on assumptions, but by using the information you gathered during the assessment to verify how being unable to achieve an eligibility outcome has an impact on the individual’s wellbeing. Assumptions may need to be made in exceptional circumstances, such as where the individual does not consent to consulting with others during the assessment process. If this is the case, then make it clear that you are making an assumption and why.

There are several key elements to consider when making an eligibility determination under the Care Act:

• Apply the national eligibility criteria.
• Use the knowledge, information and evidence gathered during the assessment process.
  • What is important to the individual and why, what needs they have and what outcomes they want to achieve?
• If an individual’s needs fluctuate, you must take account of this and ensure that all of their needs have been accounted for when determining eligibility.
• Use the evidence gathered during the assessment and your professional judgement to establish what impact the person’s needs have on their wellbeing. It is important that you evidence what has been considered and how your decisions have been made.
• Ensure you follow the Care Act and regulations, in duties and terminology, and that your professional judgement is complementing the law rather than substituting it.
• Be ‘carer-blind’, which means that any impact on wellbeing that would be reduced or minimised by what carers are currently doing must be ignored for the sake of the determination itself.
• Consider risks in relation to wellbeing using a strength-based, person-centred approach. This should include consideration of likelihood, severity and impact.
• Be transparent as to how you have made your decisions, ensuring that they are evidenced appropriately.

Every day, practitioners in adult social care must make difficult decisions that change lives. Therefore, it is important that you can defend your professional decisions.

It will be important for you to differentiate ‘needs’ from ‘outcomes’.

• A need is something which prevents an individual from achieving everyday activities and personal outcomes; for example, being unable to access community spaces due to mobility difficulties.
• An outcome is an aim or objective that an individual would like to achieve; for example, to meet with friends on a weekly basis.

The duty is to meet eligible needs and have regard to personal outcomes, so needs are met in a way that will enable the individual to meet their personal outcomes. While you have a duty to have regards to personal outcomes, there is no duty to meet personal outcomes.

• Eligible need: the need arises from, or is related to, a physical or mental impairment or illness
• Personal outcome (example): to take a Caribbean cruise on an annual basis.

[EDITORS: there is a div created image on current site – may need to be done as image: https://www.scie.org.uk/care-act-2014/assessment-and-eligibility/determination-eligibility]

As a social care practitioner, once you have determined eligibility, you have the following duties:

• to inform the individual of the outcome of the determination and your reasoning
• to send the individual, and whomever they ask, a copy of the determination and the reasoning, unless there is a risk to themselves or others in doing so (in which case you must document this appropriately)
• to provide information and advice in writing, in a format accessible to the individual, tailored to the assessed needs, that will enable the individual to prevent, reduce and/or delay the needs identified as not eligible.

If the individual has eligible needs, the local authority must:

• consider how those needs will be met – by supporting the individual to develop a care and support plan
• carry out a financial assessment where it proposes to make a charge for meeting the needs they will be meeting.

Note that the local authority has the duty to ensure the eligible needs are met, not to provide services to meet them if there is a more cost-effective or appropriate way of meeting them (i.e. building on existing skills, strengths and capabilities, or via a carer or community resources, etc.).

The local authority should bear in mind that eligibility may change over time, due to changing circumstances or needs.

You are required to do exactly the same for a self-funder.