Social Care (Self-directed Support) (Scotland) Act 2013: statutory guidance

Section 6: Eligibility, assessment and review

Eligibility criteria are used by local authorities to deploy resources in a transparent way that ensures that those resources are targeted to adults in greatest need. There is no national eligibility framework in place for children's services, which therefore assess need and provide support in a different way, with threshold criteria set by individual authorities.

A national framework for eligibility criteria for social care for older people was agreed by the Scottish Government and COSLA in 2009.^[98] This framework is used by local authorities to determine whether an adult assessed as needing social care support requires resources to be provided in order to meet those needs. The criteria are not required by statute, but most local authorities have used them as a method of allocating resources.

As part of the Joint Statement of Intent, Scottish Government and COSLA both recognised the need to ensure that the use of eligibility criteria adequately enables an early intervention and preventative approach to social care, and subsequently agreed to overhaul the current mechanism of eligibility criteria. This work continues to develop.

Please note that different rules apply to eligibility criteria for support provided to unpaid carers under the Carers Act 2016.^[99]

Current approaches to eligibility criteria

The current guidance on national standard eligibility criteria applying to adults places risks into four bands: critical, substantial, medium and low.

In relation to adults the authority may choose to apply local eligibility criteria in order to determine whether the person's needs call for the provision of services (i.e. to determine if the person's needs are eligible needs).^[100] However it is currently a matter for the authority to determine the detail of its approach, and the above risk bands should therefore not be understood as being mandatory.

Authorities should note that, the eligibility guidance states as a key principle, that 'the prioritisation process should target resources towards responding to adults at critical or substantial risk as regards independent living or wellbeing, whilst not excluding consideration of the benefits of preventative support and less intensive care services for people at less risk'.

The authority's approach to making decisions about a person's access to support – whether it applies formal eligibility criteria or not – plays a key role in the subsequent assessment, the provision of choice under the 2013 Act and the provision of support following that choice.

The authority should therefore develop its policy in line with the statutory principles provided by the 2013 Act and articulated within this Guidance.

In particular, it should consider the principles of involvement (of supported people and carers), informed choice and collaboration by taking a human rights-based approach to enabling and managing risks, and by protecting the right to dignity and participation in community life.

The authority should also take steps to involve supported people, carers and third sector organisations in the development of its policies and it should do so from the outset. It should publish its eligibility criteria framework in accessible formats and in a way that supports transparency.

See also the SDS Framework of Standards (Standard 2: Early Help and Support; 6: Risk Enablement and Standard 11: Consistency of Practice), which emphasises the importance of a positive and preventative approach that shifts focus from crisis intervention towards what matters to the person and their quality of life.

Guidance on assessment for the supported person

As set out in the section on duties, Section 1 and 2 of the 2013 Act provide a legislative framework for the authority's approach to assessment of needs for adults, children^[101] and carers and the authority's social work function must have regard to these principles in conducting the assessment. These assessments are typically carried out by social workers and, in some circumstances, other practitioners delivering social services.

Human rights approach to assessment

Social care, and the provision of choice as part of the assessment and support planning process, is a way of supporting the realisation of human rights. SDS can enable and empower the supported person to have choice and control over their own life.

The Scottish Government supports the use of the PANEL and FAIR models^[102] in ensuring that decision-making processes are at the forefront of assessments for social care provision and the further provision of support following that assessment.

Social workers, when carrying out an assessment, should consider the whole experience of the supported person. The assessment should consider the needs and the outcomes of the person, approaching decision-making in a way that manages risks in an enabling and positive way. In addition, it should consider human rights as part of its development of the relevant strategies, protocols, procedures and guidance associated with social care provision

Under Sections 6 and 17 of the 2013 Act, the authority must take reasonable steps to help the supported person to play a full part in their assessment, to understand the various choices available to them and to decide how and what ways they would like to arrange their support.

The relevant provisions within the 2013 Act are not intended to impose assistance on the supported person. Neither are they intended to create the opportunity to develop alternative proxy decision-making powers.

The initial purpose of the assessment is to identify the person's needs with a view to determining how the person can best be supported and whether the authority has an obligation to meet those needs.

The authority should view re-ablement as a part of the assessment process – an early intervention which may or may not lead to more stable forms of on-going support. However, where it is decided that the supported person will be provided with that stable on-going support, the authority must offer the person the various choices set out in the 2013 Act.

In developing its guidance, policies and procedures on assessment, the authority should recognise that policy and practice needs to move away from service-led assessment and support and towards an approach that supports the person to take control, prioritising outcomes-focused assessment as part of a continuum of early help and support. See also the SDS Framework of Standards (Standard 2 Early Help and Support).

This means more control and freedom being retained by the person, who is treated as a partner in identifying and achieving their outcomes rather than as a passive service recipient.

Assessment, support, planning and review systems and processes should be personalised, recognising people's strengths, assets and existing community supports, and result in agreed personal outcomes. See the SDS Framework of Standards 3: Strength and asset-based approach, for more information on this.

Supported people also have the right to query and challenge decisions throughout their assessment, support planning and review processes, including their budget allocations.

See the SDS Framework of Standards: Standard 5 - Accountability and the section on support planning.

Guidance on identification of carers' needs

All carers have the right to have their own personal outcomes and support needs identified via an adult carer support plan or young carer statement under the Carers (Scotland) Act 2016.

An effective plan or statement rests on an open and honest conversation between the practitioner and the carer, with a strong focus on personal outcomes.

Other parts of this section of the Guidance provide general guidance on how social workers should conduct assessments. Much of this is equally relevant to adult carer support plans and young carer statements.

Preventative support is generally more cost-effective than support provided in a crisis or emergency, as well as being more coherent with a rights-based approach to supporting people and their carers. In some cases, the carer may not wish to have a support plan. It is still important that the authority provides the carer with information on local support.

Guidance on Support planning

The support plan is a key document which is a personalised record of what matters to the supported person, including their personal outcomes and how these will be met. The person's strengths, assets, human rights, existing community supports and funded social care supports are recognised and included in their support plan.

The social worker's assessment and the identification of resources are all part of the same process, which starts with the good conversation and ends in a budgeted support plan and the offer of the four SDS options.

A supported person may choose to have an unpaid carer, family member, friend or advocate attend the assessment with them, even if they are not directly involved in providing care. Local authorities have a legal duty to take into account the views of the carer when assessing the needs of the person being cared for, as far as that is reasonable and practical. Unpaid carers should also have their needs acknowledged within their own personal assessment and support plan or young carer statement, if they want one.

The support plan should be developed in line with the statutory principles in Section 1 of the 2013 Act and in line with this Guidance. The plan should cover certain key aspects such as the personal outcomes which help to shape the plan, the resources (both financial and non-financial) which will help to meet those outcomes, the choices available to the supported person to arrange their support and all associated information.

There are different requirements for an adult carer support plan or young carer statement, but the principles are the same: there should remain a requirement to demonstrate a clear link between items and services purchased and the personal outcomes identified and agreed in an individual's support plan, adult carer support plan, or young carer statement.

The support plan may be developed in any type of format that the supported person understands, but it should be framed in such a way that it can be used as a living document. It should focus on what the person wants to achieve with the right help, rather than simply putting arrangements in place to stop things from getting any worse.

It should be capable of acting as a reference point for the supported person, the authority, the provider and, subject to the person's wishes, other important individuals in the person's life including advocacy workers. The parties involved should be able to return to the plan, review the plan, add to the plan or make changes over time.^[103]

See the SDS Framework of Standards: Standard 3: A Strengths and Assets Based Approach, and Standard 4: Meaningful and Measurable Recording Practices.

Guidance on Review

A significant change to a supported person's needs or a request for a further assessment should prompt a review of the person's needs. In addition, the supported person and/or the authority can also request a review of the choice of options under the 2013 Act. There is separate guidance on the statutory period for review of care plans for looked-after children.^[104]

The approach taken at review should be similar to the approach taken at initial assessment. In other words, it should be conducted in line with the principles of collaboration, informed choice and involvement, with adequate time given for the supported person to prepare for the review.

As with the initial assessment carried out by the social worker, the review should focus on personal outcomes with a view to meeting assessed needs. It should involve a period of reflection on whether the choices made and the support provided is helping to meet the outcomes and needs of the supported person. The review should also consider whether the needs and outcomes have changed in the intervening period. This may require some adjustments to the support plan.

The authority should aim to conduct reviews within a maximum period of 12 months. It should consider the review as a means by which to prevent crisis or to respond and adapt to the supported person's life.

If the supported person requires additional support, the relevant authority should ensure that the person is given the option of having support from an independent supporter or advocate. The authority may also wish to speak to family members and carers to satisfy itself that the person is not experiencing any difficulties with arrangements. Where an attorney, guardian or parent is in place the authority will also wish to discuss arrangements with them.

Review of the supported person's options under the 2013 Act

The 2013 Act imposes additional and distinct review duties in relation to the narrower question of how the supported person's support is arranged. In practice the two types of review – a review of the person's 2013 Act options and a review of the person's wider needs and outcomes – will tend to go hand in hand.

However, a review of a person's choice under the 2013 Act can take place without a detailed review of needs. The person may decide that they do not wish to continue with the option that they have chosen.

Alternatively, the person may decide that arranged services are not working out the way that they had thought and would like to reconsider the other options. The authority should view this as part of the on-going nature of assessment, and it should support the relevant practitioners to work with the supported person to consider what adjustments they would like to make.

The authority should ensure that an initial review date is set when the supported person and the social worker first agree the assessment and support plan. The supported person should be made aware that they can request a review sooner if their circumstances change.

Trust-based relationships and good conversations between practitioners and people are at the heart of assessment, support planning and review practice and processes.