Practice example: Strengths-based approach in assessment
Mr R is a man in his late 60s living alone since the death of his wife. Mr and Mrs R had been married since they were both 18.
Mr R is retired. He previously worked as an engineer in the aerospace industry, taking relatively early retirement at 60 due to an increase in the severity of rheumatoid arthritis (diagnosed in his 20s) and a desire to spend more time with his wife.
The couple were known to the local authority due to Mrs R’s physical health problems. Mr R acted as her carer and, with additional support from Mrs R’s personal assistant, continued working until retirement. Mr R’s needs had been supported following a carer’s assessment, however his physical condition was never significant enough while his wife was alive to require a needs assessment in his own right.
Mr and Mrs R had a very small circle of friends and no significant relatives. Despite her physical illness, Mrs R was more outgoing and better able to form friendships. Mr R is shy and awkward in social situations; most of his relationships were formed through his workplace and did not extend beyond work.
Mr R has a son and daughter, one of whom lives abroad and the other lives 300 miles from the family home. While both enjoy a good relationship with their father, visits are infrequent, but loving and fulfilling when they do occur.
Following the death of his wife 18 months ago, Mr R has become increasingly depressed and isolated, rarely leaving his home and having little social contact with friends. He is neglecting his personal hygiene and his home is becoming increasingly messy, with unwashed plates and evidence of spoilt food in the kitchen. He is not eating properly and largely feels there is no point to anything any more. He is not taking his pain medication regularly and is experiencing increased lack of mobility due to his arthritis.
His only daily social interaction is with his neighbour, Mrs S, who has been friends with Mr and Mrs R for 30 years. She ‘pops in’ regularly throughout the day to check on Mr R, but limits the extent she helps because she does not wish to intrude on what she recognises as his very private nature. Mrs S doesn’t feel comfortable offering him personal care. She regularly talks to Mr R’s children to update them on their father’s condition. Mrs S is fit and capable, being some years younger, and would like to provide more support to Mr R around the home but does not know how to begin the conversation about his needs without offending him.
In the past Mr R helped out at the local Scouts and Guides and volunteered in his children’s school when his shift patterns allowed. This allowed him to be close to his children and also helped him overcome his shyness, as he was acting in what he saw as some form of official capacity.
His son and daughter have become increasingly concerned about their father’s state of mind and physical condition, which is confirmed by their regular contact with Mrs S. Being familiar with the local authority support from their mother’s case, they have requested a social care assessment for Mr R.
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 considered?
- How do 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 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?
- Are there any risks of self-harm that need to be considered or assessed?
- What else might you need to think about with regards to this example?
Ensuring the assessment is proportionate and appropriate
Mr R faces social isolation which is contributing to the deterioration in his mental health. He feels lonely and without a social network. Adopting a strengths-based approach in the assessment allows the assessor to work with Mr R to recognise not only the problems he faces but the:
- strength of his existing, if limited, relationships
- extent that people close to him value him and are willing to offer support
- skills and experience he possesses that can be of value to others and might help to widen his social network.
In Mr R’s case the assessor considered the following.
- His personal network. Mr R has limited social contact but has very frequent contact with Mrs S, his neighbour. Mrs S offers limited support at the moment and has indicated that she would like to do more. The assessor explores the extent to which she is willing and able to provide support and it becomes clear that Mrs S would like to support Mr R to maintain his home to the standards that Mrs R previously expected, out of friendship for him and ‘… in memory of a dear friend’. However, Mrs S does not feel comfortable with the idea of providing personal care.
- His personal resources and strengths. Mr R’s mental health has deteriorated significantly due to the loss of his wife and any limited social contact he had in the past. The assessor takes time to explore with Mr R the extent of his previous social network and the activities he took part in, as well as the skills, knowledge and experience he has. At the same time the assessor considers local activities or facilities that match these existing strengths, either through their own knowledge or by working with local expert partners (CVS (Community Voluntary Services), Age UK, etc.) to assist in identifying social opportunities.
- Severity and extent of needs. Mr R has physical and mental health needs that impact most of the specified outcomes in the eligibility criteria. Therefore the assessor involves a mental health professional.
- Person’s wishes, preferences and desired outcomes. Mr R is fully able to express his needs. His needs arising from loneliness and isolation and his physical condition do not have an impact on his capacity to understand the process, collate information and articulate his needs. However, his very low mood means the assessor will need to allow as long as necessary for the assessment to enable Mr R to express his views. This will require additional support from the mental health professional.
- Potential fluctuation of person’s needs. Mr R’s mental health needs have steadily declined since the death of Mrs R, and more information is required to understand whether his mental health also fluctuates. Mr R’s physical needs do fluctuate, particularly in relation to the seasons. The assessor seeks expert mental health advice to establish the likelihood that Mr R’s mental health needs are likely to fluctuate. This involves consideration of Mr R’s condition over a suitable period of time, taking account of the experience of mental health professionals of his low mood over the years and of the assessor’s experience of dealing with people with similar conditions in similar circumstances. The views of Mr R’s son and daughter are also taken into account.
- Other information and assessments. Mr R is already known to social services from his carer’s assessment and he has been seen regularly by local health care professionals. The assessor gathers – with Mr R’s consent – all existing information: previous needs assessments; CPA (care programme approach) ; GP/district nurse’s views, etc. This information is then examined to establish what is relevant at this point to avoid asking Mr R unnecessary/duplicate questions.
- Relevance of assessment questions for the case: Mrs R has the appearance of needs across most, if not all, the eligibility outcome areas. As this is his first needs assessment all areas must be considered.
- Proportionate. As above.
- Communication needs. Mr R does not need any additional support for communication and he is capable of understanding questions, processing information and providing answers himself.
- Means. A face-to-face assessment seems to be the most suitable method for Mr R, and when asked he chooses this. He does not want a supported self-assessment largely because he feels he will not be motivated enough to complete it by himself.
- Location and timing. Due to his low mood and reluctance to leave the house Mr R prefers the assessment to take place in his own home. He feels that he is able to meet any time during the day, as his mood and condition are not affected by any particular circumstances, although he does request that visits take place after 10 a.m. to allow him time to be up and dressed.
- Capacity and level of understanding. Given Mr R’s low mood the assessor undertakes a mental capacity assessment to establish if he needs an independent advocate. The mental health professional establishes that Mr R has capacity to make informed decisions. However, they also highlight the importance of considering his current low mental state in the assessment process.
- Process. Mr R will be sent the assessment materials in advance of any face-to-face meetings to allow him to prepare his responses, along with information about the assessment and support plan process.
- Do the needs for care and support arise from a physical or mental impairment or illness?
- Do these needs mean the adult is unable to achieve two or more of the listed outcomes?
- 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. The outcome of the assessment is that Mr R has eligible needs for formal services.
Condition 1. Mr R’s needs arise from both physical and mental impairment.
Condition 2. Mr R is unable to achieve two or more of the eligibility outcomes, including: managing and maintaining nutrition; maintaining personal hygiene; being able to make use of the home safely. He has also disengaged with others around him and this may impact on maintaining relationships in the future.
Condition 3. As a result, there is a significant impact on Mr R’s wellbeing, particularly in relation to physical and mental health, emotional wellbeing and personal relationships.
How the adult’s eligible needs might be met
A care and support plan is put in place for Mr R. The intended outcome is to support a level of independence and social contact that had existed in Mr R’s life before the death of his wife.
The assessment identified that within the extent of his eligible needs an appropriate source of support for Mr R is the strength of his limited relationships with his former work colleagues and the extent to which he is able to engage in the community. This is discussed and agreed with Mr R, drawing on his own resources in this way:
- The assessor explores with Mr R the extent to which he is currently comfortable with relying on support from Mrs S, and his views on the acceptability of her providing more. The assessor also explores with Mrs S how much more she would want to support Mr R and what impact this would have on her expected outcomes. The assessor agrees with Mrs S that she will:
- continue to maintain regular social contact
- provide Mr R with the current level of support
- become more active in maintaining the home for Mr R and share this duty with a local authority-funded home support package, but not be involved in providing personal care.
- The assessor considers Mr R’s previous experience and strengths from a social point of view, including his experience as a volunteer and the significant benefit this has had in overcoming his social awkwardness. The assessor works with Mr R to establish his interests and with the help of the CVS identifies a local community centre that runs regular sessions introducing young people to the rich industrial heritage and social history of the area. The assessor encourages Mr R to volunteer his services to the group. Following suitable checks he begins to work with other volunteers of a similar age and background to develop sessions and present them to local young people. Working with people who have similar life experience involves him in an environment that is understanding of his physical limitations and supportive of his loss without putting either at the centre of the relationship. This initial contact leads to Mr R becoming more involved in the activities of the community centre, which is less than a mile from his home. He develops a small but important social network based on activities and knowledge he feels comfortable with, is experienced in and in some respects is a technical expert. This has the potential for a lasting and long-term positive impact on his wellbeing and may in time lead to him to volunteer for other roles, further extending his social network.
Taking account of the eligible needs which cannot be met from Mr R’s own resources, services and support provided by the local authority include:
- Sourcing an appropriate home support package to meet identified outcomes for Mr R. He is given a choice of the service provision to address, particularly the personal care Mrs S feels unable to provide.
- Information on bereavement services to help address the difficulties Mr R faces after the loss of his wife. This has the potential to make a real and lasting impact on his long-term wellbeing.
- A referral to the local community mental health team for an intervention from a community psychiatric nurse and support worker. This referral will concentrate on the specific and identified issues associated with Mr R’s prolonged low mood following the death of his wife and will ensure that the care he receives from mental health services allows him to achieve his desired outcomes.
- Links with the independent living team to consider any aids or adaptations to Mr R’s home that could be made to improve access and his overall wellbeing.
- Undertaking a benefits assessment to ensure that Mr R is receiving all the support he is entitled to.
- What else did you think about?
- What else might apply/be relevant in your authority?
- What might you do differently?
- What have you learned?