Fluctuating needs in assessment and eligibility for the Care Act 2014

Published: January 2015
Last reviewed/updated: October 2022

This guide provides an overview of key elements to consider in order to ensure any form of care assessment undertaken – for the adult requiring care and support or their carer with support needs – takes full account of the extent of fluctuating needs. It should be read in conjunction with the ‘Care and Support (Assessment) Regulations 2014’ and Chapter 6 of the statutory guidance.

Key messages

• The Care Act 2014 requires local authorities to take into account the full range of needs of adults with care and support needs and their carers with support needs (due to their own circumstances and/or their caring responsibilities). This must take into account any fluctuation in the needs of the person. The process of assessment provides one of the most important elements of adult care and support, and this holistic understanding of need is vital to ensuring ongoing care needs are met – not just those presenting on the day of an assessment.
• Consideration of fluctuating need ensures that assessment is not simply a ‘snapshot’ of a person’s care and support needs. Local authorities must consider the person’s care and support needs over a suitable period of time to gain a complete picture of those needs.
• People should be asked during a needs or carer’s assessment how their needs change over time. They should be encouraged to consider how their needs present themselves on the given day, how much of an issue they have been in the past, how they are likely to develop in the future, and the impact these changes have on the outcomes they want to achieve in life.
• Establishing an accurate picture of needs that fluctuate over time will also require supporting the person to provide an assessment of their own circumstances. It may also be useful for the practitioner to draw upon others’ experience of similar needs and reasonable expectation of outcome when the same condition and like circumstances exist. However, the use of previous experience should not override the person-centred approach and will provide a guide, not a definitive answer, which will vary from person to person.
• Consideration must be given to the wider causes of fluctuating need. This requires taking into account the condition itself, changing circumstances and the environment.

Fluctuating need?

In the context of a needs or carer’s assessment ‘Fluctuating need’ refers to needs which:

• may not be apparent at the time of the assessment; but
• have been an issue in the past; and
• are likely to arise again in the future.

In other words, when practitioners assess a person’s needs, those presenting at initial contact may not be a true reflection of their condition over time; they may be coping with circumstances where they:

• experience good and bad days, or parts of a day; or
• are well for weeks or months at a time.

Needs may not fluctuate just because of a condition but also because of changing circumstances, such as changes in employment or education, or the transition to adult services which may be the case for young carers entering adulthood.

An accurate assessment of any fluctuation requires practitioners to give consideration to the needs of a person and their carer over an appropriate period of time to understand the full implications of their condition and circumstances.

What do practitioners need to consider?

It is important to recognise that contact with a person at a single point in time will not necessarily provide a full picture of their needs. The experience of a person with care and support needs coping in situations where they have good days and bad days is invariably unpredictable, triggered by a range of circumstances, and is virtually impossible to capture in any one ‘snapshot’.  

To provide an accurate assessment of care needs – whatever form that assessment takes – the ‘good’ and ‘bad’ must be fully explored over a suitable period of time to provide as complete a picture of the range of fluctuation as possible. It is important to note that ‘suitable’ length of time in this instance will vary from person to person. Fluctuation may be short term over the course of a day or longer term over weeks or months.

Example issues, and this is not an exhaustive list, for practitioners to consider concerning fluctuating needs include:

For adults with care and support needs

• a person’s condition may affect their lives very differently over time, for example:
  • physical – conditions such as multiple sclerosis or Parkinson’s
  • mental – such as bipolar affective disorder or depression.

Irrespective of the condition, the person may have low support needs on any ‘good’ day, but on more challenging ‘bad’ days these will be significantly higher. Therefore, an assessment made solely on a ‘good’ day will leave the person with significant negative impact on their wellbeing with no strategy in place to mitigate this.

• Environment: for example, changes such as cold weather in winter can impact on mobility and pain due to arthritis.
• Changing circumstances: for example, if the person has caring responsibilities for a child of school age, the demands of term-time and holidays may have a varying impact on their wellbeing.

For carers with support needs

• Their own condition: it is important to recognise that carers themselves may be coping with a condition of their own, with corresponding good and bad days.
• The impact of the fluctuations in the needs of the person they provide care for on their own wellbeing. The demands of coping with a bad day or series of bad days may have significant physical and emotional impact on their own wellbeing.
• Their circumstances, for example:
  • changes in employment which place more demands on their time, reducing the time they can dedicate to their wellbeing outside caring responsibilities
  • a single parent with children at home will face the demands of holiday and term-time childcare
  • a divorced parent will face varying demands on their time depending on whether the child/children are with them.

Understanding the person’s history will enable a complete picture of their needs to be established, which may show a relatively ‘good’ condition (manageable periods) interspersed with episodic ‘bad’ (negative) events or a generally ‘bad’ standard (creating a challenging impact on wellbeing), interspersed with more severe episodes. An understanding of these issues will allow the local authority to develop as appropriate:

• subject to eligibility determination, contingency planning for events built into care plans to allow rapid response to access extra support
• the provision of preventative interventions to delay or prevent the development of further needs in the future.

It is also important to recognise that fluctuation in needs may also have implications when considering eligibility and an accurate assessment of this is vital to ensure a correct determination is made.

How can an accurate picture of fluctuating needs under the Care Act be established?

Determining the extent of fluctuating needs is a decision that must be made on a case-by-case basis but, in practice, practitioners will be required to:

• Establish what impact can be reasonably expected from knowledge of people with similar conditions or circumstances, which can be based on the practitioner’s own experience and may also require advice from someone with expert knowledge about a specific condition.
• Encourage the person and their carer to keep a diary to record the ‘good’ and ‘bad’ days to ensure need, and the impact it has on desired outcomes individually and collectively, is captured in its totality wherever possible to ensure the record is as holistic as possible.
• Establish how long a ‘suitable time’ might be to assess need fluctuation – for example, ask the person a series of questions, along the lines of:
  • How are you today? (Is it a ‘good’ day?)
  • How long since you last had a bad day or series of bad days?
  • How often does it get bad?
  • How long is it since you have felt at your best?
• Establish the extent of the fluctuation in relation to severity, duration and frequency – for example, you could ask:
  • How good/bad does it get?
  • What does a ‘bad’ day or series of days prevent you from doing? (To establish the impact of the fluctuation on desired outcomes)
  • How often do things change?
  • Who helps you on a bad day?
  • What helps you on a good day?
• If the person cannot answer these questions due to capacity or communication issues, ask the opinion of their carer or advocate and other relevant healthcare professionals on these issues.
• The impact on carers must also be considered – first by establishing if they themselves have a condition requiring care and support, and then by establishing:
  • the extent to which the fluctuation in the person’s needs has an impact on their wellbeing
  • the extent to which their circumstances and environment cause a fluctuating impact on their wellbeing.
• If the carer cannot answer these questions due to capacity or communication issues, ask the opinion of their advocate.

The local authority should assure itself that the information provided can be reasonably relied upon.

What are the implications for practice of assessing fluctuating needs under the Care Act?

Making an accurate appraisal of any fluctuating needs for a person is a vital part of assessment, which will have an impact on the eligibility determination.

The benefits of an accurate appraisal of fluctuating needs

• It establishes a full picture of the needs of the person beyond a snapshot based on the conditions presenting at any one time and therefore helps to ensure a correct determination of eligibility.
• It allows for contingency to be built into eligible care plans to mitigate the impact of the fluctuation, preventing or delaying, as far as possible, the development or escalation of further needs in the future.

The challenges involved in making an accurate appraisal of fluctuating needs

• Making an accurate appraisal of fluctuating needs requires time to establish the full extent of the fluctuation.
• The person or their carer may not fully recognise the impact on their wellbeing of the fluctuations, thinking of them as something they cope with. Therefore, asking the right questions is vital to establish the extent of that impact.
• Accessing expert opinion to support any assessment of what can be reasonably expected of a person with a similar condition and circumstance. Most importantly, recognising that this is only indicative and cannot be used as an absolute.
• Ensuring any appraisal of needs is person-centred, based on person circumstances and not on previous experience of people with similar needs. 

Examples of practice

• Eligible fluctuating need (carer): a carer is a divorced parent who struggles to provide care when his children are with him, leaving him feeling a failure as a parent which is affecting his relationships. After determining that the carer is eligible, the local authority links the carer to a local carers’ support network which is able to offer ongoing support when it is needed as well as children’s and family activities during school holidays.
• An appropriate period of time: a person with mental illness has coped for the past eight months but their health deteriorates due to a change in circumstances. The local authority is recommended to consider their needs over the past 12 months to gain an accurate picture (see Care Act guidance, p 110). On a daily basis a person with, for example, Parkinson’s disease, a degenerative neurological condition, may find it difficult to get out of bed each morning due to stiffening-up overnight.
• Accounting for eligible fluctuating needs in care planning (Care Act guidance, p 176): Ms S has multiple sclerosis and requires a frame or wheelchair for mobility. She suffers badly with fatigue, but for the majority of the time she feels able to cope with daily life with a small amount of care and support. However, during relapses she has been unable to sit up, walk or transfer, has lost the use of an arm or lost her vision completely. This can last for a few weeks, and happens two or three times a year, requiring 24-hour support for all daily activities. In the past, Ms S was hospitalised during relapses as she was unable to cope at home. However, for the past three years, she has received a care and support package that includes direct payments which allow her to save up a month’s worth of 24-hour care for when she needs it; this is detailed in the care and support plan. She has not been hospitalised since.

Checklist of core duties for local authorities when assessing fluctuating needs under the Care Act

• Local authorities must consider whether the person’s current level of need is likely to fluctuate and what their ongoing needs for care and support are likely to be.
• Local authorities must consider the person’s care and support history over a suitable period of time, both the frequency and degree of fluctuation.
• Local authorities must consider the impact of the person’s needs on anyone who cares for them and their wider family.
• Local authorities must consider a carer’s needs over a suitable period of time to ensure all of their needs have been accounted for when eligibility is being determined.
• Local authorities must involve any person that the adult with care and support needs, or the carer with support needs, wants to be involved in the assessment. The local authority should ask the person who else should be consulted, provided with information or otherwise involved.
• Local authorities must ensure that a person with needs around safeguarding (see Care Act Guidance Chapter 14), independent advocacy (see Care Act Guidance Chapter 7) and assessing mental capacity (see Mental Capacity Act Code of Practice) are met.
• Local authorities must ensure the person with care and support needs is capable of engaging in the assessment process and provide additional support if not.
• Local authorities must ensure that all other organisations and agencies with an interest and involvement in the care and support needs of the person requiring immediate support, and their carers, are engaged in the process. Authorities must ensure a seamless flow of information between assessments under different statutory duties and minimise the requirement for duplication in providing information on needs, desired outcomes, circumstances and strengths.

Further information and resources on assessing fluctuating needs under the Care Act 2014

Useful resources

• Research in Practice for Adults has many resources for practitioners in social care around the Care Act, including guides to good decision-making – but you need to be working for a partner organisation in order to access these in full.
• SCIE’s guide to co-production in social care.
• The LGA’s summary of resources including those on assessment.
• SCIE’s safeguarding resources.
• SCIE’s advocacy resources.
• Guide to questioning skills from Mind Tools – which you might find useful when reflecting on the assessment process.
• A guide to skilful questioning and active listening from the London Deanery.
• Think Local Act Personal’s Care and Support Jargon Buster – a plain English guide to social care words and phrases and what they mean.

Relevant training

• Skills for Care has developed a range of free materials with The College of Social Work to support the adult social care workforce. These include First contact and identifying needs.
• Carers UK has developed e-learning courses for professionals working with carers which include key elements of assessment under the Care Act.  

Care Act: Assessing fluctuating needs

Under the Care Act 2014, assessments should reflect more accurately a comprehensive picture of people’s needs – including how they change over time. In this film two people, one with mental health needs, the other with a physical disability, talk about their conditions, assessment, how their needs can fluctuate and the impact this has on the level of care and support they need.