Practice example: Fluctuating needs


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.

Ensuring the assessment is proportionate and appropriate



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