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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safe systems, pathways and transitions

We statement

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services.

What people expect

When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place.

I feel safe and supported to understand and manage any risks.

1. Introduction

Many of the local authority’s care and support responsibilities apply to the entire local population (see for example Information and Advice or Reducing, Preventing or Delaying Needs chapters). However, the local authority is only required to meet the care and support needs of those adults who are ‘ordinarily resident’ its area (or are present there but have no settled residence, see Section 7, Persons with no Settled Residence).

Ordinary residence is used to decide which local authority is responsible for meeting the care and support needs of adults, and their carers. Whether the person is ordinarily resident in the local authority area is a key test in determining where responsibility lies for the funding and provision of care and support.

This chapter should also be read with the Care and Support Statutory Guidance, in particular the Annexes, which provide further detailed guidance on specific situations and circumstances which may arise, and where the question of ordinary residence may be unclear.

2. Statutory Provisions of the Care Act 2014 Relevant to Ordinary Residence

The statutory provisions of the Care Act relevant to ordinary residence are:

  • Sections 9 and 10 – a duty to assess;
  • Section 13 (1) eligibility criteria;
  • Section 13 (3) and (4) ordinary residence.

Under Section 18(1)(a) of the Care Act 2014, the local authority has a duty to meet an adult’s eligible needs for care and support if they are ordinarily resident in the authority’s area or is present in its area but of no settled residence.

There is also a power for local authorities where no duty exists under the Care Act; Section 19(1) provides that a local authority, having carried out a needs assessment and, if required to do so a financial assessment, may meet an adult’s needs for care and support, if the adult is ordinarily resident in the authority’s area or is present in its area but of no settled residence, where the local authority have determined no duty under section 18.

3. How does Ordinary Residence affect the Provision of Care and Support?

Ordinary residence is one of the key tests which must be met as part of establishing if the local authority is required to meet an adult’s eligible needs for care and support. It is therefore crucial that the local authority establishes, at the appropriate time, whether an adult is ordinarily resident in their area, and the extent and nature of such duties that may arise.

The process of determining ordinary residence must not delay the process of meeting needs. In cases where ordinary residence is not certain, the local authority where that adult is physically present should meet their needs while the question of ordinary residence is being resolved. This is particularly important where there may be a dispute between two or more local authorities. If an adult has urgent needs for care and support these should be met, before completion of an assessment, regardless of the adult’s ordinary residence.

3.1 Adults and carers

The test for ordinary residence, applies differently in relation to adults and carers. For adults with care and support needs, the local authority in which the adult is ordinarily resident is responsible for meeting their eligible needs. For carers, however, the responsible local authority will be the one where the adult for whom they provide care is ordinarily resident. To establish responsibility for the provision of care and support for carers, the local authority will need to establish the ordinary residence of the adult the carer is supporting.

Where a carer provides care for more than one person in different local authority areas, the authorities should consider how best to cooperate and share the provision of support. For example, where services or interventions directly relate to the caring responsibilities for one individual (for example, equipment installed in the carer’s home for use by one adult), then it is straightforward to identify which local authority is responsible. However, where the same piece of equipment is used by the carer with more than one adult, then the local authorities concerned should agree how to arrange the package. There might be an agreement to jointly fund the support for the carer, or the authorities may agree that one takes overall responsibility for certain aspects. For example, one authority might lead on reviews because it is geographically closer to the carer’s home.

4. How to Determine Ordinary Residence

The local authority’s responsibility for meeting a person’s eligible needs is based on the concept of ordinary residence. There is, however, no definition of ordinary residence in the Care Act, so the term should be given its ordinary and natural meaning.

In most cases, establishing the person’s ordinary residence is a straightforward matter. However, there will be circumstances in which ordinary residence is not clear cut, for example when people spend their time in more than one area or move between areas.

Factors such as time, intention and continuity (each of which may be given different weight in individual cases) should be considered. The courts have considered the meaning of ordinary residence, and the leading case is that of Shah v London Borough of Barnet (1983) 2 AC 309. In the Shah case, Lord Scarman stated that:

unless … it can be shown that the statutory framework or the legal context in which the words are used requires a different meaning I unhesitatingly subscribe to the view that ordinarily resident refers to a man’s abode in a particular place or country which he has adopted voluntarily and for settled purposes as part of the regular order of his life for the time being, whether of short or long duration.

Local authorities must have regard to this case when determining the ordinary residence of adults who have the mental capacity to make decisions about where they wish to live, and should apply the principle that ordinary residence is the place the person has voluntarily adopted for a settled purpose, whether that be for a short or long duration.

Ordinary residence can be acquired as soon as the person moves to an area, if their move is voluntary and for settled purposes, irrespective of whether they own, or have an interest in a property in another local authority area.

There is no minimum period in which a person must be living in a particular place for them to be considered ordinarily resident there, it is the nature and quality of their connection with the new place which is important. Ordinary residence can be acquired as soon as a person moves into an area.

In certain situations, a person’s ordinary residence can be in a different area to that in which they are  physically present (see Section 6, Looked after Children Transitioning to Adult Social Care ServicesSection 7, Persons with no Settled Residence and Section 8, Ordinary Residence when Arranging Care and Support in another Area).

Temporary absences – such as holidays, hospital visits, and term times at university do not break the continuity of ordinary residence. People may have more than one home, they may own or have an interest in another property in another area. See Section 11.1, Temporary absences and Section 11.2, People with more than one home.

5. Where a Person Lacks Mental Capacity to Decide where to Live

See also Mental Capacity and Code of Practice chapter

All issues relating to mental capacity should be decided with reference to the Mental Capacity Act 2005 (MCA). Under the Act, it must always be assumed that adults have capacity to make their own decisions, including decisions relating to their accommodation and care, unless it is established to the contrary.

The test for mental capacity is specific to each decision at the time it needs to be made, and a person may have mental capacity to make some decisions but not others.  It is not necessary for a person to understand local authority funding arrangements for them to have capacity to decide where they want to live.

If it can be shown that a person lacks mental capacity to make a particular decision, the MCA makes clear how decisions should be made for that them. For example, if a person lacks mental capacity to decide where to live, a best interests decision about their accommodation should be made. Any actions or decision made for a person who lacks mental capacity (including decisions relating to where they live), must be taken or made in their best interests.

Where an adult lacks mental capacity to decide where to live, and their place of ordinary residence needs to be determined, the test in the Shah case (see Section 4) is not directly applicable, as it requires the voluntary adoption of a place.

However, in the Cornwall case (R (on the application of Cornwall Council) v Secretary of State [2015] UKSC 46) the Supreme Court made it clear that to establish the ordinary residence of adults who lack mental capacity, local authorities should adopt the Shah approach and have no regard for the fact that the adult, by reason of their lack of capacity, does not live there voluntarily.

In such cases, the local authority should consider the following when establishing whether the purpose of the residence has a sufficient degree of continuity to be described as settled, whether for a long or short duration:

  • the place of the person’s physical presence;
  • their purpose for living there;
  • the person’s connection with the area;
  • their duration of residence there;
  • the person’s views, wishes and feelings (as far as these are ascertainable and relevant).

6. Looked after Children Transitioning to Adult Social Care Services

In the Cornwall judgement, the Supreme Court held that a looked after child who had been placed by local authority B with foster carers who live in local authority A, continued to be ordinarily resident in local authority B when they reached 18 years for the purposes of deeming provisions in the 1948 National Assistance Act (NA Act). This legislation predated the Care Act statutory framework around ordinary residence; the provisions are set out in sections 21; 24;29; 32(3)-(5) of NA Act and supporting directions LAC (93) 10 Approvals and Directions for Arrangements Ordinary Residence Disputes NA Act1948 Directions 1948. The Supreme Court set out that the underlying purpose behind deeming provisions in both children’s and adult legislation is that: ‘an authority should not be able to export its responsibility for providing the necessary accommodation by exporting the person who is in need of it.’

This means that any person who moves from accommodation provided under the Children Act 1989 to accommodation provided under the NA Act or the Care Act, remains ordinarily resident in the local authority in which they were ordinarily resident under the Children Act. This includes a situation where a child has been placed out of area under the Children Act as a looked after child, and at the age of 18 requires residential accommodation under the NA Act or the Care Act as well as support as a care leaver under the Children Act.

The types of accommodation to which these adult deeming provisions apply is:

  • ‘specified accommodation’ (under the Care Act) in circumstances where the adult’s needs can be met only if they are living in accommodation of a specified type. The types currently specified are: care homes, shared lives scheme accommodation and supported living accommodation;
  • NHS accommodation (under the Care Act);
  • residential accommodation (under the NA Act);
  • NHS accommodation (under the NA Act).

6.1 Accommodation to which deeming provisions do not apply.

In cases where the deeming provisions do not apply, although the provisions of the Children Act normally no longer apply once a young person reaches the age of 18, local authorities should start from a presumption that for the purposes of the NA Act or the Care Act, the young person remains ordinarily resident in the local authority in which they were ordinarily resident under the Children Act.

However, this is only a starting point, and if the young person moves to other than specified accommodation and has mental capacity to decide where to live, then the Shah test can be applied to determine ordinary residence.

7. Persons of No Settled Residence

Where there are questions in relation to a person’s ordinary residence, it is usually possible for the local authority to decide that the person has resided in the area long enough or has sufficiently firm intentions in relation to that place, to have acquired an ordinary residence there. Therefore, it should only be in rare circumstances that the local authority concludes that someone is of no settled residence. For example, if a person has clearly and intentionally left their previous residence and moved to stay elsewhere on a temporary basis during which time their circumstances change, the local authority may conclude the person to be of no settled residence.

The Care Act makes clear that local authorities have a duty to meet the eligible needs of people who are present in its area but of no settled residence.  This means, people who have no settled residence, but are physically present in the local authority area, should be treated in the same way as those who are ordinarily resident.

The local authority may conclude that a person arriving from abroad is of no settled residence, including those people who are returning to England after a period of residing abroad and who have given up their previous home in this country. See also Annex H: Ordinary Residence, British citizens resuming permanent residence in England after a period abroad.

8. Ordinary Residence when Arranging Care and Support in another Area

There may be some cases where the local authority considers that the person’s care and support needs can only be met if they are living in a specified type of accommodation. This could be in a care home, or other kinds of provision. If the specified accommodation in which the care is provided is located in the area of another authority, it is important that there is no question as to which local authority is responsible for meeting the person’s needs.

The Care Act and the Care and Support (Ordinary Residence) (Specified Accommodation) Regulations set out what should happen in these cases; a  person placed ‘out of area’ is deemed to continue to be ordinarily resident in the area of the first authority, and does not acquire ordinary residence in the ‘host’ or second authority. The local authority which arranges the care in the specified accommodation retains responsibility for meeting the person’s needs.

The regulations specify three types of specified accommodation to which this provision applies:

1) nursing homes / care homes: accommodation which includes either nursing care or personal care

2) supported living / extra care housing this is either:

  • specialist or adapted accommodation: this means accommodation which includes features that have been built in or changed to in order to meet the needs of adults with care and support needs. This may include safety systems and features which enable accessibility and navigation around the accommodation and minimise the risk of harm, as appropriate to the individual;
  • accommodation which is intended for occupation by adults with care and support needs, in which personal care is also available, usually from a different provider.

3) shared lives schemes: accommodation which is provided together with care and support for an adult by a shared lives carer, approved by the scheme, in the shared lives carer’s home under the terms of an agreement between the adult, the carer and any local authority responsible for making the arrangement. The shared lives carer will normally be providing personal care, but they will not need to provide it in every case.

Where an adult’s care and support needs can only be met by living in one of these specified types of accommodation, and the accommodation arranged is in another local authority area, then the principle of ‘deeming’ ordinary residence applies. This means that the adult is treated as remaining ordinarily resident in the area where they were resident immediately before the local authority began to provide or arrange care and support in any type of specified accommodation.

8.1 Deeming provisions for specified accommodation post Care Act 2014

Section 39 (1) Where an adult has needs for care and support which can be met only if the adult is living in accommodation of a type specified in regulations, and the adult is living in accommodation in England of a type so specified, the adult is to be treated for the purposes of this Part as ordinarily resident:

  1. in the area in which they were ordinarily resident immediately before they began to live in accommodation of a type specified in the regulations, or
  2. if they were of no settled residence immediately before they began to live in accommodation of a type so specified, in the area in which they were present at that time.

This means that that the local authority initially providing that care and support will remain responsible for meeting the person’s eligible needs, and responsibility does not transfer to the authority in whose area the accommodation is physically located. However, in circumstances where a person with mental capacity moves to accommodation in a different area of their own choice without the local authority making the arrangements, they would be likely to acquire ordinary residence in the area of the authority where the new accommodation is situated.

The deeming rule does not apply where a person has chosen to arrange their own care in a type of specified accommodation in another area, and then later asks for local authority support.

Decisions about whether needs are ‘able to be met’ or of a kind that ‘can be met only’ through a specified type of accommodation should be made with the adult as part of the assessment and care and support planning processes. Where the outcome of the care planning process is that the adult’s needs should be met in one of the specified types of accommodation, this should be clearly recorded in the care and support plan. The local authority is not required to demonstrate that needs cannot be met by any other type of support. The local authority must have assessed those needs in order to make such a decision – the ‘deeming’ principle therefore does not apply to cases where a person arranges their own accommodation, and the local authority does not meet their needs.

The first local authority’s responsibility will continue in this way for as long as the person’s eligible needs are being met by the specified type of accommodation. This will include situations where the person moves between care and support provided in different specified types of accommodation in another (or more than one other) area. As an example, if the first authority arranges care and support in one type of accommodation in the area of the second authority (for example in a shared lives scheme or a care home) and the person’s needs change, leading to them moving into another type of accommodation in the second authority’s area (for example a supported living scheme), the person would continue to be ordinarily resident in the area of the first authority, and that authority would remain responsible for the care and support. However, should the person no longer require the care and support to be provided in a specified type of accommodation, then it is likely that their ordinary residence will change, and the first local authority will no longer retain responsibility.

As part of the care and support planning process, where the local authority is arranging a person’s accommodation, they have a right to make a choice about their preferred accommodation (see Charging and Financial Assessment chapter and Annex A: Choice of Accommodation and Additional Payments). This right allows the adult to make a choice about a particular individual provider, including where that provider is located. Provided that certain conditions are met, the local authority must arrange for the preferred accommodation.

The ordinary residence rules described above will apply when the adult’s preferred accommodation is in the area of another local authority. The ordinary residence ‘deeming’ principle applies most commonly where the local authority provides or arranges care and support in the accommodation directly.

8.2 Direct payments

The principle also applies where the adult takes a direct payment and arranges their own care (since the local authority is still meeting their needs).

In such cases, the adult has choice over how their needs are met and arranges their own care and support. If the care and support plan stipulates that the adult’s needs can only be met if they are living in one of the specified types of accommodation and the adult chooses to arrange that accommodation in the area of a local authority which is not the one making the direct payments then the same principle applies; the local authority which is meeting the person’s care and support needs by making direct payments retains responsibility.

However, if the person chooses accommodation that is outside what was specified in the care and support plan or of a type of accommodation not specified in the regulations, then the ‘deeming’ principle does not apply.

If a local authority arranges care and support in a type of accommodation in another area or becomes aware that an adult receiving a direct payment has done so themselves, the authority should inform the host authority, to ensure the host authority is aware that the adult is living in their area. The first authority should ensure that satisfactory arrangements are made before the accommodation begins for any necessary support services which are provided locally, such as day care, and that clear agreements are in place for funding all aspects of the person’s care and support.

In practice, the first local authority may enter into agreements to allow the authority where the accommodation is located to carry out functions on its behalf. This may particularly be the case where the accommodation is located some distance away, and some functions can be performed more effectively locally. For example, a carer may live in a different authority from the person they are caring for. Local authorities may make arrangements to reimburse to each other for any costs which occurred through such agreements.

There may be occasions where a provider chooses to change the type of care which it provides, for instance to de-register a property as a care home and to redesign the service as a supported living scheme. Where the adult remains living at the same property, and their needs continue to be met by the new service, then ordinary residence should not be affected, and the duty to meet needs will remain with the first authority. This will occur even if the person temporarily moves to another address whilst any changes to the property occur.

9. NHS Accommodation

When an adult goes into hospital, or other NHS accommodation, there may be questions over where they are ordinarily resident, especially if they are subsequently discharged into a different local authority area. For this reason, the Care Act makes clear what should happen in these circumstances.

Section 39(5) applies to NHS accommodation. It ensures that an NHS stay i.e. accommodation (as defined in s 39(6)) in England, Scotland, Wales or Northern Ireland will not affect a person’s ordinary residence. This means that their care and support must continue to be provided by the local authority in whose area they were ordinarily resident before their admission to NHS accommodation.

An adult for whom NHS accommodation is provided is to be treated as being ordinarily resident in the local authority where they were ordinarily resident before the NHS accommodation was provided. This means that where an adult, for example, goes into hospital, they are treated as ordinarily resident in the area where they were living before, they went into hospital. This applies regardless of the length of stay in the hospital and means that responsibility for the adult’s care and support does not transfer to the area of the hospital, if this is different from the area in which the person was previously ordinarily resident.

Where a person who is ordinarily resident in England goes into hospital in Scotland, Wales or Northern Ireland, their ordinary residence will remain in England (in the local authority in which they ordinarily resided before going into hospital) for the purposes of responsibility for the adult’s care and support.

10. Mental Health Aftercare

See Section 117 Aftercare chapter

Under section 117 of the Mental Health Act 1983 (MHA), local authorities together with integrated care boards have a joint duty to arrange the provision of mental health aftercare services for people who have been detained in hospital for treatment under certain sections of the MHA. Aftercare services must have both the purposes of ‘meeting a need arising from or related to the person’s mental disorder’ and ‘reducing the risk of a deterioration of the person’s mental condition and, accordingly, reducing the risk of the person requiring admission to a hospital again for treatment for mental disorder.’

In brief, aftercare services have a dual purpose, firstly to meet a need arising from or related to the person’s mental disorder; and secondly to reduce the risk of the person’s mental condition deteriorating. In so doing, this reduces the risk of the person being readmitted to a hospital for further treatment of a mental disorder.

The range of services which can be provided is broad. Under section 117, the duty on local authorities to commission or provide mental health aftercare rests with the local authority for the area in which the person concerned was ordinarily resident immediately before they were detained under the MHA, even if the person becomes ordinarily resident in another area after leaving hospital.

Section 75 of the Care Act 2014 amends section 117 of the MHA to provide that the local authority responsible for providing or commissioning aftercare services is the local authority in which the person was ordinarily resident immediately before they were detained.

Section 39(4) of the Care Act provides that an adult who is being provided with accommodation under section 117 of the MHA will be treated for the purposes of Part 1 of the Care Act 2014 as ordinarily resident in the area of the local authority in England or Wales which is under a duty to provide the adult with services under section 117 MHA.

By section 117A, the Secretary of State is empowered to make rby a person for particular accommodation, with the person paying a top-up fee if the preferred accommodation is more than the authority’s usual cost. In discharging the s 117 duty, the local authority is permitted to provide the person with direct payments.

However, if the person is subsequently re-detained for treatment under the MHA, responsibility for the new aftercare services under section 117 will lie with the local authority in whose area the adult was ordinarily resident immediately before their most recent detention.

Case Law

(R (Worcestershire County Council) v Secretary of State for Health and Social Care [2023] UKSC 31)

The Supreme Court overturned the Court of Appeal findings that first and originating local authority Worcestershire County Council had a duty to provide aftercare services rather than the second or host local authority Swindon Borough Council for an adult who had been re-detained in Swindon. The Supreme Court determined that after the person’s second discharge, Swindon had a duty to provide aftercare services, not Worcestershire. The case turned on whether the person, ‘JG’, had been “ordinarily resident…immediately before being detained” for the purposes of s 117(3)(a) of the MHA.

Worcestershire successfully argued that Swindon owed a duty to provide aftercare services, at the time of the second discharge, because the person had been ordinarily resident in Swindon immediately before the second detention. It was concluded where there had been more than one period of detention, the words ‘immediately before being detained’ must refer to the most recent period of detention. The Supreme Court found that although the person lacked mental capacity to decide where to live, the decision to live in Swindon was still made voluntarily ‘because it was the result of a choice made by those with the power to make decisions on their behalf.’ The person’s residence in Swindon was also adopted for settled purposes, therefore, they were ordinarily resident in Swindon before their second detention on its plain meaning.

11. Other Common Situations

11.1 Temporary absences

If ordinary residence is established in a particular place, this should not be affected by the adult taking a temporary absence from the area. The courts have held that temporary or accidental absences, including for example holidays or hospital visits in another area, do not break the continuity of ordinary residence, and local authorities should take this into account.

The fact that the adult may be temporarily away from the local authority in which they are ordinarily resident, does not preclude them from receiving any type of care and support from another local authority if they become in urgent need (see Annex H: Ordinary Residence, Persons in Urgent Need). Local authorities have powers to meet the needs of people who are known to be ordinarily resident in another area, at their discretion, and subject to them informing the authority where the person is ordinarily resident.

Urgent needs are covered under Sections 19(3) and (4) of the Care Act which provide that a local authority may meet an adult’s needs for care and support which appear to be urgent (regardless of whether the adult is ordinarily resident in its area). A local authority may meet an adult’s needs under subsection (3) where, for example, the adult is terminally ill.

11.2 People with more than one home

Although in general terms it may be possible for a person to have more than one ordinary residence (for example, a person who divides their time equally between two homes), this is not possible for the purposes of the Care Act. The purpose of the ordinary residence test in the Care Act is to determine which single local authority has responsibility for meeting the adult’s eligible needs, and this purpose would be defeated if a person could have more than one ordinary residence.

If a person appears genuinely to divide their time equally between two homes, it is necessary to establish (from all the information available) to which of the two homes the person has the stronger link. Once this has been established, it is the responsibility of the local authority in whose area the person is ordinarily resident, to provide or arrange care and support to meet their needs during the times when they are temporarily away at their second home.

Further examples are set out in Annex H: Ordinary Residence, and used for references when there is  uncertainty around an adult’s ordinary residence.

11.3 People who arrange and fund their own care.

People who self-fund and arrange their own care (self-funders) may choose to move to another area and then find that their funds have depleted. Self-funders can apply to the local authority area that they have moved to in order to have their needs assessed. If it is decided that they have eligible needs for care and support, the person’s ordinary residence will be in the place where they moved to and not the first authority (see Annex H Ordinary Residence, People who have Sufficient Funds to pay for their own Care and Accommodation).

The rule of thumb supported by the Care and Support Statutory Guidance is that self-funders who arrange their own care and who choose to move to another area for that care but find their funds depleted, are likely to take the ordinary residence in the new area which they voluntarily choose to move.

11.3.1 Self-funders and local authority arrangements

A person who seeks the help of the local authority under section 18(3) of the Care Act i.e. a person who has sufficient financial means to pay for their own care, but who has eligible needs, can ask the local authority to meet their needs (for example, where they lack the skill or confidence to arrange their own care). In such cases, where a person who pays for their own accommodation but the local authority has arranged it and provided a care and support plan, then the deeming provisions will apply. That person will keep the ordinary residence of the arranging local authority (see Annex H Ordinary Residence, People who have Sufficient Funds to pay for their own Care and Accommodation).

12. Resolving Ordinary Residence Disputes

In most cases, determining ordinary residence should be straightforward. However, there will be occasions where it is more complicated to establish the adult’s ordinary residence.

Please note: Where the local authorities concerned agree about a person’s ordinary residence, but the adult is unhappy with the decision, they would have to pursue this with the authorities concerned and cannot apply to the Secretary of State or an appointed person for a determination.

Where two or more local authorities are in dispute about an adult’s ordinary residence, they can apply for a determination to the Secretary of State or appointed person.

The Care and Support (Disputes Between Local Authorities) Regulations 2014 set out the procedures to be followed when disputes arise between local authorities regarding a person’s ordinary residence. When a dispute between two or more local authorities occurs, local authorities must take all reasonable steps to resolve the dispute between themselves.

It is critical that the adult does not go without the care they need, during any dispute.

The local authority that is meeting the needs of the adult or the carer on the date that the dispute arises, must continue to do so until the dispute is resolved.

If no local authority is currently meeting the person’s needs, then the local authority where the person is living or is physically present must accept responsibility until the dispute is resolved.

The local authority which has accepted provisional responsibility is referred to as the ‘the lead authority’.

The lead authority must identify all the authorities involved in the dispute and co-ordinate an ongoing discussion between all parties involved. The parties involved must provide the lead authority with contact details of a named person to contact regarding the dispute. The lead authority must be responsible for the co-ordination of any information that may be relevant to the dispute and keep all parties informed of any developments. The lead authority must also keep the adult, or their carer if appropriate, fully informed of dispute and progress regarding any resolution.

Applications for determinations by the Secretary of State or appointed person must be submitted by the lead authority before or by the end of a period of four months from the date when the dispute arose. The provisional acceptance of responsibility by the lead authority will not influence any determination made by the Secretary of State.

12.1 Process for seeking a determination

The regulations place a duty on the parties involved in the dispute to provide specified information to the Secretary of State or appointed person. The lead local authority must make a request in writing to the Secretary of State or appointed person, together with a statement of facts and other documentation. All previous correspondence between the local authorities must also be sent in when seeking a determination. The statement of facts must include certain specified information as set out in the regulations. Local authorities should, wherever possible, produce a statement of facts; that is jointly agreed. If the parties cannot agree on some of the information, the statement should make clear what information the parties agree on and what is in dispute. Local authorities should ensure that all documents sent to the Secretary of State or appointed person are in the required format.

Once the Secretary of State – or appointed person – is satisfied that the parties have had adequate opportunity to make representations, will make a determination. Any local authority failing to have due regard to a determination by the Secretary of State or appointed person, would be at risk of a legal challenge by the adult or their representative or the other local authorities to the dispute.

Local authorities should seek legal advice before making an application for a determination, although they are not required to do so. If legal advice is sought, local authorities may, in addition to the required documentation, provide a separate legal submission. Where legal submissions are included, these should be exchanged between the local authorities in dispute and evidence of this should be supplied to the Secretary of State.

If the local authorities involved in the dispute reach an agreement whilst the Secretary of State is considering the determination, they should notify the Department of Health and Social Care. Both parties must confirm that the dispute has been resolved after which the determination will be closed.

If a determination by the Secretary of State or an appointed person subsequently finds another local authority to be the authority responsible for funding of that person under the regulations and rules of ordinary residence the lead local authority may recover costs from the authority which should have been providing the relevant care and support.

The Department of Health and Social Care makes available anonymised copies of determinations it has made. Each case must be considered on its  own particular facts, but past determinations may provide local authorities with useful guidance when faced with similar circumstances.

12.2 Reconsidering a determination

If further facts come to light after a determination has been made, local authorities may consider it appropriate for the Secretary of State or appointed person to reconsider the original determination. As a consequence of this, a different determination may be substituted on account of any redetermination. This may mean that payments made from one local authority to another, as a consequence of the first determination will need to be repaid.

Any review of the determination must begin within three months of the date of the original determination. This is needed to ensure clarity and fairness in the process and minimise the amount of time taken for determinations to be made.

13. Financial Adjustments between Local Authorities

Sometimes a local authority will have been paying for a person’s care and support, but it later becomes apparent (for example as a result of an ordinary residence determination) that the person is in fact ordinarily resident elsewhere. In these circumstances, the local authority that has been paying for that person’s care may reclaim the costs from the local authority where the person was deemed to be ordinarily resident.

This can occur in cases where it is not clear initially where the person is ordinarily resident. To ensure that the adult does not experience any delay to their care due to uncertainty over their ordinary residence, local authorities should be able to recover any losses due to initial errors or delays in deciding where a person is ordinarily resident. This also extends to costs spent supporting the carer of the person whose ordinary residence was in dispute. It should be noted that only the costs of care can be recovered, not the local authority’s legal or social work costs.

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Knowsley Advocacy Hub Professional Leaflet

Knowsley Advocacy Hub Referral Form

The above information for the Knowsley Advocacy Hub was added to this portal in November 2023.

Further Reading

Relevant chapters

Independent Advocacy

Independent Mental Capacity Advocate Service

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This chapter was added to the Portal in September 2023.

1. Introduction – What is Culturally Appropriate Care?

Culturally appropriate care (also called ‘culturally competent care’) is about understanding and being sensitive to people’s cultural identity or heritage, especially when arranging or providing care and support. It involves staff working in a person-centred way (see Personalisation chapter), to recognise, consider and respond sensitively to a person’s beliefs or conventions.

Cultural identity or heritage covers different things. For example, it might be based on a person’s ethnicity, nationality or religion, or it might be about their sexuality or gender identity. Lesbian, gay, bisexual and transgender people have their own cultures, as do Deaf people who use British Sign Language. However, it is important to note that people’s cultural identity or heritage may include a number of different cultures; they may identify with more than one.

In order to provide culturally appropriate care, staff must not provide standardised care – which involves giving the same service to everyone – instead they should always adapt their practice and interventions in line with the cultural values of the adult.

2. Why is Culturally Appropriate Care Important?

Care and support which reflects a person’s culture must be at the heart of person-centred care that is delivered by social care staff.

Providing culturally appropriate care will better meet people’s needs and is therefore more likely to achieve positive outcomes for adults and their families; their physical health and emotional wellbeing will also benefit.

When adults are not provided with care and support which is culturally appropriate, they can:

  • feel marginalised and discriminated against;
  • experience low self esteem and low self confidence;
  • have restricted opportunities;
  • feel stressed and anxious; and
  • experience a loss of rights.

Providing care which recognises and responds to cultural differences also helps build better relationships between social care staff and the adult and their family.

3. Key Considerations in Providing Culturally Appropriate Care

Understanding and communicating well with people from different cultures is an important part of providing person-centred care (see Personalisation chapter).

Everyone is part of a culture, and sometimes a number of different cultures. People are more likely to receive the care and support they need, and experience positive outcomes if their culture is recognised and their cultural needs are met.

It is often easier for people’s cultural needs to be met if they are closer to cultural norms in an organisation, so staff should carefully consider the needs of those who are not so close to these cultural norms.

Providing culturally appropriate care does not require staff to be experts on different cultures, but it does need them to understand how culture can affect aspects of care, and to be open, respectful, and willing to learn.

4. Recognising Cultural Values

Cultural values are the core beliefs in a culture about what is good or right.

All cultures have values. They are informed by the cultures that each person most associates themselves with. These values are neither positive nor negative – they are just differences.

Cultural values can influence the way people treat each other and want others to treat them.

4.1 Differences between and within groups

While different groups can have different cultural values, there can also be differences within groups as well. Therefore, it is important not to make assumptions about people or stereotype them.

Cultural values are not just based on a person’s ethnic background. Other social contexts influence them too – for example profession, age, gender or faith.

4.2 Cultural values are not always visible

We are not always aware of a person’s cultural values. As a result, there may be bias or discrimination; this may be unconscious – when someone does not realise they are being biased or discriminatory.

It is not always easy to see our own cultural values because we take them for granted. But assumptions we may make can be based on them, and therefore can affect other people, especially those who have different cultural values.

4.3 Being sensitive to cultural values makes a difference

When staff are aware of their own cultural values and recognise other people’s, it can have a positive impact on:

  • relationships between people using the service and the staff;
  • whether people take part in activities;
  • how likely it is that people will speak up if they are unhappy about something.

Staff should be aware of their own cultural values and how they might sometimes be different from other people’s. It can help them understand people better.

To ensure a good working relationship between staff and the people they are working with, they should:

  • be curious about how people are feeling;
  • ask people questions;
  • listen without judgement;
  • check their own thoughts – try to be aware of assumptions and judgements that could come from bias or stereotypes.

5. Providing Culturally Appropriate Care –Practice Guidance

There are many different aspects and variations in culture. Providing care should always be based on an assessment of a person’s individual needs.

5.1 Key points

Often, small changes make a big difference to people. The most important things for staff to do are:

  • spend time getting to know adults and their families; ask questions especially if you are unsure;
  • be curious about what is important to the person, to help them live their fullest lives; every person is different.;
  • try to understand and meet people’s preferences, and remember adults are the experts in their own lives;
  • do not make assumptions; and
  • be aware of your own cultural values and beliefs (see Section 4, Recognising Cultural Values).

 5.2 Providing person centred care which is culturally appropriate

  • Look at people’s needs as a whole, including their cultural needs, and protect them from discrimination.
  • People, their families and carers should be involved in developing their care plans, and these should  incorporate culturally appropriate care. Again, look at people’s needs as a whole, including identifying their needs on the grounds of equality characteristics (see Equality, Diversity and Human Rights chapter, Section 4.2, Protected characteristics) and looking at how they are met. It also includes finding out about their choices and preferences.
  • Staff must support people in culturally sensitive ways. They should recognise when people’s preferences are not being taken on board or properly respected and take action accordingly, by raising it with managers for example.
  • When carrying out strengths-based assessments, and developing and reviewing care and support plans, staff should support people to take part in activities that are culturally relevant to them, if they wish to do so.
  • Cultural considerations may impact on a person’s decision to take medicines. Such issues should be recorded, and action taken as required.
  • Cultural, ethical and religious needs should be taken into account when considering or discussing with diet and drinks. Cultural needs should also be reflected in how premises are decorated, for example.
  • If someone lacks capacity for a particular decision, their cultural preferences should be taken into account when applying the Mental Capacity Act – for example, by consulting with people that know them and understand their cultural values, if the person is not able to fully respond.
  • Staff should also ensure any cultural needs are also considered when working with carers and family members of an adult with care and support needs.
  • In end of life care, people – and their families – should feel their cultural needs have been considered and provided for, as part of the planning process. Their religious beliefs and preferences must be respected.

5.3 Across the local authority

  • Leaders, managers and staff should encourage people and their families, with whom they are working, to express their views and any concerns they may have. They should listen and act on such feedback to help shape the service and culture (see also Coproduction chapter).
  • Staff should actively promote equality and diversity within the service in which they work.
  • Staff should have access to training and learning and development opportunities to help them understand and meet people’s cultural needs. This should be considered as part of supervision and personal development appraisals.
  • Staff should also feel that they are treated equally. The local authority should make sure it hears the voices of all staff and acts on them to help shape the service and culture (see Staff Engagement chapter).

See also Examples of culturally appropriate care – Care Quality Commission for more detailed examples of ways care can be adapted to reflect cultural differences around:

  • religious or spiritual practice, including planning care and support around religious festivals;
  • food and drink;
  • healthcare;
  • clothes and personal presentation;
  • personal and shared space;
  • shared activities;
  • relationships and community connections.

6. Further Reading

6.1 Relevant chapters

Personalisation

Equality, Diversity and Human Rights

6.2 Relevant information

Culturally Appropriate Care (Care Quality Commission)

People’s Experience in Adult Social Care Services: Improving the Experience of Care and Support for People using Adult Social Care Services (NICE) 

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

What people expect

I feel safe and supported to understand and manage any risks.

KNOWSLEY SPECIFIC INFORMATION

Knowsley Multi-Agency Risk Assessment and Management (MARAM) Process

Knowsley Risk Management Arrangements

RELEVANT CHAPTER

Domestic Abuse

November 2023: This section has been updated to include a link to Knowsley Risk Management Arrangements, as above.

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

What people expect

I feel safe and supported to understand and manage any risks.

KNOWSLEY SPECIFIC INFORMATION

Knowsley Safeguarding Multi-Agency Escalation Process (downloadable Word version: KSAB Escalation Policy)

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CQC WE and I Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

I statement

I feel safe and supported to understand and manage any risks.

KNOWSLEY SPECIFIC INFORMATION

Knowsley Safeguarding Adults Procedures

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CQC Quality Statement

Theme 4 – Leadership: Governance, management and sustainability

We statement

We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes and we share this securely with others when appropriate.

KNOWSLEY SPECIFIC INFORMATION

Secure Transfer of Personal Information Protocol

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CQC Quality Statements

Theme 1 – Working with People: Supporting people to live healthier lives

We Statement

We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce future needs for care and support.

What people expect

I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally. I am supported to plan ahead for important changes in my life that I can anticipate.

KNOWSLEY SPECIFIC INFORMATION

Paying for Care (Knowsley Council)

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CQC Quality Statement

Theme 4 – Leadership: Learning, improvement and innovation 

We statement

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

Being professionally curious is essential to help identify abuse and neglect which isn’t always obvious. Asking questions, looking, listening, and reflecting on information received is vital to keep adults safe from abuse and neglect.

Professional curiosity is a reoccurring theme in Safeguarding Adult Reviews (SARs) and Domestic Homicides Reviews (DHRs).  The purpose of reviews is to learn lessons and influence best practice. Lack of professional curiosity is highlighted locally and nationally as an area to develop.

KSAB’s 7-Minute Professional Curiosity Briefing has been updated to give practitioners practical tips, to help be professionally curious within your role.

Other useful links:

Please get in touch with KSAB@knowsley.gov.uk if you have any further questions.

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

What people expect

I feel safe and supported to understand and manage any risks.

1. Introduction

‘Cuckooing‘ is the term for when professional criminal gangs target the homes of adults who they have identified as vulnerable. They then use the property for dealing drugs, hiding firearms, stolen goods and money and other crimes. Arson and violence are other crimes associated with such gangs. The adult victim may have care and support needs, but this is not always the case.

The female cuckoo bird lays its eggs in other birds’ nests, which is where the term comes from.

2. Cuckoo Victims

Cuckooing victims may include:

  • people with drug or alcohol problems;
  • people already known to the police;
  • older people;
  • people who have mental or physical health problems;
  • people with learning disabilities;
  • female sex workers;
  • single mums; and
  • people living in poverty.

Other adults may also be at risk.

Where the victim is known to have drug problems, criminals often offer them free drugs in exchange for using their home for dealing.

Once they have gained control of the adult and their home there is significant risk to the victim of physical and psychological abuse, sexual exploitation and violence. Such adults are often used as drug runners, to move drugs from one place to another on behalf of the criminals, often under threat of violence if they do not agree.

The adult may be made to travel to places which are a distance away from their local area, but such exploitation make also take place in properties in the same vicinity. Movement of people for the purposes of exploitation is a criminal offence covered by the Modern Slavery Act 2015 (see Modern Slavery chapter), as it is a type of trafficking and slavery.

In such circumstances the victim may not feel they cannot go to the police or tell other professionals, as they are frightened that they will be suspected of being involved in drug dealing or being identified as a member of the gang. They may be afraid this could result in them being evicted from their home. Some victims feel forced out of their homes, or are actually made to leave by the gangs, which makes them homeless.

3. Gangs

Gangs may use a number of such residential properties, moving between them within hours, days, weeks or longer in an effort to avoid being detected by the police.

They may use accommodation in rural areas, including serviced apartments, holiday lets, budget hotels and caravan parks, again in an effort to avoid police detection.

Such criminals are very skilled at identifying adults who they think are in some way vulnerable to their coercive behaviour. They are often very business-like in how they operate, with a view to make as much money as possible.

4. Signs of Cuckooing

4.1 Signs an adult is being exploited or abused

The following are some of the signs that an adult is being exploited or abused:

  • they associate with someone older than them and / or someone who controls what they do and where they go;
  • they travel alone to places far away from home, where they may not have any connections;
  • they get more telephone calls or people calling to their property than they usually do;
  • they have physical injuries that they cannot, or do not, explain easily;
  • they seem quiet and withdrawn, as if something is concerning them that they cannot talk about;
  • they are known or suspected to be carrying or selling drugs;
  • they are going missing from home or college, work or work placements;
  • they have new clothes, possessions, more than one mobile phone or money than they cannot usually afford.

4.2 Signs of cuckooing in a local neighbourhood

The following are some of the signs that accommodation belonging to a vulnerable adult has been taken over by criminal gangs:

  • people are entering and leaving the property, often throughout the day and night;
  • there is an increase in the number of cars (including new vehicles), bikes, or taxis or hire cars outside the property;
  • there is an increase in anti-social behaviour in and around the property, including litter and drug using equipment outside;
  • the adult stops attending, or misses, appointments with support and / or healthcare services;
  • professionals who visit the property to see the adult see new people there, who may also not introduce themselves;
  • the property may not have many or any valuable possessions inside and may start to become neglected as items and stolen and damage is caused by people coming to the property and repairs not made;
  • there are signs of drug use in and around the property, including discarded needles, crack pipes for example.

Such properties are often multi-occupancy accommodation (for example, a block of flats or a house that has been converted to a number of flats) or a social housing property.

5. Taking Action

If a member of staff is concerned about that an adult with care and support needs is being victimised by criminal gangs, particularly in their own home they should:

If a member of staff believes an adult is a victim of cuckooing but they do not have needs for care and support, this is still a crime and should be reported to the police.

All concerns or suspicions should be recorded in the adult’s case records as well as actions that have been taken and decisions that have been made (see Case Recording Standards and Information Sharing chapter).

6. Further Reading

6.1 Relevant chapter

Safeguarding Procedures for Responding in Individual Cases

6.2 Relevant information

Tackling ‘Cuckooing’ and County Lines Drug Networks (Crimestoppers)

Tackling Cuckooing: Multi-Agency Guidance (Kent Safeguarding Children Partnership)

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1. Introduction

Staff must only prepare witness statements for court on behalf of the local authority by whom they are employed (except in certain circumstances) and only when requested to do so by the legal services department, who acts on behalf of the local authority.

A solicitor from the legal services department accepts instructions from the social worker as their client. A barrister from a set of barristers’ chambers may need to be briefed by the instructing solicitor when a complex matter is before the court or where a hearing may take several days.

The circumstances when a member of staff may be asked to provide a witness statement on behalf of the local authority will usually be made in relation to adults who lack mental capacity. These may include but are not limited to:

  • section 16 welfare applications brought by the local authority in the Court of Protection;
  • appeals issued against a DoLs under s21A of the Mental Capacity Act 2005;
  • third party or private applications. There may also be other situations when staff may be asked by a third party (either by an individual or a partner agency) to provide a report or a witness statement. Any such documentation could result in the worker being asked to attend court. In such circumstances, they should inform their team manager, who should then seek advice from the legal services department.

Staff should remember that the local authority is a statutory body and its constitution sets out who is authorised to act in performing its functions and how staff must conduct themselves as local authority employees (Code of Conduct for Employees). Whilst this applies whenever employees are acting on behalf of or representing the local authority, it should be particularly remembered in matters relating to the court. Failure to comply with court directions in the Court of Protection can lead to cost orders being made against the local authority.

Please note: If a direct request for court documentation, especially by way of a direction in a court order, is received from any person other than a solicitor in the legal services department, you should inform your team manager, who should immediately contact legal services for advice.

2. Examples of Requests Within or External to the Local Authority

Some of the circumstances when a statement may be requested by another service within the local authority, another statutory agency or a third party are outlined below. Please note this list is not exhaustive.

2.1 Office of the Public Guardian

In cases of financial abuse, where the local authority may have completed a section 42 safeguarding investigation, the Office of the Public Guardian (OPG) can bring proceedings in the Court of Protection to remove an attorney. It may request that the local authority files a witness statement to support the application. Advice should be provided on the formatting and contents of any such statement. The local authority may assist with the application, but legal advice should be sought before responding to any requests from the OPG.

2.2 Coroner

When a coroner is involved in the case of a deceased person, they may approach adult social care for information.

The coroner’s office can informally request information about the involvement of adult social care in relation to a deceased person, such as safeguarding reports or a chronology of the local authority’s involvement with the deceased person. A coroner may request the worker to attend any coroner’s hearing when the cause of death needs to be ascertained and there are public liability issues for the public bodies to address to family members, connected persons and others.

The coroner can also formally request that a witness statement is provided by a member of staff who was involved with the provision of services or support to the deceased person. The member of staff may be required to attend the Inquest to give evidence in person. In complex and protracted coronial matters, it is advisable for legal services to assist with witness preparation.

2.3 Children’s social care

Children’s services can ask a member of adult social care staff who are working with a parent to provide a report in relation to safeguarding or child protection proceedings in accordance with the statutory guidance Working Together to Safeguard Children; also under Practice Direction 12A, the Public Law Outline (PLO) and the Children Act 1989. The local authority is required to prepare or obtain all its multi-agency partner assessments and reports on the family prior to the issue of any court proceedings.

The report must be signed and dated and bear a ‘Statement of Truth’ at the end of the report which should confirm that the matters contained within the report are true to the best of the member of staff’s knowledge and belief.

If care proceedings are issued and the local authority has filed a copy of the member of staff’s report as part of its evidence, they may be called to give evidence in relation to that report. Children services are often involved when the adult has been a looked after child who moves on to an adults and young person’s team for example. Ordinary residence often becomes a difficult issue when the adult moves from one local authority to another (see Liverpool City Region: Ordinary Residence Practice Guidance chapter). Ordinary residence matters are not normally determined by a court but by the Secretary of State.

Please note: staff should not provide a witness statement on behalf of a parent or have any contact with the solicitor representing the parent to avoid any accusation of bias or conflict of interest. All communication with the parents’ solicitors should be done through or in the presence of the local authority solicitor.

2.4 Housing

Proceedings to repossess property or end a tenancy are civil proceedings brought in the County Court by a landlord and are determined under housing legislation. Staff may be asked by the defendant or by the social housing landlord to submit a witness statement. Advice from legal services should always be sought first.

2.5 Social Work England investigations

If Social Work England (SWE) contact staff for a witness statement in relation to investigations about an individual on the SWE register, the member of staff should first speak to their team or service manager and the principal social worker.

2.6 Criminal proceedings

The police may want to interview staff if they are a witness to a crime concerning an adult who receives care and support services or if they have knowledge about a crime based on their involvement with them. The member of staff may be required to provide a witness statement and to attend to give evidence in person if the matter proceeds to court. If a request is made by the police for case records relating to an adult who uses services, this should be referred to the legal services department.

2.7 Forced marriage protection order applications

The police may request a witness statement from a member of staff working with a person who has, or is at risk of, a forced marriage to support an application for a forced marriage protection order. Many such applications are urgent, as  immediate action is required to prevent the person at risk of being removed from the UK jurisdiction. It is advisable to seek assistance from the local police Public Protection Unit or the Foreign and Commonwealth Office.

2.8 Education, Health and Care Plan Tribunal hearings

In such instances, staff should speak to their team or service manager and ask for the name of the Education Officer who is responsible for the matter. These officers prepare Education, Health and Care Plan (EHCP) for the Special Educational Needs and Disability Tribunal (SENDIST) hearings. There is often a social care part in the EHCP that may require the worker to complete Sections B and F of the ECHP, so the tribunal can decide on placement.

3. Instructing Legal Services

3.1 Legislation

Decisions that need to be taken could be under the following legislation:

Most often they relate to:

3.2 Requesting legal services

A request for legal services support should always be made when:

  • an application is going to be made to the High Court, for example inherent jurisdiction applications;
  • a health and welfare application is going to be made to the Court of Protection. A checklist of documents should be made so the witness statement when presented to the court will have appropriate exhibits for judicial consideration so a gateway order can be issued;
  • s21A witness statement in response to a deprivation of liberty safeguard challenge. The local authority should disclose standard authorisations under the gateway order and witness statement should be filed after first hearing. Staff should follow bullet points in directions order to complete the witness statement;
  • another person or organisation has made an application to court or a letter has been received saying another person is going to make an application to court. The court will decide whether local authority should be made a party in any proceeding;
  • a report or paper is being prepared that requires legal comments.

A request should also be made for property and financial affairs applications to the Court of Protection when this application is not to be managed by a dedicated deputyship service within the local authority. A family member will often privately instruct a firm of local solicitors to make the same application.

3.3 Supported decision making

In such cases as listed above, advice from legal services is useful to support decision making including in the following situations:

  • where the decision will likely have a significant impact on the person receiving services or their carer;
  • when the legislation, codes of practice or other available guidance is unclear on what decision should be made in a particular set of circumstances;
  • where the risk of complaint or legal challenge is significant;
  • when the decision that needs to be made is complex;
  • when there are a number of options available should be thoroughly explored and investigated.

3.4 Complaints and investigations

Whilst legal advice should not be routinely requested in complaints and other investigations, advice from legal services can be particularly useful in complex complaints or investigations when:

  • statutory processes and duties are being challenged; and
  • there are legal implications for the outcome of the complaint or investigation. Please note a complaint should not be decided when the same subject is part of legal proceeding, until the court hearing is concluded.

4. The Role of Legal Services in Court Hearings

It is the role of legal services to co-ordinate and manage the following:

  • the application process;
  • response to a s21A challenge or any application when the local authority has party status;
  • any correspondence sent to or received from the court;
  • how and when evidence is provided, including how it is organised and submitted;
  • how other staff and agencies are involved in the process.

Legal services should also:

  • help develop adult social work staff understanding of court processes;
  • support staff to assess the quality of the evidence they provide, which may include amending the social worker’s witness statement for court purposes;
  • advise about completing the required forms correctly; and
  • supporting staff giving evidence in person and prepare them for cross-examination.

 5. Practice Guidance

5.1 How staff can support legal services

Staff should always:

  • inform legal services of any changes in a case where they are already involved and provide the solicitor with regular and updated instructions;
  • complete witness statements and submit evidence before the specified deadline;
  • provide up to date information when asked;
  • review statements and sign and date them when requested, as otherwise they cannot be submitted to the court;
  • attend court hearings in good time before the commencement of the hearing unless advised otherwise.

5.2 Writing a good report

Tips include:

  • plan – consider using bullet points or headings;
  • write first draft – it should not just be a summary of facts but include analysis;
  • write a summary – this may include a recommendation to the court;
  • edit – eliminating repetition and irrelevant information;
  • check – ask a manager or a colleague to check the accuracy of the report.

Avoid:

  • irrelevant, inappropriate information;
  • meaningless phrases;
  • illogical conclusions.

See How to write a good report (Community Care)

5.2.1 Court reports: three key tips for writing clearly

  • say what you mean clearly and concisely;
  • use a strong active voice and avoid the passive (for example, ‘the support worker shared concerns about visitors to the house’);
  • put the action in the verb – to do this you need to make the action clear (that can be either something you say has happened or something you think needs to happen).

See Court reports: three key tips for writing clearly (Community Care)

5.3 Top tips for giving evidence in court

  • communicate effectively and clearly, in a strong tone of voice;
  • direct your answers to the decision maker;
  • seek assistance of the decision maker;
  • assume nothing, be very thorough and ensure you are familiar with the contents of your own statement and the exhibits;
  • be ready for cross-examination techniques – your answer should not go outside the scope of the question put to you;
  • do not go outside the facts or your area of expertise;
  • take your time to answer the questions. Do not be afraid to seek clarification from the questioner about what you are being asked to comment on.

See Top tips for giving evidence in court (Community Care)

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1. Introduction

With increasing pressure on services, it is vital that all those providing care and support – both employers and employees – are able to take time to think about their health and wellbeing as well as that of their colleagues, and the people and families they support.

The information in this chapter is taken from Health and Wellbeing of the Adult Social Care Workforce (Department of Health and Social Care). Whilst written during the COVID-19 pandemic, it includes relevant advice and links to other information that employers and managers can use to support their teams and address any concerns their staff may have.

2. Mental Wellbeing

The guidance recommends the following key steps to support staff with their mental health:

  • have a structure to the day and try to develop a daily routine; writing a plan for the day or week may be helpful. It is also important that staff keep doing things they enjoy as this can give relief from anxious thoughts and feelings and can boost mood;
  • physical health has a significant impact on mental wellbeing. As the body releases endorphins when exercising, this can relieve stress relief and also boost mood;
  • maintaining relationships with family and / or friends is important for mental wellbeing. Staying in touch with people on the phone or via video or social media is particularly if people are feeling anxious;
  • avoid continually checking the news – via 24-hour channels and social media – can people feel more worried and anxious. It may more helpful to only check the news at set times in the day;
  • good-quality sleep can have a positive impact on how people feel mentally and physically. Every Mind Matters gives advice on how to get a good night’s sleep;
  • people should be asked if they are ‘ok’, and always be encouraged to seek help if they are struggling. Services available include:
    • sending a message with the word FRONTLINE to 85258 to start a conversation with Shout’s messaging support service;
    • Samaritans offer support NHS and social care workers in England. They can be contact for free, day or night, on 116 123;
    • Every Mind Matters provides comprehensive support, tips and ideas on mental health and wellbeing.
    • link to local employee support scheme if available.

2.1 How managers can help

During supervision, managers should check in with their staff and ask about their wellbeing (although staff should be clear they can ask for help in between supervision if they are struggling).  Mind recommend developing Wellness Action Plans  with staff as a practical well of supporting their mental health and wellbeing.

See also Wellbeing Resource Finder (Skills for Care)

3. Building Resilience and Managing Stress and Anxiety

It is important that staff are helped to find ways of coping with increased pressure. Skills for Care has a guide on How to Build Personal Resilience. The guide includes tasks for staff to complete that help to recognise pressure and stress. It provides advice on developing resilience through emotional intelligence, accurate thinking and realistic optimism.

MindEd provides free educational resources on mental health and has a coronavirus staff resilience hub to help manage the mental health and wellbeing of frontline staff.

The Every Mind Matters page on anxiety provides good advice on managing worries that people may have.

Other information and support includes:

4. Physical Wellbeing

Staff should try to keep active, where and when possible. This can include walking outside or running or riding a bike once a day, as fresh air is extremely beneficial for mental health.

For those who are not able to exercise outdoors, there are several online workouts that can be done at home. The NHS provides free, easy 10-minute workouts and the NHS Fitness Studio has a collection of accessible exercise videos.

Staff should ensure they get rest and respite during work or between shifts, eat healthily, engage in physical activity and stay in contact with family and friends. People should avoid unhelpful coping strategies such as tobacco, alcohol or other drugs. In the long term, these can worsen mental and physical health.

Although the COVID pandemic has been officially declared over, it is still possible for staff to catch the virus. To reduce the risk of getting COVID and what to do if someone does get it, staff and managers should follow NHS advice COVID-19 (NHS).

5. Financial Wellbeing

Financial wellbeing is about people having a sense of security and having enough money to meet their needs; it is about being in control of day-to-day finances and having the financial freedom to make choices that allow people to enjoy their life.

There are a number of organisations to help staff with financial problems they may have:

There is also information on:

6. Concerns about Work

It is important that people’s rights as workers are protected, especially during times of increased pressure. Similarly, staff have a professional duty to act if they are concerned that the safety of those they care for is at risk. If any member of staff has any concerns about employment practices, it is important that they feel able to raise them.

Any concerns should be raised with the senior management team in the first instance. There will be internal procedures in the workplace about what to do.

Staff can also contact their union or professional body, if they have one, for advice about what to do if they have concerns. They can play a helpful role in trying to resolve any problems staff may be facing and improve workplace practice.

Finally, if staff want to report a serious case of bad practice or have been unsuccessful in resolving any issues with their organisation, they can contact CQC and local council safeguarding teams (see also Whistleblowing chapter).

7. Further Reading

7.1 Relevant chapter

Supervision

7.2 Relevant information

Health and Wellbeing of the Adult Social Care Workforce (Department of Health and Social Care)

Taking Care of your Staff (Mind) 

Social Worker Wellbeing and Working Conditions Toolkit (BASW) 

Looking After Yourself (Skills for Care)

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CQC Quality Statement

Theme 4 – Leadership: Learning, improvement and innovation

We statement

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

September 2023: A link has been added in Section 4.2, Relevant information to Am I Invisible? Using Co-production to Advocate Change in Social Care, published by SCIE.

1. Introduction

Adults who use care and support services, and those of partner agencies, are at the centre of the personalisation agenda and the Care Act 2014. Feedback from adults and carers about their service experience and outcomes – that were either achieved or not achieved – are vital to providing effective and appropriate services.

2. Co-production

Co-production is a way of working whereby everybody – adults who use services, carers and staff – work together on an equal basis to create a service or come to a decision which works for them all.

However, the definition of co-production changes in different settings (see What is Co-production? TLAP).

The Care Act states:

Co-production is when you as an individual influence the support and services you receive, or when groups of people get together to influence the way that services are designed, commissioned and delivered.

The TLAP National Co-production Advisory Group says:

Co-production is not just a word, it is not just a concept, it is a meeting of minds coming together to find shared solutions. In practice, co-production involves people who use services being consulted, included and working together from the start to the end of any project that affects them. When co-production works best, people who use services and carers are valued by organisations as equal partners, can share power and have influence over decisions made.

The New Economics Foundation notes six main aspects of co-production:

Recognising people as assets: People are seen as equal partners in designing and delivering services, rather than as passive beneficiaries or burdens on the system.

Building on people’s capabilities: Everyone recognises that each person has abilities and people are supported to develop these. People are supported to use what they are able to do to benefit their community themselves and other people.

Developing two-way reciprocal relationships: All co-production involves some mutuality, both between individuals, carers and public service professionals and between the individuals who are involved.

Encouraging peer support networks: Peer and personal networks are often not valued enough and not supported. Co-production builds these networks alongside support from professionals.

Blurring boundaries between delivering and receiving services: The usual line between those people who design and deliver services and those who use them is blurred with more people involved in getting things done.

Facilitating not delivering to: Public sector organisations (like the government, local councils and health services) enable things to happen, rather than provide services themselves. An example of this is when a council supports people who use services to develop a peer support network.

3. Involving Adults

Adults who use services should be involved at each level of development, delivery, and review of care and support services in order to ensure:

  • that services are developed to meet the care and support needs of adults;
  • that the services which are provided are of good quality;
  • positive outcomes for those who use the service.

Service commissioners should ensure that adults who use services can:

  • have their views considered in the development of new strategies and services;
  • contribute to the review and performance management of existing strategies and services;
  • receive information on planning and delivering of new services in an accessible and jargon-free format;
  • contribute to meetings and decision making where practicable. This may include practical support (for example, reimbursement of expenses; considering the time and venue for meetings) and other assistance (for example help to deal with jargon – see TLAP Care and Support Jargon Buster);
  • access appropriate training and mentoring support to enable them to contribute to planning arenas.

Social workers and service providers should ensure adults:

  • have easy access to information about their rights and responsibilities within the service;
  • have easy access to clear information on all the services available (see Information and Advice chapter);
  • have access to information on their care and support options (see Care and Support Planning chapter);
  • are fully involved in the assessment process and development and review of their individual care plan and have their needs, wishes and goals incorporated into their plan (see Assessment chapter);
  • receive information on how to make comments, complaints and compliments about the service they receive (see Complaints, Comments, Compliments and Questions chapter);
  • contribute to the evaluation of the service.

User led organisations (ULOs) are one approach to facilitating user involvement as referenced in the Care and Support Statutory Guidance. ULOs are organisations that are run by and controlled by people who use care and support services, including disabled people of any impairment, older people, and families and carers. See also A Commissioner’s Guide to Developing and Sustaining Local User-Led Organisations (SCIE).

4. Further Reading

4.1 Relevant chapters

The Care Act 2014

Personalisation

4.2 Relevant information

Think Local Act Personal, Coproduction

Am I Invisible? Using Co-production to Advocate Change in Social Care (SCIE)

Quality Statement 4: Using People’s Views to Improve Services (NICE)

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CQC Quality Statements

Theme 1 – Working with People: Supporting people to live healthier lives

We Statement

We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce future needs for care and support.

What people expect

I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally. I am supported to plan ahead for important changes in my life that I can anticipate.

1. Introduction

There are a many different factors that contribute to a person living in poverty. Broadly these can be described as a) personal – their individual situation of employment, opportunities, life circumstances etc and b) universal – that is factors that affect everyone such as the costs of food, fuel, heating and lighting etc.

This chapter outlines the main issues regarding poverty, how it affects people, how it can additionally affect people with care and support needs and specialist organisations that can provide support.

2. What is Poverty?

The Joseph Rowntree Trust (JRF) is the leading UK charity whose aim is to solve poverty. It defines poverty simply as being when someone’s resources are well below their minimum needs.

However, it goes on to say that there is not just one definition of poverty and that it is a complicated problem that needs a range of measures to tell us about the different features of poverty.

JRF gives a number of different measures of poverty (see What is Poverty?), but a government publication just gives two:

  • relative low income: a person is in relative low income (or relative poverty) if they are living in a household with income below 60% of the average household income in that year;
  • absolute low income: a person is in absolute low income (or absolute poverty) if they are living in households with income below 60% of the 2010/11 median (taking inflation into account). This is a base line measure which looks at how living standards of low income households change over time (Poverty in the UK: Statistics, House of Commons Library).

Income can be measured before or after housing costs are taken out of the calculation, and poverty is calculated based on these different definitions of income.

2.1 Levels of poverty

JRF defines different levels of poverty:

  • a person or household has a minimum amount of income (the income standard) or better: this means they are able to afford a decent standard of living;
  • a person or household has income that is below the accepted minimum income standard: they can just about get by on a daily basis, but it is difficult for them to manage unexpected costs and events;
  • a person or household does not have enough income: and they are falling well short of a decent standard of living and it is quite likely they will not be able to pay their needs;
  • a person or household is destitute: that means they cannot afford to eat, keep clean and stay warm and dry.

See What is Poverty? (JRF)

3. What are the Causes of Povrkerty in the UK?

The causes of poverty are issues that either reduce a person’s financial resources and / or increases their needs and the cost of meeting those needs. Life events and moments of change – such as getting ill, suffering bereavement, losing a job or a relationship breaking down – are common triggers for poverty.

JRF states that some of the causes of poverty in the UK today are:

  • unemployment and low-paid jobs which have little prospect of getting better paid and are insecure (or a lack of jobs): many areas in the country have a lot of these jobs or do not have enough well-paid jobs. Low pay and unemployment can also lead to not being able to save or have a pension;
  • low levels of skills or education: young people and adults who do not have the right skills or qualifications can find it difficult to get a job, especially one with security, prospects and decent pay;
  • the benefit system: the level of welfare benefits for some people – who are either already in work (which is low paid), looking for work or being unable to work because of health or care issues – is not enough to avoid poverty, when combined with other resources and high costs. The benefit system is often confusing and hard to engage with, leading to errors and delays. The system can also make it difficult for a person to move into work or increase their working hours;
  • high costs: the high cost of housing and essential goods and services (for example gas, electricity, water, Council Tax, telephone or broadband) creates poverty. Some people face particularly high costs because of where they live, because they have increased needs (for example, personal care for disabled people) or because they are paying a ‘poverty premium’ – where people in poverty pay more for the same goods and services;
  • discrimination: people can be discriminated against because of their class, gender, ethnicity, disability, age, sexuality, religion or parental status (or even because of poverty itself). This can prevent them from getting out of poverty and can restrict access to services;
  • relationship issues: a child who, for whatever reason, does not receive warm and supportive parenting can be at higher risk of poverty when they are older, because of the impact on their development, education and social and emotional skills. Family relationships breaking down can also result in poverty;
  • abuse, trauma or chaotic lives: for some people, problematic or chaotic use of drugs and / or alcohol can make poverty worse and longer. Neglect or abuse in adult life can also cause poverty, as the impact on mental health can lead to unemployment, low earnings and links to homelessness and substance misuse. Being in prison and having a criminal record can also make poverty worse, by making it harder to get a job and its impact on relationships with family and friends.

There are a number of worldwide factors that have pushed up prices, further impacting on the number of people in poverty and worsening levels of poverty. These include:

  • inflation in the UK is now higher than it has been for many years and this is impacting on the cost of goods, rents and mortgages;
  • there is a shortage of workers which has meant companies have had to increase their wages to attract staff, which in turn means prices have to rise;
  • the cost of shipping and importing and exporting goods have risen partly due to the UK leaving the European Union (Brexit);
  • the war in Ukraine – this is impacting on food prices, because Ukraine is usually a very big exporter of sunflower oil and wheat;
  • the worldwide cost of oil production is resulting in record heating, lighting and fuel costs.

4. What are the Consequences of Poverty in the UK?

JRF state that some of the consequences of poverty include:

  • ‘health problems;
  • housing problems;
  • being a victim or perpetrator of crime;
  • drug or alcohol problems;
  • lower educational achievement;
  • poverty itself – poverty in childhood increases the risk of unemployment and low pay in adulthood, and lower savings in later life;
  • homelessness;
  • teenage parenthood;
  • relationship and family problems;
  • biological effects – poverty early in a child’s life can have a harmful effect on their brain development.’

In addition, people may:

  • be less able, or unable, to afford:
    • clothing;
    • vital home treatments such as oxygen and dialysis machines due to electricity costs;
    • leisure or sports activities;
    • transport (this is particularly an issue for people who live in the countryside and also may result in people not being able to attend social care, hospital and other important appointments);
    • broadband – further limiting their opportunities for finding work or saving money;
    • attend employment / training;
  • need to go to food banks;
  • need to borrow money either from family or friends, official (banks or credit unions), or unofficial sources such as loan sharks which can result in threats, intimidation and their possessions seized if they cannot afford to repay them;
  • have to pay for goods and services on high interest credit;
  • resort to crime or sex work to get money to pay bills.

In turn this can lead to increased stress, anxiety and mental health problems.

This guidance is specifically referring to adults. But where there are children living in families suffering from poverty, there are additional issues. See Child Poverty (JRF).

5. How Poverty Affects People with Care and Support Needs

People with care and support needs may be particularly vulnerable to poverty because:

  • they may be less able to work, or work in lower paid jobs, due to ill health or having a disability;
  • if their health issues have been long term, this may have impacted on their education and training opportunities, which may have resulted in them never being able to get decent paid jobs, or any job;
  • their health needs or disability may result in having to:
    • pay for care and support services, such as home carers;
    • regularly buy equipment or supplies;
    • needing adaptations to their house as a result of mobility and other issues;
    • having to move home, if it becomes unsuitable for them as a result of their needs;
    • have the heating and / or lighting on more often;
    • relying on local food shops which may be more expensive / have less choice;
    • buy food for specialist diets;
    • they may not be able to walk or use public transport due to health issues and therefore need their own car or pay for taxis.

In addition, their carers may also be living in poverty, because:

  • they are not able to work / work full time because they need to look after their family member with care and support needs;
  • the household income is reduced because of having to pay for those issues listed above.

6. Poverty and Safeguarding

Living in poverty can increase the likelihood of an adult experiencing or being at risk of abuse and / or neglect. There may be safeguarding incidents committed – accidentally or deliberately – by people close to the adult who are struggling as a result of living in poverty. These people include:

  • spouses or other family members;
  • neighbours or friends;
  • carers – paid or unpaid;
  • other professionals.

The types of abuse and neglect that may be committed by those who are suffering as a result of poverty and who are involved with someone with care and support needs, include:

  • physical abuse;
  • domestic abuse;
  • sexual abuse;
  • psychological abuse;
  • financial or material abuse;
  • modern slavery;
  • discriminatory abuse;
  • organisational abuse;
  • neglect and acts of omission.

See also Adult Safeguarding chapter

6.1 Self-neglect

In addition, incidences of self-neglect are likely to rise as a result of more people living in poverty due to the reason outlined in Section 5, How Poverty Affects People with Care and Support Needs. Chronic illness and disability increase the risk of self-neglect, both of which are associated with poverty.

See Self-Neglect (SCIE)

6.2 Taking action where there are safeguarding concerns

Where there are concerns that a person with care and support needs is experiencing or at risk of abuse or neglect, whether as a result of poverty or not, staff should follow their organisation’s safeguarding procedures and the local safeguarding adults procedures (see Safeguarding Procedures for Responding in Individual Cases chapter.

7. Supporting People who are Living in Poverty

7.1 Practical help

People with care and support needs may need support with specific areas of their lives that are contributing towards them living in poverty.

There are some areas where practical help and advice is available. Whilst social work staff may have significant knowledge about appropriate interventions for people living in poverty, there are specialist agencies that can also help. These include:

  • employment or education advice: specialist agencies can provide support and advice to people with care and support needs, based on their individual needs and wishes, to help them get into work or education, although it should be acknowledged that this may not be possible for everyone;
  • benefits advice: specialist services can work with people, and their carers, to make sure that both are receiving all the benefits they are entitled to and can support them to apply for new benefits, such as carers allowance. The benefits system is very complex and can be overwhelming, so people will often gain from having expert advice;
  • medical and associated professions: where people are receiving care and treatment for specific health issues from doctors, nurses, occupational therapists or physiotherapists for example, they should be supported to make sure that they attend all their appointments and any obstacles, such as transport problems or a clash of appointment times are addressed well in advance to avoid stress for the person or the likelihood of them missing an appointment. If they do miss an appointment, they should be supported to contact the professional to explain what happened and to rebook it, rather than risk being removed from the service. Ensuring they receive the best possible health care can help improve their life circumstances with the goal of being less susceptible to poverty;
  • care and support services: where a person is living at home and receiving care and support services, they should be supported by staff to ensure that services from providers run according to the care and support plan, are timely and if any issues arise the person, and their carer, are supported in addressing them. A financial assessment should be conducted to make sure that someone living in poverty is not asked to pay for services.
  • equipment, supplies and adaptations: where someone requires equipment, supplies or adaptations to them home as a result of their care and support needs, staff should make sure that they are referred to an occupational therapist, physiotherapist or other service as appropriate, to be assessed and provided with the equipment they need rather than have to pay for it themselves. This includes technology assisted care;
  • moving home: if a person has to move home as a result of their changing care and support needs, or for any other reason, staff should make sure that they are given all the available assistance and financial support to enable this to happen. The Department for Work and Pensions should be contacted to see if the person is eligible for any financial support for their move and refurbishment of the new accommodation;
  • utility bills: if the person is struggling to pay their gas, electricity and water bills, staff should support them to contact the relevant service provider to come to an arrangement about overdue bills or in advance of bills being sent. This also applies to internet providers, which may be essential for people with care and support needs living at home;
  • leisure and sport: leisure and sport can be essential for mental and physical health. Where people with care and support needs are able and want to take part, staff should help them source free activities, including through social prescribing services, and / or grants to enable them to take part. Local organisations can be key in offering events and activities;
  • specialist diets: where someone with care and support needs requires a specialist diet, staff should support them to speak to their GP or dietician to see what support is available, such as prescriptions, to reduce the cost of buying specialist foods;
  • transport: a person with care and support needs who is living in poverty may not be able to afford bus or taxi fares, and particularly unable to run their own car. Staff should support them to find out what financial support is available for them. This will be dependent on their particular needs, but will be particularly important for those who cannot walk far or whose mental health affects their ability to travel.

7.2 Local and national organisations

Poverty can be a very complex and challenging issue for staff who do not have a lot of knowledge and experience in this area. There may be local organisations who specialise in issues of poverty, including food banks, who can work with people with care and support needs. Staff can put the person, or their carer, in touch with these organisations or otherwise take advice on an anonymous basis about specific aspects of supporting someone in poverty. Local community or service directories will contain the contact details for such key organisations.

There are also a number of national organisations whose aim is to support people living in poverty. They have lots of information and advice for people. Again, staff can give their details to adults or their carers, or contact them directly for general advice. They include:

8. Further Reading

8.1 Relevant information

Joseph Rowntree Charitable Trust

The Trussell Trust

Understanding Social Work and Poverty (BASW)

Cost of Living Crisis (Mencap Easy Read)

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safe systems, pathways and transitions

We statement

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services.

What people expect

When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place.

I feel safe and supported to understand and manage any risks.

KEY POINTS

  • NHS Continuing Healthcare (CHC) is arranged and funded by the NHS and provided to adults who have been assessed as having a ‘primary health need’.
  • Deciding whether an adult has a primary health need and is eligible for NHS CHC involves a multidisciplinary team (MDT) assessing all the adult’s relevant needs using the Decision Support Tool (DST). A checklist tool is also available, and this can be used initially to identify adults who may need a full assessment of eligibility for NHS CHC.
  • Local Integrated Care Boards (ICBs) will review the assessment of eligibility completed by the MDT. Only in exceptional circumstances, and for clearly stated reasons, can the MDT’s recommendation not be followed.
  • Where an adult receives NHS CHC, a review should be undertaken within three months of the decision being made. After this, further reviews should be undertaken on at least an annual basis.

1. Introduction

NHS Continuing Healthcare (CHC) is care arranged and funded by the NHS and provided to adults who have been assessed as having a ‘primary health need’ (see Section 2.3, Eligibility). It is free of charge, unlike care from adult social care for which there may be a charge depending on the adult’s income and savings (see Charging and Financial Assessment chapter).

It can be provided in any setting, including a care home, nursing home, hospice or the home of the adult with the healthcare needs. It will cover their care home fees (including board and accommodation), personal care (help with bathing, dressing and laundry for example) and healthcare costs (community nursing or specialist therapy services for example).

For adults living at home, it will cover their personal care and healthcare costs.

Support for carers may also be available – see NHS Continuing Care: Information for Adults and Carers.

There is a difference between NHS CHC and NHS-funded Nursing Care; NHS-funded Nursing Care is the funding provided by the NHS to those who are eligible and living in care homes with nursing, to support the provision of nursing care by a registered nurse.

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (Department of Health and Social Care)  was revised in July 2022. It includes Practice Guidance to support staff delivering NHS CHC.

This chapter is a summary of key information in the Framework.

2. Key Concepts in NHS Continuing Healthcare

2.1 Primary health need

To assist in deciding which – if any- health services it is appropriate for the NHS to provide to someone, the term ‘primary health need’ is used. Where an adult has been assessed to have a primary health need, they are eligible for NHS CHC and the NHS will be responsible for providing for all of their assessed health and associated social care needs, including accommodation – if that is part of their overall need. Deciding whether an adult has a primary health need involves looking at all of their relevant needs; to do so they must be assessed by a multidisciplinary team (MDT) using the Decision Support Tool (DST), see Section 7, Decision Support Tool.

An adult is said to have a primary health need if, having completed the DST, it can be said that most of the care they require is focused on addressing and / or preventing health needs. Having a primary health need is not about why someone needs care or support, nor is it based on their diagnosis; it is about the level and type of their overall actual day-to-day care needs taken as a whole.

Each adult’s case has to be considered on its own facts, in line with the principles outlined in the National Framework.

There should be no gap in the provision of care. People should not find themselves in a situation where neither the NHS nor the relevant local authority will fund care, either separately or together.

The requirement for a primary health need means that ineligibility for NHS CHC is only possible where, taken as a whole, the nursing or other health services the person requires:

  • are no more than incidental or ancillary to the provision of accommodation which local authority social services are under a duty to provide (depending on the adult’s circumstances); and
  • are not of a type beyond which a local authority could be expected to provide.

In applying the primary health need test, Integrated Care Boards (ICBs) should take into account that section 22 of the Care Act 2014, applies the ‘incidental and ancillary’ test in all situations, including where care is being provided in the adult’s own home. As there should be no gap in the provision of care, ICBs should consider this test when determining eligibility. Eligibility is the same for all individuals, whether their needs are being met in their own home or in care home accommodation.

Please note: ICBs replaced Clinical Commissioning Groups on 1 July 2022.

2.2 Characteristics of need

Certain characteristics of need – and their impact on the care required to manage them – may help determine whether the ‘quality’ or ‘quantity’ of care required is more than the limits of a local authority’s responsibilities, as set out in the Care Act 2014:

  • nature: this describes the particular characteristics of an adult’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the adult, including the type (‘quality’) of interventions required to manage them;
  • intensity: this relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained / ongoing care (‘continuity’);
  • complexity: this is concerned with how the adult’s needs present and interact to increase the skill required to monitor the symptoms, treat the condition/s) and / or manage their care. This may arise with a single condition, or multiple conditions or the interaction between two or more conditions. It may also include situations where an adult’s response to their own condition has an impact on their overall needs, for example where a physical health need results in the adult developing a mental health need.
  • unpredictability: this describes the degree to which an adult’s needs fluctuate, which can create challenges in managing them. It also relates to the level of risk to the adult’s health if adequate and timely care is not provided. An adult with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.

Each of these characteristics may, alone or together, show the adult has a primary health need, because of the quality and / or quantity of care that is required to meet their needs. All of their overall needs and the effects of the interaction of their needs should be carefully considered when completing the DST.

Practice Guidance note 3 in the National Framework contains examples of questions which the multidisciplinary team can use to develop an understanding of how each characteristic relates to the needs of the adult being assessed.

2.3 Eligibility

Eligibility for NHS CHC is a decision taken by the local ICB, based on an assessment of the adult’s needs, which is undertaken by the multidisciplinary team (MDT) using the Decision Support Tool. The diagnosis of a particular disease or condition is not in itself a deciding factor of eligibility for NHS CHC. As noted above, NHS CHC may be provided in any setting (including for example a care home, hospice or the adult’s own home). Eligibility is, therefore, not decided or influenced either by the setting where the care is provided or by the characteristics of the adult who delivers the care. When making a decision whether someone is eligible for CHC, a need should not be dismissed just because it is successfully managed: well-managed needs are still needs. Only where the successful management of a healthcare need has permanently reduced or removed an ongoing need will this have an impact on the adult’s eligibility for NHS CHC.

Financial issues should not be considered as part of the decision on an adult’s eligibility for NHS CHC.

In summary, the reasons given for a decision on an adult’s eligibility should not be based on the:

  • adult’s diagnosis;
  • setting of care;
  • ability of the care provider to manage care;
  • whether or not NHS-employed staff provide care;
  • need for ‘specialist staff ’ in care delivery;
  • the fact that a need is well-managed;
  • the existence of other NHS-funded care; or
  • any other input-related (rather than needs-related) rationale.

Eligibility for NHS CHC is not indefinite, as needs could change. This should be made clear to the individual and / or their representatives.

Not all those with a disability or long term health condition will be eligible.

A decision about whether or not an adult is eligible should usually be made within 28 days of completion of the assessment.

2.4 Options for people who are not eligible

If the adult is not eligible for NHS CHC funding, the local authority maybe responsible for assessing their care and support needs and providing services if they are eligible.

If the adult is not eligible for NHS CHC but is assessed as having healthcare or nursing needs, they may still receive some care from the NHS. For an adult who lives in their own home, this may be provided as part of a joint package of care and support, where some services come from the NHS and some from adult social care services (see the chapters on Integration, Cooperation and Partnerships, Eligibility and Charging and Financial Assessment).

If the adult moves into a nursing home, the NHS may contribute towards their nursing care costs.

Once eligible for NHS CHC, care will be funded by the NHS, but this is subject to review; should care needs change, the funding arrangements may also change.

3. Information for Adult Social Care Staff

The National Framework sets out the principles and processes which should be applied in order to assess an adult’s eligibility for NHS continuing healthcare and NHS funded nursing care.

Joint working between NHS and adult social care, and any other partner organisation/s who are involved, is essential to ensure the adult’s needs are met in the right way and that their care is effectively coordinated. The National Framework sets out the local authority responsibilities in relation to NHS continuing healthcare.

In order to understand and be able to implement CHC procedures, staff should:

  • familiarise themselves with the National Framework for NHS Continuing Healthcare documentation;
  • understand the definition of ‘primary health need’;
  • be familiar with the Decision Support Tool;
  • be able to apply the four key characteristics of need (see Section 2.2, Characteristics of need);

as well as the primary health need test to the adult’s assessed needs (see National Framework p.60).

If adult social care staff consider that an adult may be eligible for NHS CHC, they must follow their local processes in order to refer the adult to the ICB.

Where at all possible, the same staff member should be involved with the adult and their carers throughout the continuing healthcare assessment process.

4. Consent

See also: Full Consent Form for Participating in the NHS Continuing Healthcare Process and for Information Sharing with Family / Friends / Advocates (DHSC) and Data Protection: Legislation and Guidance chapter.

There are a number of principles which underpin this process. Most importantly is that assessments and reviews should always focus on the adult’s individual needs and follow a person-centred approach. The adult should be fully informed and empowered to participate actively in the assessment process and any subsequent reviews, and their views should always be considered. There are also a number of legal requirements when it comes to obtaining an adult’s consent for parts of the NHS CHC process.

Before completing the Checklist and the Decision Support Tool (DST) (see below), consent must be obtained and recorded. Consent is sought for:

  • completion of the DST;
  • sharing of the adult’s personal information between different organisations involved in their care, and the continuing healthcare assessment and decision making process.

5. Mental Capacity

If there is a concern that the adult may not have mental capacity to give consent to taking part in the continuing healthcare process, this should be decided in line with the Mental Capacity Act 2005 and Code of Practice (see Mental Capacity chapter). A third party can give consent for an assessment of eligibility for NHS CHC on behalf of an adult who lacks capacity, if they can demonstrate they have a valid Lasting Power of Attorney for Welfare or that they have been appointed a Welfare Deputy by the Court of Protection.

If the adult lacks the relevant capacity to either give or refuse consent to a physical intervention / examination, care and treatment as part of continuing healthcare, a ‘best interests’ decision should first be made and recorded (see Best Interests chapter).

ICBs and local authorities should ensure that all staff involved in NHS CHC assessments are appropriately trained in Mental Capacity Act 2005 principles and responsibilities.

6. Checklist Tool

See NHS Continuing Healthcare Checklist

The Checklist is the NHS CHC screening tool which can be used in a variety of settings to help practitioners identify individuals who may need a full assessment of eligibility for NHS CHC.

The regulations state that if an initial screening process is used to identify where someone may have a need for CHC, the Checklist is the only screening tool that can be used for this purpose. The purpose of the Checklist is to encourage proportionate assessments of eligibility so that resources are directed towards those people who are most likely to be eligible for NHS CHC, and to ensure that a rationale is provided for all decisions regarding eligibility.

The Checklist can be completed by a variety of health and social care practitioners, who have been trained to use it. This could include local authority staff such as social workers, care managers or social care assistants.

Completion of the Checklist should be quite quick and straightforward. It is not necessary to provide detailed evidence along with the completed Checklist.

There are two potential outcomes following completion of the Checklist:

  • a negative Checklist, meaning the adult does not require a full assessment of eligibility, and they are not eligible for NHS CHC; or
  • a positive Checklist meaning an adult now requires a full assessment of eligibility for NHS CHC. However, that does not necessarily mean they will be eligible for NHS CHC.

7. Decision Support Tool

See NHS Continuing Health Care Decision Support Tool

Once an adult has been referred for a full assessment of eligibility for NHS CHC – after the Checklist has been completed or if it was not used in an individual case –a multidisciplinary team (MDT) must assess whether the adult has a primary health need using the Decision Support Tool (DST).

The DST is used to inform the decision as to whether an adult is eligible for NHS CHC. It is not an assessment in itself; the information gathered will need to be supplemented with professional analysis and conclusion. It is designed to assist data collection, analysis and presentation of information of the adult’s healthcare needs, including evidence from assessments and reports completed by other members of the MDT.

8. Multidisciplinary Working

See The Multidisciplinary Team (MDT), National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care 

The core purpose of the MDT is to make a recommendation on eligibility for NHS CHC drawing on the multidisciplinary assessment of needs and following the processes set out in the National Framework.

An MDT in this context means a team consisting of at least:

  • two professionals who are from different healthcare professions, or
  • one professional who is from a healthcare profession and one adult who is responsible for assessing people who may have needs for care and support under the Care Act 2014.

The MDT should usually include both health and social care professionals, who are knowledgeable about the adult’s health and social care needs and, where possible, have recently been involved in their assessment, treatment or care.

As far as is reasonably practicable, the ICB must consult with the local authority before making any decision about the adult’s eligibility for NHS CHC. Different approaches can be used (for example face-to-face, video / tele conferencing) for arranging an MDT assessment, to ensure active participation of all MDT members, the adult and their representative, and any others with knowledge about the person’s health and social care needs as far as is possible.

It is best practice for assessors to meet with the person being assessed, ideally before the MDT meeting. All arrangements should take a person-centred approach.

If an adult with mental capacity refuses to participate in the assessment process, the MDT may consider relevant health and care records or existing assessments to decide the best way to meet their needs and whether they are eligible for NHS CHC. The consequences of undertaking the NHS Continuing Healthcare assessment or review as a paper-based exercise should be carefully explained to the adult, including that this may affect the quality of the assessment, if information is not up to date for example.

Both the MDT recommendation and the decision should be recorded in the adult’s case records. The NHS CHC process should usually be completed within 28 calendar days. This timescale is measured from the date the ICB receives the completed Checklist, indicating the need for full consideration of eligibility (or receives a referral for full consideration in some other acceptable format), to the date that the eligibility decision is made. However, wherever practicable, the process should be completed in a shorter time than this.

9. Decision-making by the ICB

See Decision-making on eligibility for NHS Continuing Healthcare by the ICB, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care

ICBs are responsible for eligibility decision making, based on the recommendation made by the MDT. Only in exceptional circumstances, and for clearly stated reasons, should the MDT’s recommendation not be followed.

ICBs should ensure consistency and quality of decision making.

The ICB may ask an MDT to carry out further work on a DST if it is not completed fully or if there is a significant lack of consistency between the evidence recorded in the DST and the recommendation made.

10. Care Planning and Delivery

See Care planning and delivery, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care

Where an adult is eligible for NHS Continuing Healthcare, the ICB is responsible for care planning, commissioning services, and for case management. It is also responsible for their case management, including monitoring the care they receive and arranging regular reviews.

The adult should be encouraged to have an active role in their care, be provided with information or signposting to enable informed choices and supported to make their own decisions.

ICBs may wish to commission NHS-funded care from a wide range of providers, in order to secure high-quality services that meet the adult’s assessed needs and offer value for money.

11. NHS CHC Three and 12 Month Reviews

See NHS Continuing Healthcare Reviews (at three and 12 months), National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care

Where an adult has started receiving NHS CHC, a review should be undertaken within three months of the decision being made. After this, further reviews should be undertaken on at least an annual basis, although some adults will require more frequent reviews in line with clinical judgement and changing needs.

These reviews should mostly focus on whether the care plan or arrangements remain appropriate to meet the adult’s needs. It is expected that in most cases there will be no need to reassess for eligibility.

12. Equipment

See Equipment, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care

Where an adult is eligible for NHS CHC and chooses to live in their own home, the ICB is financially responsible for meeting all their assessed health and associated social care needs. This could include:

  • equipment provision;
  • routine and incontinence laundry;
  • daily domestic tasks such as food preparation, shopping, washing up, bed-making; and
  • support to access community facilities (including additional support needs for the adult while their carer has a break.

However, the NHS is not responsible for paying for rent, food and normal utility bills such as gas, electricity and water.

13. Disputes

There are two types of disputes that may arise in relation to NHS CHC:

  1. challenges by the adult or their carer / advocate, including requests for reviews (also known as appeals). Staff may be involved in the appeal process, including undertaking an assessment / review of the adult’s needs and attending MDT / DST meetings;
  2. disputes between NHS and local authorities. In such cases staff should provide a clear rationale for disputing the outcome.

See Individual Requests for a Review of an Eligibility Decision and Inter-agency disputes, National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care for information about processes for resolving these situations including ordinary residence issues (see Ordinary Residence chapter).

14. Further Reading

 14.1 Relevant information

National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (Department of Health and Social Care)

NHS Continuing Healthcare Decision Support Tool

NHS Continuing Healthcare Checklist

NHS-Funded Nursing Care Practice Guidance

NHS Continuing Healthcare Fast-Track Pathway Tool

Full Consent Form for Participating in the NHS Continuing Healthcare Process and for Information Sharing with Family / Friends / Advocates

See also:

NHS Continuing Healthcare (NHS) 

NHS Continuing Healthcare (AgeUK) 

Appendix 1: Flow Diagram which sets out the Process for NHS Continuing Healthcare

Appendix 1: Flow diagram CHC Process

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1. Introduction

Falling, or worrying about falling, can be a great concern and anxiety for those who are getting older or who have illnesses or disabilities which may make them more vulnerable to falls.

Many people may not worry about having a fall until it actually happens. Straight after the fall, the main concerns will probably be about the physical impact and whether they need to see a doctor, go the the Accident and Emergency Department or even be admitted to hospital.

But, after the physical effects have faded, a fall can affect someone’s confidence, self-esteem and impact on the activities they enjoy, particularly if they are frightened it might happen again. A fall does not have to result in broken bones or bad bruising to seriously impact on a person’s mental well-being; even trips and small falls can have a significant effect.

As well as the physical and psychological effects of a fall for adults and their families, there is also an impact on health and social care services. For example, a person may need to be admitted to hospital for an operation to repair a broken hip or other significant injuries; a referral for home care services may be needed for support at home, or they may not be able to return home and need to move to permanent residential or nursing care. As well as the psychological impact on the adult and their family and friends, this puts additional pressure on hospital beds (particularly in relation to delayed discharge), hospital and social care staff and domiciliary and residential care services.

For a number of reasons therefore, reducing the possibility of someone having a fall is vital. This chapter outlines some of the main issues to consider in relation to falls, and summaries actions that can be taken to reduce the likelihood of a person having a fall. Issues raised in relation to preventing falls may be considered as part of a strengths based assessment.

2. Preventing Falls

There are a number of ways that people can reduce their risk of having a fall. These can be divided into actions for their person and also to their environment.

2.1 Actions for the person

2.1.1 Contacting the GP

The adult should discuss any falls they have had with their GP, and let them know if it had any impact on their physical and mental health or wellbeing.

The GP can carry out some easy balance tests, to see if they are likely to have another fall in the future. They can also refer them to appropriate services in the local area. They may also need to review any medication the adult is taking, as the side effects of some prescription drugs may increase the risk of someone having a fall; for example by making them feel dizzy.

2.1.2 Doing strength and balance exercises

Doing regular exercise can improve a person’s strength and balance and in turn reduce their risk of having a fall. These can be:

  • simple exercises such as walking or dancing;
  • community centres and local gyms often offer training programmes specifically designed for older people;
  • exercises that can be carried out at home;
  • tai chi can reduce the risk of falls. This is a Chinese martial art that focuses on movement, balance and coordination. It does not involve physical contact or rapid physical movements, so is a good exercise for older people.

See also Physical Activity Guidelines for Older Adults (NHS)

When someone had a fall, strength and balance training programmes should be personalised for that individual person, and monitored by an appropriately trained professional. In such circumstances, a GP should be consulted, and they will make a referral to other services and professionals as appropriate.

2.1.3 Eye tests

Eyesight changes as people get older and can lead to a trip or loss of balance. People should make sure they have eye tests at least every two years, and wear the right glasses for them, as problems with vision can increase the risk of having a fall. They should also get a test if they think their vision has got worse, even if this is before two years.

Not all vision problems can be cured, but some can be treated with surgery, for example cataracts can be removed which will improve a person’s sight.

See also Look after your eyes (RNIB) 

2.1.4 Hearing tests

Hearing also changes as people get older. Adults should get a hearing test if they think their hearing has got worse. They should also talk to their doctor, as ear problems can affect balance. It may be something which is easily treated, such as a build up of ear wax or an ear infection, or they may need a hearing aid.

See also Hearing Loss (NHS)

2.1.5 Alcohol and drugs, including prescription drugs

Drinking alcohol or taking drugs – including some prescription drugs – can lead to a loss of co-ordination. Alcohol can also make the effects of some medicines worse. This can significantly increase the risk of falls.

Avoiding alcohol or illegal drugs or reducing the amount of alcohol a person drinks can reduce their risk of having a fall. People should see their GP if they think their dizziness or lack of coordination may be related to prescription medication.

See also:

Alcohol Misuse (NHS)

Drug Addiction: Getting Help (NHS)

2.1.6 Footcare

People should take care of their feet by trimming toenails regularly, and seeing a GP or podiatrist (footcare professional) about any foot problems. If someone has foot pain it may cause them to walk differently, or limp which may affect balance. Wearing well fitting shoes and slippers that are in good condition and support the ankle can also reduce the risk of having a fall:

  • footwear should fit well and not slip off;
  • sandals with little support and high heels should be avoided;
  • slippers should have a good grip and stay on properly;
  • people should always wear shoes or slippers and not walk in bare feet, socks or tights.

2.1.7 Eating well

Having food that is nutritious, as well as tasty, helps people stay well. If people do not have a good appetite, it is better to eat little and often instead of three main meals, if they prefer. Having enough energy is important in keeping up strength and preventing falls.

See also Eat Well (NHS)

2.1.8 Drinking fluids

In addition to eating well, people should make sure they drink plenty. Not having enough fluids may result in someone feeling light-headed, which may increase their risk of a fall. People should drink about six to eight glasses of fluid (non alcoholic) a day.

2.1.9 Bone health

Bones can become weaker as people get older, and weak bones are more likely to break if a person falls. Bones can be kept healthier and stronger by eating food rich in calcium, getting enough vitamin D from sunlight and doing some weight bearing exercises as mentioned above.

2.2 Environment issues

2.2.1 Avoiding falls at home

Tips for preventing falls in the home include:

  • wiping up anything that has been spilt on the floor;
  • removing clutter, trailing wires and repairing or replacing frayed carpet;
  • using non slip mats and rugs;
  • making sure all rooms, passages and stairs are well lit, especially when it is dark. A night light near the bed so people can see where they are going if they wake up in the night – including motion-activated lights that come on as needed – are useful;
  • organising the home so that climbing, stretching and bending are kept to a minimum, and making sure that drawers and cupboards are closed immediately after use so they are not bumped into;
  • the adult getting help from other people to do things they cannot safely do themselves;
  • not wearing loose fitting, trailing clothes that might catch on door handles or trip the person up.

Mobile phones or alarms should always be carried, even around the house.

Personal alarms and telecare allow people to call for help if they are unwell or have a fall and cannot reach the phone. People can wear a button on a pendant or wristband at all times, or have other technology aids which will alert a 24 hour response centre. The staff at the response centre will contact friends or family on the adult’s pre-decided list of contacts or contact the emergency services.

See also Tips on Adapting Your Home as You get Older (Age UK)

2.2.2 Avoiding a fall outside

Falls do not just happen in the home, they can also occur in the garden, in the street and on outings, particularly if places are not familiar. The following should be considered to reduce risk:

  • if people are wearing a mask or face covering, they should be extra careful about moving around, as these can make it harder to see.  They may need to slow down to reduce the risk of falling;
  • people should use a walking stick, walking frame or walk with others for support if this helps them feel more confident;
  • walking on uneven ground in gardens may make some people more vulnerable to losing their balance, as can reaching and stretching to do gardening jobs. Mobile phones should always be carried, especially in the garden;
  • walking dogs who may pull, even if they are small dogs, can cause people to lose their balance, as can dogs who jump up;
  • take extra care in icy, snowy and wet weather – wet leaves and mud can also be very slippery. See also What to do when the Weather is Particularly Bad (Age UK)
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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

What people expect

I feel safe and supported to understand and manage any risks.

KNOWSLEY SPECIFIC INFORMATION

Knowsley Risk Management Arrangements

Domestic Abuse and Dementia (KSAB)

January 2024: This section has been updated to include a link to Knowsley Safeguarding Adults Board Dementia and Domestic Abuse Toolkit, as above.

1. Introduction

This chapter is a summary of the main parts of the Domestic Abuse Act 2021. For further information please see the Domestic Abuse Statutory Guidance (Home Office).  

2. Definitions

2.1 Domestic abuse

The Domestic Abuse Act provides a definition of domestic abuse.

It is the behaviour of one person towards another where:

a) both people are aged 16 or over and are personally connected to each other (see Section 2.2, Personally connected); and

b) the behaviour is abusive.

Behaviour is defined as abusive if it consists of any of the following:

  • physical or sexual abuse;
  • violent or threatening behaviour;
  • controlling or coercive behaviour;
  • economic abuse;
  • psychological, emotional or other abuse.

It does not make any difference whether the behaviour is a single incident or consists of a number of incidents over a period of time.

Economic abuse is any behaviour by a person that has a negative impact on the other person’s ability to:

  • obtain, use or maintain money or other property (such as a mobile phone or car. This would also include pets);
  • buy goods or services (for example utilities such as heating, food or clothing).

Under the Act, abusive behaviour towards a child who is under the age of 16 is considered child abuse, not domestic abuse (see Knowsley Safeguarding Children Partnership Procedures). Children are also recognised as victims of domestic abuse if they see, hear, or experience the effects of the abuse, and are related to the victim and / or perpetrator of the domestic abuse, or if the victim and / or perpetrator have parental responsibility.

Domestic abuse also includes so called ‘honour’ based abuse (see So Called Honour Based Abuse and Forced Marriage, the Crown Prosecution Service , forced marriage (see Forced Marriage, gov.uk) and female genital mutilation (see Female Genital Mutilation, gov.uk).

2.2 Personally connected

The Act introduced the term ‘personally connected’. This applies to people who:

  • are married to each other;
  • are civil partners;
  • have agreed to marry one another or have a civil partnership (whether or not they are still planning to);
  • are or have been in an intimate personal relationship with each other;
  • have, or have had, a parental relationship in relation to the same child;
  • are relatives.

2.3 Controlling or coercive behaviour

Controlling or Coercive Behaviour Statutory Guidance Framework (Home Office)

Controlling behaviour is a range of acts designed to make a person subordinate and / or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.

Both coercive and controlling behaviour can apply to people who are no longer in a relationship, but who were previously.

3. Victims and Perpetrators of Domestic Abuse

The majority of domestic abuse is committed by men against women, however victims do not come solely from one gender or ethnic group. Men are abused by female partners, abuse occurs in same sex relationships, can be committed by young people against other family members or their own partners (teenage domestic abuse is the most common), as well as abuse of older relatives or those with physical or learning disabilities. Domestic abuse occurs irrespective of social class, racial, ethnic, cultural, religious or sexual relationships or identity.

4. Working with People where there are Concerns of Domestic Abuse

On average, victims live with abuse for between 2 to 3 years before seeking help, and will experience 50 incidents of abuse before they receive effective help (see Safelives).

Social work interventions with adults who are experiencing, or at risk of, domestic abuse should seek to:

  • support victims to get protection from violence by providing relevant practical and other assistance;
  • identify those who are responsible for perpetrating such abuse, so that there can be an appropriate criminal justice response;
  • provide victims with full information about their legal rights, and about the extent and limits of statutory duties and powers;
  • support non-abusing parents in making safe choices for themselves and their children, where appropriate.

Professionals from any agency may receive a disclosure from a victim or perpetrator about domestic abuse, or have concerns that such behaviour may be taking place. All staff working with adults and families should be familiar with signs of domestic abuse, and know how to respond.

Concerns about domestic abuse may also be reported by a member of the extended family, friend or neighbour for example. Such information must be responded to in accordance with the Knowsley Safeguarding Adults Board Procedures.

Social workers in contact with adults who are threatening or abusive to them as professionals should be aware of the potential for that individual to be also abusive in their personal relationships. They should, therefore, assess whether domestic abuse may be occurring within the family environment.

4.1 Carrying out assessments

See also SafeLives: Resources for identifying the risk victims face, including the Domestic Abuse, Stalking and Harassment (DASH) checklist.

When carrying out any assessments, social workers should consider seeing the adult on their own so they can ask whether they are experiencing, or have previously experienced, domestic abuse. This may include asking direct questions about domestic abuse and asking whether domestic abuse has occurred whenever adult abuse is suspected. This should be considered at all stages of assessment, enquiries and intervention.

When assessing domestic abuse and the needs of the adult living with domestic abuse, the following factors should be considered:

  • age and vulnerability of the adult;
  • the adult’s description of the effects of the abuse upon them;
  • frequency and severity of the abuse, how recent and where it took place
    whether there were any children or other adults who either witnessed the abuse or was in the property at the time;
  • any weapons used or threatened to be used;
  • whether the adult victim has been locked in the house or prevented from leaving;
  • has there been any actual or threatened abuse of animals.

The social worker should decide, based on the assessment and their professional judgement, whether there is a threat to the safety of the adult or anyone else in the home environment.

If the threat is imminent, the police should be contacted immediately, by telephoning 999. If the threat is not imminent, the professional should raise a safeguarding enquiry (see Safeguarding Procedures for Responding in Individual Cases chapter).

The police are often the first point of contact for adults experiencing domestic abuse. However, the ambulance service and hospital Accident and Emergency Departments may also often be involved as a first point of contact.

Social workers should ensure that they make a full record of all discussions, including with whom they take place and any actions taken, including referrals to other agencies (see Case Recording Standards and Information Sharing chapter).

Under the Domestic Abuse Act the local authority has a duty to provide support to victims of domestic abuse and their children in refuges and other safe accommodation. In addition, all eligible homeless victims of domestic abuse automatically have ‘priority need’ for homelessness assistance (see Homelessness chapter).

5. Domestic Violence Disclosure Scheme

See also Domestic Violence Disclosure Scheme Factsheet (gov.uk)

The Domestic Violence Disclosure Scheme (also known as Clare’s Law) is made up of two elements: the Right to Ask and the Right to Know.

Under the Right to Ask, a person or relevant third party (for example, a family member) can ask the police to check whether a current or ex-partner has a violent or abusive past. If records show that an individual may be at risk of domestic abuse from a partner or ex-partner, the police will consider disclosing the information.

Right to Know enables the police to make a disclosure on their own initiative if they receive information about the violent or abusive behaviour of a person that may impact on the safety of that person’s current or ex-partner. This could be information arising from a criminal investigation, through statutory or third sector agency involvement, or from another source of police intelligence.

6. Professional Safety

It is important to assess any potential risks to social care staff, carers or other staff who are providing services to a family where domestic abuse is or has occurred. In such cases a risk assessment should be undertaken. Social care staff should speak with their manager and follow the local guidance for staff safety. Such issues should also be discussed during supervision (see Supervision chapter).

7. Further Reading

7.1 Relevant chapters

Safeguarding Procedures for Responding in Individual Cases

7.2 Relevant information

Domestic Abuse Statutory Guidance (Home Office)  

Controlling or Coercive Behaviour Statutory Guidance Framework (Home Office)

Domestic Abuse – How to Get Help (Home Office)

Safelives

Controlling or Coercive Behaviour Statutory Guidance Framework (Home Office)

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CQC Quality Statement

Theme 4 – Leadership: Learning, improvement and innovation 

We statement

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

1. Introduction

This chapter summarises the Emerging Concerns Protocol which was developed via the Health and Social Care Regulators Forum, to enable organisations and partners to act early and share information with regulators where there are concerns about risks to people using services, their carers, families or professionals.

The protocol was first published in 2016 and revised in 2021 to strengthen the arrangements previously in place and ensure a shared approach to any proposed actions.

Partners to the protocol  share a common objective of making sure that health and social care professionals and systems across the UK serve to protect the public, whilst maintaining the health, safety and wellbeing of professionals, people using services and also their families and carers.

They expect providers  and professionals to work together to provide the best possible care. The importance of sharing concerns at the right time is emphasised as this makes it easier to understand the links between pieces of information, which can indicate a problem is emerging. They note that working together more effectively can reduce unnecessary burdens; the aim of the protocol is to strengthen and encourage good practice by enabling the sharing of information about emerging quality concerns in a timely fashion.

Each of the organisations signed up to the protocol has a responsibility for responding to concerns about care provision and health professional education / learning environments and a role in ensuring that those who use services, their carers and families receive high-quality services from professional staff and registered health and social care organisations.

2. Purpose of the Protocol

The Protocol states:

‘The purpose of the protocol is to provide a clearly defined mechanism for organisations which have a role in the quality and safety of care provision, to share information that may indicate risks to people who use services, their carers, families or professionals. No piece of information is too small to invoke the protocol.

Information might include, but is not limited to:

  • situations that may not be seen as an emergency, but which may indicate future risks;
  • cultural issues within health and social care settings (including educational environments) that would not necessarily be raised through alternative formal systems.

The objective of the protocol is to be flexible and empowering, supporting regulators to understand how they can share information. This protocol is designed to work alongside protocols that already exist, however, it is specifically aimed at helping staff across the partner organisations to make decisions about when to escalate information of concern with one or more organisations. It is not intended to work against good working relationships and existing informal mechanisms that already exist, but to strengthen and encourage good practice. Nor is it intended to override the autonomy of existing organisations.’

One of the aims of the protocol is to provide guidelines on how to raise and escalate concerns that may seem small and not urgent, but which could point to a future risk. It intends to support a process of discussions taking place safely and without judgement, and decisions being made as to how relevant concerns can be addressed proactively rather than reactively. It does not replace existing responsibilities and arrangements for taking emergency action.

3. Principles

The following principles are laid down in the protocol:

  • organisations should have an open culture where staff can speak up about their concerns;
  • organisations should be transparent about how the protocol is used, whilst maintaining confidentiality;
  • organisations should be open about confidentiality agreements and limitations (including working with information shared by third parties);
  • organisations involved should maintain and respect the executive autonomy of each individual organisation involved;
  • the protocol must operate within the law, including any restrictions on sharing information;
  • it should be short and simple, with a focus on practicality;
  • it should be developed through a collaborative, partnership approach between the organisations involved;
  • no issue should be too small for an organisation to consider using the protocol;
  • the model should be linked to other system tools such as the Quality Risk Profiling Tool and existing Memoranda of Understanding.

4. The Process for Responding to Emerging Concerns

4.1 Categories of concern

Concerns may come into three categories:

  1. concerns about individual or groups of professionals;
  2. concerns about healthcare systems and the healthcare environment (including the learning environments of professionals);
  3. concerns that might have an impact on trust and confidence in professionals or the professions overall.

4.2 How to use the protocol

This is a summary of the process. See the Annexes for more detailed information about each stage.

4.2.1 Organisation A has a concern

4.2.2 Evaluate information

  • Evaluate information and source;
  • Does the protocol need to be triggered?

REMEMBER: no piece of information is too small to invoke the protocol.

At this stage it may be decided that the Protocol does not need to be triggered and the information can be dealt with through other routes.

4.2.3 Consider the interests of partner organisations

  • Who do we need to share with?
  • Who do we need information from? (See Annex A: Organisations Involved).

At this stage it may be decided that the Protocol does not need to be triggered and the information can be dealt with through other routes.

4.2.4 Contact organisations B, C & D to share (and request information)

  • All organisations store information in their own systems;
  • Organisation A responsible for formal recording of the use of the protocol.

See Section 6, Recording Requirements and Section 7, Sharing Personal Data

4.2.5 Hold regulatory review panel (RRP)

  • RRP convened, coordinated, chaired and minuted by Organisation A;
  • Use the template agenda for a regulatory review panel.

4.2.6 Share outcomes

  • RRP record shared with all partners and Health and Social Care Regulators Forum secretariat for monitoring and report at next Forum (including if there is no further action);
  • Use of protocol reviewed for learning every time.

5. Safeguarding

Any organisation may receive information that indicates that abuse, harm or neglect has taken place. Any form of abuse, avoidable harm or neglect is unacceptable. Each organisation has procedures for managing these types of concerns and they must be followed (see Safeguarding Procedures for Responding to Concerns in Individual Cases chapter). Each organisation remains responsible for ensuring they follow their own internal safeguarding procedures. Nobody should wait to activate the protocol instead of acting on safeguarding concerns – immediate action should always be taken where necessary (see Adult Safeguarding chapter).

6. Recording Requirements

See also Case Recording Standards and Information Sharing chapter

Each organisation involved in the use of the protocol should ensure records are made on their own system.

Each organisation should be able to report on:

  • the number of times they have initiated use of the protocol;
  • anonymised information about information shared;
  • RRPs convened;
  • RRPs attended;
  • actions as a result of the protocol.

The minimum information expected to be stored includes:

  • dates;
  • providers, professionals, others involved;
  • partners contacted;
  • actions agreed and taken;
  • decisions to call / not call RRP.

7. Sharing Personal Data

See also Annex C Sharing of Personal Data and Case Recording Standards and Information Sharing chapter

When using the protocol, mostly there should not be a need to share personal data about individuals. Organisations convening an RRP must ensure however that only those who need to know the information should attend if personal information is to be shared in the panel.

Any processing of personal data is subject to the requirements of the Data Protection Act 2018 and the UK General Data Protection Regulation (see Data Protection: Legislation and Practice chapter).

8. Further Reading

8.1 Relevant chapter

Whistleblowing

8.2 Relevant information

Emerging Concerns Protocol (Care Quality Commission and partners) 

Annex A: Organisations Involved

Organisations Involved

Annex B: An example of Protocol Use

An Example of Protocol Use

Annex C: Sharing of Personal Data

Sharing of Personal Data

Annex D: Questions to Consider when Determining whether to use the Protocol

Questions to Consider when Determining Whether to use the Protocol  

Annex E: Information for Regulatory Review Panel Chair

nformation for Regulatory Review Panel Chair

Annex F: Template Agenda for a Regulatory Review Panel

Template Agenda for a Regulatory Review Panel

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CQC Quality Statements

Theme 1 – Working with People: Assessing needs

We statement

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

What people expect

I have care and support that is coordinated, and everyone works well together and with me.

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

ADASS: Deprivation of Liberty Safeguard Forms

See also Mental Capacity Act Deprivation of Liberty chapter

Please note: The Liberty Protection Safeguards (LPS) were introduced in the Mental Capacity (Amendment) Act 2019 and proposed a new system for protecting people aged 16 years and above who lack capacity to consent to care and treatment and who need to have their liberty deprived. However, in April 2023, the Department of Health and Social Care announced that the LPS will not now be implemented before the next general election (which must be held no later than 28 January 2025).

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CQC Quality Statement

Theme 4 – Leadership: Governance, management and sustainability

We statement

We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes and we share this securely with others when appropriate.

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CQC Quality Statements

Theme 1 – Working with People: Supporting people to live healthier lives

We Statement

We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce future needs for care and support.

What people expect

I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally. I am supported to plan ahead for important changes in my life that I can anticipate.

KNOWSLEY INFORMATION

Knowsley’s Dementia Friendly Strategy

Merseyside Police Herbert Protocol (for people with dementia at risk of going missing)

Domestic Abuse and Dementia (KSAB)

January 2024: This section has been updated to include a link to Knowsley Safeguarding Adults Board Dementia and Domestic Abuse Toolkit, as above.

1. Introduction

As people get older, they sometimes find that loss of memory becomes problematic. Whilst it is normal for memory to be affected by a number of different factors including age, increased levels of stress, tiredness, menopause or certain illnesses and medications, it may be that there are underlying medical reasons that may require investigation and treatment, including dementia.

The following statistics relate to dementia in the UK:

  • there are currently an estimated 944,000 people with dementia;
  • the number of people with dementia is predicted to rise to 1.1m by 2030, 1.4m by 2040 and will reach 1.6m by 2050;
  • one in 14 people in the UK aged over 65 have dementia;
  • the financial cost is £34.7 billion each year;
  • women are more likely than men to develop dementia in their lifetimes, partly due to the fact that women live longer than men. (Alzheimers SocietyDementia Statistics Hub).

2. What is Dementia?

Dementia is a common condition which is more likely to develop with age and usually occurs in people over the age of 65.

It is a syndrome (which is a group of related symptoms) associated with an ongoing decline of brain function. It affects:

  • memory loss;
  • thinking speed;
  • mental agility;
  • language;
  • understanding;
  • judgement.

An adult with dementia may experience different mental changes. This includes losing empathy with other people, hearing or seeing things that are not real (auditory or visual hallucinations), becoming up and down in their mood (being less emotionally stable), not having any interest in things and losing interest in past activities. Social situations may become more difficult as their personality changes.

Where there are concerns that an adult with dementia no longer has mental capacity, safeguards should be put in place to ensure decisions are made in their best interests (see also Mental Capacity and Code of Practice chapter).

The speed at which a person’s symptoms get worse and the way they develop depends on the cause of the dementia, as well as their overall health. This means that the symptoms, the rate of progress and experience of dementia can be different for each person. There are no treatments yet that can slow the progression or delay the onset of the diseases which cause dementia, but a number of treatments which care currently available on the NHS can help to temporarily reduce symptoms.

An adult who is experiencing a number of the symptoms related to dementia may find it difficult to keep being independent and may often need help from family or friends, including help to make decisions.

If a person – or their family or friends – is worried that they may be developing dementia, in the first instance they should see their GP.  Following investigations, early diagnosis can help people get the right treatment, care and support and help those close to them to prepare, access support for themselves and plan ahead. With treatment, care and support many adults can lead active and fulfilled lives.

3. Different Types of Dementia

3.1 Alzheimer’s disease

Alzheimer’s disease is the most common cause of dementia, it causes changes to the chemistry and structure of the brain which results in brain cells dying. Common symptoms of Alzheimer’s disease and other forms of dementia include:

  • memory loss – especially problems with memory for recent events, such as forgetting messages, remembering routes or names, and asking questions repetitively;
  • having increasing difficulty with everyday tasks and activities;
  • becoming confused in places they do not know / do not know well;
  • having difficulty finding the right words;
  • having difficulty with numbers and / or paying in shops, particularly with cash;
  • changes in their personality and mood;
  • feeling depressed.

Early symptoms of dementia (sometimes called cognitive impairment) are often mild and may get worse very gradually. This means that some people – and their family and friends – do not notice them or take them seriously for quite a while.

3.2 Vascular dementia

Vascular dementia is caused when the oxygen supply to the brain fails and brain cells die as a result. This can either happen suddenly such as after a stroke, or over time as a result of a number of small strokes. Symptoms can start quite suddenly and quickly get worse, although they can also develop gradually over many months or years.

People with vascular dementia may also experience stroke-like symptoms, including weakness or paralysis on one side of their body.

3.3 Dementia with Lewy bodies

This form of dementia is caused by tiny round structures that develop inside nerve cells in the brain, which leads to a deterioration of brain tissue. Dementia with Lewy bodies has many of the symptoms of Alzheimer’s disease, but people with the condition also usually experience:

  • periods of being awake or drowsy, or fluctuating levels of confusion;
  • seeing things that are not there (visual hallucinations);
  • becoming slower in their way they move.

3.4 Frontotemporal dementia

In this type of dementia, damage usually occurs in the front part of the brain, so an adult’s personality and behaviour are more affected to start with than their memory. An adult with this type of dementia may become less sensitive to other people’s emotions, perhaps seeming cold and insensitive. They may also behave in a way that is out of character for them, such as making inappropriate comments. Some adults also experience language problems, which may result in them not speaking, speaking less than usual or having problems finding the right words.

4. Symptoms in Later Stage Dementia

As dementia progresses, memory loss and difficulties with communication often become very severe. In the later stages of their life, the affected adults is unlikely to be able to care for themselves and will require constant care and attention.

  • Memory symptoms: adults may not recognise close family and friends, remember where they live, know where they are and find it impossible to understand simple bits of information or carry out basic tasks or follow instructions.
  • Communication problems: adults may have increasing difficulty speaking and may eventually not be able to speak at all.
  • Mobility problems: adults may become less mobile, eventually becoming unable to walk and may be mostly in a bed and / or a chair.
  • Incontinence: urinary incontinence is common (wetting), and some people will also experience faecal (bowel) incontinence.
  • Eating, appetite and weight: losing their appetite and having difficulties eating or swallowing are common. This may lead to them choking, which may be followed by getting chest infections. People with these problems may lose weight as well.

As well as issues of mental capacity, care should be taken to make sure the adult’s human rights are not breached if they lack capacity to consent to care and treatment (see Mental Capacity and Code of Practice and Mental Capacity Act Deprivation of Liberty chapters).

5. Adults with Care and Support Needs

Getting a dementia diagnosis is a frightening time and receiving the right treatment and care and support early, when a person has first noticed symptoms, are some of the key points in the Care Act 2014 (see Promoting Wellbeing and Preventing, Reducing and Delaying Needs chapters).

Whilst an adult with an early diagnosis of dementia may not initially require care and support services at first, they will inevitably do so as the disease progresses (see Assessment chapter). Their carers may also require assessment and a support plan (see Assessment, Section 6, Carers’ Assessment).

When the time comes that they do need care and support services, some adults with dementia will be self-funders, that is they or a family member, for example, will pay for their care. They may not then want an assessment carried out by the local authority.

Where an adult is assessed by the local authority, a care and support plan should be developed with them, to make sure that they are able to state what their needs are and what they want to happen wherever possible, as well as those of their carer (see Care and Support Planning chapter).

6. Carers

Dementia is a very distressing illness for the person’s family and friends, as well as the person themselves. They often see the personality and abilities of their loved one change so much, sometimes to the point of being unrecognisable to how they were before. For couples who have been together a long time, for example, it is very upsetting when their partner or spouse no longer recognises them or the person physically or verbally abuses them.

When adults with dementia are being looked after at home by family or friends, it is very important that they receive all the multi-agency support needed to be able to best care for them for as long as they are able. This should include an assessment by the local authority if they wish, and the development of a support plan for the carer to put in place to support them to continue caring for their loved one, if this is what they wish to do. This may include home visits from care workers to help with care and support needs, day centre placements, short breaks in residential homes or having someone live in at home whilst they go on holiday.

Carers may feel a range of emotions, including not wanting their loved one to go into long-term care, when in reality they are struggling to cope looking after them at home. A review of the carer’s support plan should include discussions about the longer term future for the adult and their carer, Staff should sensitively discuss with them what may happen, and any preferences they may have, if there comes a time when they can no longer care for the adult.

Both the adult’s care and support plan and the carer’s support plan should include plans for what should happen if the carer cannot care for the adult on either a short term (illness for example) or permanent basis, including planning for what may happen in an emergency situation.

7. Making Advance Decisions

People can make some decisions to make sure their wishes and views are respected should they lose mental capacity in the future, as a result of dementia for example. This includes decisions about their health care treatment and authorising lasting power of attorney in relation to their health and welfare and / or property and financial affairs. See Making Advance Decisions chapter.

8. Safeguarding Adults with Dementia

As outlined above, common symptoms for adults with dementia include memory loss, disorientation, confusion, communication difficulties, behavioural issues, low mood and cognitive impairment. One or more of these factors can put an adult at risk of suffering, or experiencing, abuse or neglect.

They are vulnerable to abuse or neglect because:

  • dementia can affect a person’s ability to communicate or can make them confused, so they maybe unable to tell anyone what is happening to them;
  • they may not be able to manage their own financial affairs, and if an unsuitable person takes this over for them, it gives them opportunity to steal the adult’s money or other possessions;
  • they can be susceptible to psychological or physical abuse because carers cannot cope – either on a temporary or long term basis – and for example become angry, shout, care for them roughly or are otherwise unkind;
  • they can be targeted by abusers who take advantage of their condition and know they may be unable to refuse them or they may give in to people who bossy or overbearing and who ignore their wishes;
  • the adult may forget that the abuse has happened and not tell anyone.

As the condition progresses and the adult gets worse, their ability to self-protect lessens and often disappears completely.

Where there are safeguarding concerns, the Knowsley Safeguarding Adults Board procedures should be followed

9. Training and Supervision

Training should be available for all staff working directly with adults with dementia, but also to other frontline staff to ensure they have an awareness and understanding of the issues that are important for both adults and their carers when managing the person’s symptoms.

This is particularly important considering the expected rise in the number of people who will be affected by dementia over the next 10 years.

Staff supervision sessions need to recognise the difficulties that working with adults with dementia can present for staff, who are involved in supporting both them and their carer. The symptoms of dementia can result in behaviour that is difficult to manage in an effort to offer care and support to adults and carers, whilst also being emotionally distressing for the individual member of staff.

Support for these issues needs to be available for staff through supervision, as well as external sources of specialised support where required.

10. Further Reading

10.1 Relevant chapters

Mental Capacity and Code of Practice

Mental Capacity Act Deprivation of Liberty

10.2 Relevant information

Dementia: assessment, management and support for people living with dementia and their carers (NICE)

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CQC Quality Statements

Theme 1 – Working with People: Supporting people to live healthier lives

We Statement

We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce future needs for care and support.

What people expect

I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally. I am supported to plan ahead for important changes in my life that I can anticipate.

1. What is Frailty?

The term frailty or ‘being frail’ is often used to describe older people.

People who are frail often have reduced muscle strength and so get more tired easily (fatigue). They may find it much harder to recover from health issues such as a urinary tract infection or leg ulcers.

Frailty describes a person’s overall stamina and how this relates to their chance of recovering quickly from health problems. Approximately 10% of people aged over 65 live are frail. In those aged 85 and over, this increases to 25-50% (Age UK).

People living with frailty may or may not have other major health conditions. Being frail can be seen as a fairly ‘minor’ health problem, but in reality it can have a severe and long term impact on someone’s physical and mental health and wellbeing.

2. Frailty and General Health

There are a number of health conditions that are associated with being frail. Where staff from different organisations are working together with a person, their carers and family, the overall aim should be that the person’s frailty does not result in poorer health outcomes for them (see the Promoting Wellbeing and Preventing, Delaying or Reducing Needs chapters). It is important that a well-planned, joined-up care package is in place, to prevent problems arising in the first place and provide a rapid, specialist response if their situation changes.

Where frailty is a concern, the following should be assessed and monitored on an ongoing basis as part of the person’s care and support plan (see Assessment and Care and Support Planning chapters):

  • general health;
  • malnutrition and dehydration;
  • bladder and bowel problems;
  • dementia;
  • delirium (confusion);
  • mental health.

2.1 General health

As people age their health needs change, but there are practical steps people can take at any age to improve their health and reduce their risk of frailty.

All aspects of a person’s health should be addressed as part of their general health needs. These include:

  • looking after their eyes;
  • looking after their mouth and teeth;
  • keeping active;
  • getting the right medicines;
  • getting vaccinations;
  • preventing falls;
  • looking after their hearing;
  • eating and drinking well;
  • looking after their bladder and bowels;
  • keeping mentally healthy;
  • keeping their brain active.

There are other issues that can affect a person’s general health, including:

  • keeping warm;
  • making sure their home environment is safe;
  • preparing for winter as well as for heatwaves;
  • caring and looking after themselves.

Information about all of these issues can be found in A Practical Guide to Healthy Ageing (NHS and Age UK). 

2.2 Malnutrition and dehydration

Having a balanced diet and sufficient (non-alcoholic) fluids are essential to keep well. This is particularly important for someone living with frailty.

Malnutrition affects approximately 1 in 10 older people and is a risk factor for becoming frail. It is a serious condition where a person’s diet does not have the right amount of nutrients. This could be due to not getting enough nutrients (undernutrition) or getting more than is needed (overnutrition). Both these factors can contribute to health conditions. Nutrients are important to maintain physical health and promote healing after injury or illness.

People who are malnourished are more likely to visit their GP, have hospital admissions and take longer to recover from illness or operations. If an older person loses weight, whilst it could be due to health conditions, it may also be a result of being malnourished.

Older people are also more at risk of dehydration, where the body loses more fluid than it is taking in. Symptoms of dehydration include:

  • feeling thirsty;
  • having dark yellow and strong-smelling urine;
  • feeling dizzy or lightheaded;
  • feeling tired;
  • having a dry mouth, lips and eyes;
  • not passing much urine – fewer than four times a day.

Dehydration is one of the most common reasons why an older person is admitted to hospital. It is also associated with increased risk of urinary tract infections, falls and pressure ulcers.

If it is suspected that a person who is frail is malnourished or dehydrated, with their permission (or their relevant person) their GP should be informed as soon as possible.

If the person is likely to become malnourished or dehydrated, ensuring sufficient intake of nutrition and fluids should be included in their care and support plan including working with the person to ensure they have food and drink that they like and can tolerate.

2.3 Falls

Falls can be common in older people and can result in serious health issues. Once someone has experienced a fall, particularly if it has resulted in a significant injury, it can be a main cause of loss of independence and even eventually going into long-term care. After a person has had a fall, the fear of falling again can result in a loss of confidence and self-esteem which can lead to them becoming increasingly inactive, this in turn leads to a loss of strength and a greater risk of further falls.

Working with someone to prevent them falling or from having further falls can include a number of simple practical measures such as:

  • making simple changes to their home;
  • ensuring they have the right medication;
  • ensuring they have the right prescription glasses; and
  • doing regular exercises to improve their strength and balance.

See Falls – Prevention (NHS)

2.4 Bladder and bowel problems

Urinary and bowel incontinence and constipation are very common, particularly in older people. However, embarrassment and stigma about these issues mean people often delay seeking help and support. These conditions in older people are often poorly managed and can cause them a lot of distress. Not enough of an appropriate diet and fluids can also impact on a person’s bowel and urinary problems.

If there are concerns that a person who is frail is suffering incontinence or constipation, they – or their relevant person – should be supported to speak to their GP.

For further information about these issues, visit the websites below:

Urinary Incontinence (NHS)

Bowel Incontinence (NHS)

Constipation (NHS)

2.5 Dementia

More than 850,000 in the UK are estimated to be living with dementia. People who are living with frailty and who also have dementia are at increased risk of poor health as a result of not being able to care for themselves adequately, particularly if they are living alone.

See Working with People with Dementia chapter and Knowsley’s Dementia Friendly Strategy

2.6 Delirium

Delirium is an episode of acute confusion. It can often be mistaken for dementia, but it is preventable and treatable. Older people are more at risk of developing delirium and it can be quite common (particularly for those who have cognitive impairment, severe illness or have broken their hip or have a urinary tract infection for example).

Older people with delirium may have longer stays in hospital, have an increased risk of complications such as falls, accidents or pressure ulcers and be more likely to be admitted into long-term care.

For further information please see these websites:

Sudden Confusion (Delirium) (NHS) 

Delirium (Sudden Confusion) (Dementia UK)

2.7 Mental health problems

Mental health problems such as depression and anxiety can be quite common for older people, and can have a major impact on their quality of life. Mental health problems in older adults may not be reported and so often go undetected and are therefore under-treated.

Where an adult who is living with frailty is suspected of having mental ill health issues, they may be supported to speak to their GP or other relevant agencies.

See also Your Mind Matters (Age UK)

3. Related Issues

3.1 Loneliness and social isolation

Many elderly people suffer from loneliness in England. This can have a serious effect on their mental and physical health and wellbeing.

Loneliness and social isolation can have additional negative impact on someone who is already living with frailty. There are different ways that loneliness can be addressed, depending on the needs, wishes and interests of the person. Discussions should take place with them to see what local services they may be interested in to support them to feel less lonely and isolated.

For further information see Loneliness (Age UK)

3.2 Physical activity

The benefits of physical activity for older adults is well evidenced, with multiple health benefits including promoting general health, improving cognitive function, lowering the risk of falls and reducing the likelihood of developing some long-term conditions and diseases.

Depending on the needs, wishes, interests and physical ability of the person living with frailty, there will be different options and organisations for them if they want to get involved in activities in their local area.

See also Being Active as You get Older (Age UK)

3.3 Safeguarding

People who are frail may experience, or be at risk of, abuse or neglect. This may be a result of their frailty or in combination with other mental or physical health conditions. They may be directly targeted by perpetrators who perceive them to be vulnerable or suffer unintentional abuse. Abuse may be committed by people they know such as family, friends or carers or by strangers.

People living with frailty may experience health and social care services that are not suited to their individual needs. They can also be vulnerable to receiving poor quality healthcare and services. In such circumstances they or their relevant person should be supported to make a complaint, as appropriate, to ensure that they receive the care and support to which they are entitled. This may need to involve the local authority and / or the Care Quality Commission if there are safeguarding concerns related to a service provider.

For further information see Safeguarding Procedures for Responding in Individual Cases chapter

3.4 Supporting people at the end of life

Advanced care planning is key to ensuring a person who is frail receives good, personalised care at the end of their life. People should be encouraged to have proactive discussions about their wishes for care at the end of life as early as possible and their wishes recorded. These discussions should include advance decisions to refuse treatment and do not attempt resuscitation decisions.

See Making Advance Decisions chapter and End of Life Care chapter.

4. Living with Frailty

People living with frailty can be supported to live as full a life as they wish and are able, although this may mean they need to adapt how they live their life and find new ways to manage daily tasks and activities. This may apply to their family and friends too.

If someone is living with frailty, it does not mean they lack mental capacity (see Mental Capacity and Code of Practice chapter) or cannot lead a full and independent life. Just because a person is frail does not mean that they cannot make decisions about their daily life or wider issues such as finances and where they live for example. They may need some practical support to put those decisions into practice however, where they may have physical difficulties for example in achieving those goals.

Frailty can deeply challenge a person’s sense of themselves as well as change how they are perceived and treated by others, including health and social care professionals. Ensuring they receive person centred care and their wishes and desires are listened to and acted upon wherever possible therefore, is key to their sense of self-esteem and ongoing enjoyment of life (see Personalisation chapter).

5. Further Reading

5.1 Relevant chapters

Preventing, Reducing or Delaying Needs

Assessment

5.2 Relevant information

Frailty in older people (Age UK)

Frailty and the NHS Long Term Plan (Age UK)

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CQC Quality Statement

Theme 4 – Leadership: Learning, improvement and innovation 

We statement

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

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CQC Quality Statements

Theme 1 – Working with People: Supporting people to live healthier lives

We Statement

We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce future needs for care and support.

What people expect

I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally. I am supported to plan ahead for important changes in my life that I can anticipate.

September 2023: A link has been added in Section 8.2, Relevant information to Case Studies about Improving Support for People with a Learning Disability and Autistic People published by the LGA.

1. Introduction

Autistic adults may have been diagnosed as a child, or when they are older. Some may not have been diagnosed at all; this may be because they do not realise they are autistic, have not wanted support or have not felt able to speak to anyone about it.

Many people learn to cope with autism in their own way, although this may not be easy. They may be married or living with a partner, have families and successful careers. Others may be socially isolated, especially if they find it difficult to spend time with family or make friends.

This chapter is a summary of some of the main issues that staff need to consider when working with autistic adults, to help ensure their needs and wishes are identified and taken into account and adjustments are made as required so they can participate fully in decision making. It also provides additional references and website links.

2. What is Autism?

Autism affects how people communicate and interact with the world. The cause of autism is unknown, or if in fact if there is a definite cause. More than one in 100 people are autistic, and there are around 700,000 autistic adults and children in the UK (National Autistic Society). Whilst people from all nationalities, cultural, religious and social groups can be autistic, more males are seem to be diagnosed than females, but this may be a result of under-diagnosis in women and girls.

Autism is not an illness or disease; it cannot be ‘cured’. It is a life-long condition, and some people feel that being autistic is an important part of their identity. Autism may not be visible and therefore can be easily missed (see Working with Adults with Hidden Disabilities chapter).

All autistic people can learn and develop. Getting the right type of support and understanding, makes a huge difference to autistic people.

3. The Autism Spectrum

See also What is Autism (National Autistic Society)

Autism is a spectrum condition; there is a wide variation in the type and severity of symptoms that people can experience. All autistic people are affected in different ways. ‘Autism spectrum disorder’ (ASD), or more simply autism, is the commonly used term.

Autistic people may:

  • find it hard to communicate and interact with other people;
  • find it hard to understand how other people think or feel, and find it how to say how they feel themselves;
  • find it hard to make friends or preferring to be on their own;
  • seem blunt, rude or not interested in others without meaning to;
  • be highly focused on interests or hobbies;
  • find things like be over or under sensitive to light, sound, taste or touch, finding them stressful or uncomfortable;
  • get very anxious or upset which can lead to meltdowns or shutdowns;
  • take longer to understand information;
  • do or think the same things over and over and feel very anxious if their routine changes. resulting in repetitive and restrictive behaviour.

Autism is not a learning disability, and autistic people can have any level of intelligence. However, autistic people may have other conditions (see Section 4, Other Conditions), which will mean they need different levels of support.

4. Other Conditions

Other conditions that can also affect autistic adults include:

  • Attention deficit hyperactivity disorder (ADHD);
  • dyslexia and dyspraxia;
  • problems sleeping (insomnia);
  • mental health problems;
  • learning disabilities;
  • epilepsy;
  • problems with joints and other parts of the body, including:
    • flexible or painful joints;
    • skin that stretches or bruises easily;
    • diarrhoea or constipation.

For more information on these conditions see Other Conditions that affect Autistic People (NHS)

5. Assessment and Diagnosis

If someone thinks they may be autistic and wants to speak to someone about it, they should make an appointment to see their GP. If you think an adult you are supporting may be autistic, the National Autistic Society has advice on how to discuss this with them (see Broaching the subject, National Autistic Society).

They may be referred to a specialist for an autism assessment (see What happens during an Autism Assessment, NHS).

An autism diagnosis can be a daunting time, and may come as a shock, but for others it is a relief to find out why they think, feel and act the way they do.

Autism is not a medical condition that can be treated or cured, but following assessment, autistic people can access appropriate support and interventions, and adjustments can be made to help them stay well and have a good quality of life.

See also Newly Diagnosed: Things to Help (NHS)

Assessments and care and support plans should be reviewed and revised if it is felt that a person’s condition, or related conditions, are either deteriorating or improving. In addition, under the Equality Act 2010, services should make changes to the way they are delivered to ensure they are accessible to autistic people and people with other disabilities. The changes are called ‘reasonable adjustments’. Autistic people should always be asked if they require reasonable adjustments, and details of these should be clearly recorded and referred to each time the person accesses the service. Reasonable adjustments should be reviewed to ensure they continue to reflect a person’s circumstances.

6. Working with Autistic Adults

Autistic people can live a full life; it does not have to stop anyone having a good life. Like everyone else, autistic people have some things they are good at as well as things they find more of a challenge. A strengths-based assessment (see Section 5, Assessment and Diagnosis) should reveal these and be included in the person’s care and support plan, alongside any agreed ‘reasonable adjustments’ to the way services will be delivered.

Everyone is different, but there are some common characteristics that staff should consider when communicating and working with an autistic person.

  • Personalisation: Make sure the person is at the heat of all decision making, work with them to identify their unique abilities and challenges, and then work alongside them to achieve their (self) identified needs.
  • Communication: Staff should remember that the person may find it difficult to communicate and interact with other people. Staff should understand that what the person says and how they say it may well be a feature of their condition. They should give the person time to communicate and be calm and considered in their communication with them.
  • Understanding: The adult may find it difficult to understand how other people think or feel, therefore staff should remember that they may not be deliberately unfeeling or uncaring, but they are not able consider other people in the way that others do.
  • Suitable Environment: Staff should ensure that any meeting or intervention with an autistic person does not take place in a noisy and over-stimulating environment. If they meet the person outside the workplace, they should find out from them what type of place they like to go, that is manageable for them and does not cause them additional stress.
  • Anxiety: Autistic people can get anxious or stressed about unfamiliar situations and social events. Staff should take this into consideration when working with someone and plan interventions or meetings accordingly.
  • Presenting information: Some autistic people may take longer to understand information that is presented to them. Staff should give them additional time to process information and provide it in easy read formats or give other assistance where required. They should also check with the person that they have understood what is being communicated, both at the time and also check their understanding again at later dates.
  • Take time: Some autistic people may do or think the same things over and over again. Staff should bear this in mind when working with an autistic person and build additional time into their meetings and visits so that the person does not feel pressured to be quicker than is comfortable for them. Attempts to rush them may result in them feeling stressed which in turn may negatively impact on other behaviours.
  • Training:Training is important, as it helps to ensure that staff have the right skills and knowledge to be able to provide safe, compassionate, and informed care to autistic people. The Health and Care Act 2022 introduced a requirement for regulated service providers to ensure that their staff receive training on learning disability and autism which is appropriate to their role. The Oliver McGowan Mandatory Training on Learning Disability and Autism is the government’s preferred and recommended training for staff to undertake. The training is delivered in two parts: Tier 1 is for people who require general awareness of the support autistic people and people with a learning disability may need, and Tier 2 is for people who provide care and support to autistic people or people with a learning disability. Both tiers begin with an e-learning session. Employers are responsible for ensuring their staff have the appropriate training for their role, and will advise staff on whether they should complete Tier 1 or Tier 2.

7. Further Information

7.1 National organisations and sources

National organisations that provide detailed or further information include:

Social media pages dedicated to issues affecting autistic people include

Facebook:

Twitter:

Forums and communities:

7.2 Local support

Support services in a person’s local area should include:

  • local support groups (this information should be available from the local autism assessment service);
  • the local authority who may carry out a needs assessment with the person;
  • the local authority’s information and advice service;
  • at college or work – speak to student support services or the human resources department about reasonable adjustments which can be made;
  • search for local groups using:
  • the National Autistic Society services directory;
  • autism support groups on the NHS website.

8. Further Reading

8.1 Relevant chapter

Working with Adults with Hidden Disabilities

8.2 Relevant information

Capabilities Statement for Social Work with Autistic Adults (BASW)

Core Capabilities Framework for Supporting Autistic People (Department of Health and Social Care)

The Oliver McGowan Mandatory Training on Learning Disability and Autism (NHS Health Education England)

Case Studies about Improving Support for People with a Learning Disability and Autistic People (LGA)

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

What people expect

I feel safe and supported to understand and manage any risks.

1. Introduction

It is essential that workers in adult social care and partner agencies who are working with an adult who has care and support needs consider and include the needs of all family members when carrying out assessments and developing plans.

There are four steps to the Whole-Family Approach:

  • Step one: Think family;
  • Step two: Get the whole picture;
  • Step three: Make a plan that works for everyone;
  • Step four: Check it is working for the whole family.

This chapter is taken from The Care Act and Whole-Family Approaches (Local Government Association et al) and provides guidance about using the Whole-Family Approach in daily practice.

2. Step One: Think Family – Early Intervention and Prevention

Under the Care Act 2014, a whole system, whole council, whole-family approach which organises services and support around the adult and their family must be taken. It also means that everyone must think about the impact of the care needs of the adult on their family, including any children they have.

The principle of wellbeing is at the heart of this approach (see Promoting Wellbeing chapter). A vital part of an adult’s wellbeing is the situation they live in, who they live with and  family relationships. It is important to achieve a balance between their wellbeing and that of any family or friends  caring for them.

A whole-family approach to promoting wellbeing and preventing need for care and support may include helping the adult and their family to think about what changes may happen in the future, and to plan for these – when the adult needs more care or if a carer becomes unwell for example (see Reducing, Preventing or Delaying Needs chapter).

The needs of young carers, for example a teenager who has to look after their disabled parent, are included in both the Care Act 2014 and in the Children and Families Act 2014. This is to make sure the council takes a whole-family approach to assessing and supporting the adult and their young carer and delivers support in a coordinated, organised way. (See Young Carers chapter, Children’s Social Care procedures and Annex A of The Care Act and Whole-Family Approaches (Local Government Association et al).

In a council that thinks family:

  • There is leadership and commitment across the council to a whole-family approach with protocols in place across a wide range of local partnerships to enable services to be coordinated.
  • A Workforce Change Programme ensures the skills and referral arrangements are in place so that service protocols are operating ‘on the ground’.
  • Family-related questions are embedded in processes at first contact and subsequently, such as:
    • Who else lives in your house?
    • Who helps with your support and who else is important in your life?
    • Is there anyone that you provide support or care for?
    • Is there a child in the family (including stepchildren, children of partners or extended family)
    • Does any parent need support in their parenting role?
  • There is an active approach to establishing if there are any significant potential changes in families’ lives and working with them to plan for these.
  • Families and carers are an integral part of the design delivery and evaluation of services and support. (LGA p. 3)

3. Step Two: Get the Whole Picture – Whole Family Assessment

Getting the whole picture means seeing each person as an individual, as well as recognising the part they play in their family and community. Everyone has something to contribute to addressing the adult’s needs. The Whole-Family Approach builds on everyone’s strengths and develops their resilience. It also promotes working together with carers as partners, as well as the adult and other members of the family and friends where appropriate.

Understanding the needs of the whole family and getting them to think about the outcomes they want to achieve individually, as well as a family is vital. It means the worker can then provide the right guidance, information and services.

Assessment is an important part of the process for everyone (see Assessment chapter). During the assessment, the worker can give guidance and information to help the family understand the situation, their needs and strengths. This can help to reduce or delay any increase in the adult’s needs and make sure that they have support when they need it. The aim of assessment is to get a full picture of the person and their needs and goals, so any carers must be consulted. Carers are recognised in the Care Act, in the same way as those they care for (see Carer’s Assessment, Assessment chapter).

In a council that gets the whole picture:

  • There is a joint protocol in place between children and adult services that makes clear where responsibilities lie and how services work.
  • Information on the assessments and care and support plans that family members are having from other organisations is routinely identified. Where possible and appropriate, assessments are coordinated or combined.
  • Proportionate assessments are undertaken in a way that is most appropriate to each family.
  • People providing care and support are identified and involved in the assessment to provide their expertise and knowledge and views of what works and what does not.
  • Risks to carers of sustaining their caring role are always considered.
  • Carers’ willingness to continue caring is always established
  • Carers are always provided with an assessment on the appearance of need. Carers’ eligibility for support in their own right is always considered.
  • In all instances, even when a person can achieve an outcome independently, consideration is given to any impact on others and whether they might be adversely impacting on the health or safety of others, particularly family members and including children.
  • At assessment, all of a person’s eligible needs are identified regardless of whether such needs are being met by any carer.
  • When looking at eligible needs, consideration of the ability to maintain family or other significant relationships, including with any children, and the impact of these not being maintained on the adult’s wellbeing is always considered. This applies to both the person in need of care and support and their carer.
  • When a child may be a young carer, consideration is always given as to whether to undertake a young carer’s needs assessment under section 17 of the Children Act 1989.
  • Assessments of an adult identify any potential child in need who does not have any caring responsibilities. (LGA p. 4)

Where an assessment does identify a potential child in need, the worker should contact their line manager to discuss the situation and a referral should be made to children’s services as appropriate (see Knowsley Safeguarding Children Partnership procedures).

4. Step Three: Make a Plan that Works for Everyone – Developing the Care and Support Plan

When councils and other agencies adopt a whole-family approach to developing care and support plans this can help achieve the best outcomes for the whole family. Sometimes, however, a plan can have a negative impact on other members of the family, particularly carers. This is something which must be considered when plans are reviewed.

A whole-family approach can also make better use of resources. Sometimes plans are needed for more than one member of the family and from different organisations, for example the Care Programme Approach if mental health services are involved. Plans should not be developed in isolation from one another but should be developed together. If everyone involved agrees, including the practitioners, plans for different family members can be combined to form a single plan in which there may be parts for individual family members as well as the family as a whole. This can be particularly important in making sure that everyone’s wellbeing is being considered and it can also be helpful in addressing any areas of conflict that arise and agreeing a way forward so that everyone achieves what they need, as far as possible.

In a council that makes plans that work for everyone:

  • Support planning takes into account the wellbeing of all the family and the impact of any services and support on other family members. This includes identifying and responding to situations such as mutual caring, and carers living at a distance or outside of the local authority area.
  • Support planning always involves any carer and consideration is given to the involvement of other family members.
  • Support planning considers how carers can be supported to look after their own health and have a life alongside caring.
  • Plans include consideration of support to ensure a carer is able to fulfill any parenting role.
  • Consideration is given to how a person’s circle of support can be developed, where this might benefit them.
  • Where the local authority is going to meet the needs of multiple people in the same family, consideration is given to producing a combined plan with a joint personal budget (where this is appropriate and all involved agree).
  • Plans from different organisations for any family members are identified and consideration given as to whether these can be aligned, coordinated or integrated into a single plan (where all involved agree).
  • Where plans are integrated, a lead organisation is established to undertake monitoring and assurance and it is clear about when the plan will be reviewed and by whom. (LGA p. 5)

5. Step Four: Check it is Working for the Whole Family – Review of Plans

As with assessment and care planning, wherever possible a whole-family approach to review should be taken. It should concentrate on the results that are being achieved by the adult and their family (known as an outcome focused review). Workers should consider giving others permission to conduct the review; this could be the person themselves, a carer or someone else.

Workers need to oversee the process and sign off all reviews. Sometimes a ‘light touch’ approach can be helpful in the early stages, which might include a telephone call or asking the adult or another family member to carry out a self-review to check that things are working as intended. Whatever approach is used, it should always include consider any impact of the care and support plan on other family members.

Where the review identifies things that have changed, the care and support plan may need to be updated to include these. Again the adult, their carer and anyone else they want included should be involved. The whole-family approach should make sure that everyone’s needs and wellbeing are considered (including any children), that there are no consequences for anyone that had not been seen in advance and that everyone agrees with the plan.

In a council that knows its approach is working for the whole family:

  • The impact of the plan and results being achieved are reviewed in relation to both the individual and the whole family. This includes consideration of any unintended consequences for other members of the family.
  • Consideration is given to any changes that can be made to maximise the benefit to the whole family.
  • Carers’ (including young carers’) needs are routinely reviewed and the support they are willing and able to provide, as well as the outcomes they want to achieve, is re-established.
  • Any anticipated changes in the family that may impact on needs and support are identified and considered in any revised plan.
  • The plan is checked to see that it is providing adequate support to ensure children are not expected to offer inappropriate or excessive levels of care. (LGA p. 6)

6. Tools to Use with the Whole-Family Approach

Annex C of The Care Act and Whole-Family Approaches (Local Government Association et al)

includes some practical tools for working with families which can be adapted and developed for local use. These include:

  • questions to consider including in conversations at initial contact, assessment and care planning stages;
  • whole-family care planning discussion questions;
  • a genogram
  • how to identify support networks;
  • emergency crisis plans.

Annex D also provides a checklist of key practice points.

7. Further Reading

7.1 Relevant chapter

Domestic Abuse

7.2 Relevant information

The Care Act and Whole-Family Approaches (Local Government Association et al) 

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safe systems, pathways and transitions

We statement

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services.

What people expect

When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place.

I feel safe and supported to understand and manage any risks.

KEY POINTS

  • most people should be discharged to their home
  • discharge planning should begin at the point of admission
  • discharge planning should be person centred and involve a range of partner agencies, and the adult, their family, and carers (including unpaid carers) and independent advocates
  • an initial safety and welfare check should take place on the day of discharge

1. Introduction

The Hospital Discharge and Community Support Guidance (Department of Health and Social Care) came into effect from 1 April 2022. It sets out how NHS bodies (including commissioning bodies, NHS trusts and NHS foundation trusts) and local authorities can plan and deliver hospital discharge and recovery services from acute and community hospital settings.

According to the guidance, local areas should adopt discharge processes that best meet the needs of the local population. This could include the ‘discharge to assess, home first’ approach. Systems should work together across health and social care to jointly plan, commission, and deliver discharge services that are affordable within existing budgets available to NHS commissioners and local authorities, pooling resources where appropriate.

Under Discharge to Assess, Home First approach to hospital discharge, most people will be expected to return home (to their usual place of residence) following discharge. The Discharge to Assess model is built on evidence that the most effective way to support people is to ensure they are discharged safely when they are clinically ready, with timely and appropriate recovery support if needed. An assessment of longer-term or end of life care needs should take place once they have reached a point of recovery, where it is possible to make an accurate assessment of their longer-term needs.

Multi-disciplinary hospital discharge teams and transfer of care hubs, comprising professionals from all relevant services – including health, social care, housing and the voluntary sector – should work together so that, other than in exceptional circumstances, no one should transfer permanently into a care home for the first time directly following an acute hospital admission. Everyone should have the opportunity to recover and rehabilitate at home, wherever possible, before their long-term health and care needs and options are assessed and agreed.

This approach reduces exposure to risks such as hospital-acquired infections, falls and loss of physical and cognitive function by reducing a person’s time in hospital, and enables people to regain or achieve maximum independence as soon as possible. It also supports hospital ‘flow’, maximising the availability of hospital beds for people requiring this level of inpatient care and elective surgery, such as hip replacements.

Local areas should work together to develop the model within existing resources. This should include agreeing any investment to reshape provision towards more home-based, strengths-based care and support, and with less reliance and expenditure on bed-based provision.

The principles in the guidance should form the foundation for local planning of arrangements for discharge from acute hospitals and community rehabilitation units. This can best be achieved by providing choice for individuals, who should be supported to make fully informed decisions, with input from their wider family or unpaid carers (where appropriate, and where the individual consents) or their independent advocate. This process should be person-centred, strengths based, and driven by choice, dignity and respect.

2. NHS and Local Authorities Working Together

2.1 The care journey

The Hospital Discharge and Community Support Guidance (Department of Health and Social Care) aims to support local partners to jointly agree how to use their existing resources to best effect, to deliver the best possible outcomes for their population.

The local NHS body and local authority should agree the discharge models that best meet local needs and that are affordable within existing budgets available to NHS commissioners and local authorities.

This could include the discharge to assess, home first approach. Funding to support discharge can be pooled across health and social care via an agreement under section 75 of the NHS Act 2006 to minimise delays, ensure effective use of available resources and ensure the decisions about an individual’s care needs are made in their own environment.

Local areas can choose the appropriate funding mechanisms to enable these processes, such as the Better Care Fund (BCF), or other means that are affordable within existing budgets available to NHS commissioners and local authorities. For example, the BCF can, subject to local agreement, continue to be used to fund services at the interface of the health and social care system, such as intermediate care and hospital discharge planning, as well as core adult social care services and breaks for unpaid carers.

Care, when delivered at home, not only leads to better outcomes for the individual, but is also a better use of resources.

NHS bodies and local authorities should ensure that local funding arrangements are agreed by all partners and are aligned with existing duties, including those under the Care Act 2014 and the Mental Health Act 1983. These arrangements should also include clear information for self-funders of adult social care, so they can make informed choices about any onward care needs that do not fall under locally funded eligible costs.

Where local areas agree to fund a period of care (pending a long-term needs assessment being carried out), agreements should be in place to ensure no one is left without care or – if needed – an assessment of long-term needs prior to the end of this period. This should also ensure that no carers are left without adequate support or an assessment of their longer-term needs (if needed) at the end of this period.

Regardless of the hospital discharge, community support and funding model that is adopted locally, people and, where relevant, their families, unpaid carers, and independent advocates, should expect to receive personalised support that meets their needs and maximises the person’s independence. People should not be routinely discharged to a community step-down bed simply to free a hospital bed, nor should they routinely be discharged to a community bed simply because home-based care is not available. Where relevant, the decision about when to discharge a person, and any support they might need before an assessment of their long-term needs, should take into account the views and circumstances of any unpaid carers as well as those of the individual. Hospital discharge teams should also consider unpaid carers’ preferences and involve them to ascertain whether they are both willing and able to provide care and support post-discharge, before an assessment of longer-term needs. This should include an offer to refer to local carers’ support services.

If a person’s preferred placement or package is not available once they are clinically ready for discharge, they should be offered a suitable alternative while they await availability of their preferred choice. People do not have the right to remain in a hospital bed if they do not need acute care, including to wait for their preferred option to become available.

While NHS organisations should seek to offer choice to patients where such choice exists, in practice, there may be limited situations where an NHS organisation may decide to reduce the choice of services offered to people on discharge. Such situations include times of extreme operational pressures, for example, the UK COVID-19 Level 4 National Incident. A record should be produced of the considerations of the relevant discharging body in deciding to offer that patient a reduced choice, setting out all of the material considerations for and against doing so, and the balancing exercise between the patient choice duty in the NHS Act 2006, and relevant competing duties and countervailing factors.

2.2 Planning for discharge

Planning for discharge from hospital should begin on admission. Where people are undergoing elective procedures, the planning should start pre-admission, with plans reviewed before discharge. This will enable the person and their family or carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs. Further detail on the four discharge to assess pathways is set out in Annex 3 of the Hospital Discharge and Community Support Guidance (Department of Health and Social Care).

From the outset people should be asked who they wish to be involved and / or informed in discussions and decisions about their hospital discharge, and appropriate consent received. This may include a person’s family members, friends or neighbours, some of whom would be considered unpaid carers. Paid care workers and personal assistants may also be included. The person or people identified at this stage may be wider than a person’s next of kin. A person who does not have family or friends to help, or who may find it difficult to understand, communicate or speak up, should be informed of their right to an independent advocate (see Independent Advocacy chapter).

Multi-disciplinary teams (see Section 4, Joint Accountability across Health and Social Care Leads to Better Outcomes) should work across hospital and community settings – including with services provided by community health, adult social care and social care providers – to plan post-discharge care, long-term needs assessments and, where appropriate, end of life care (see End of Life Care chapter). Social workers, including children’s social workers of young carers and young adult carers, should be involved at an early stage of the discharge planning process where appropriate, including where that planning takes place in a hospital setting. The multi-disciplinary team should also ensure that any mental capacity and safeguarding concerns have been considered alongside other support needs post-discharge (see Mental Capacity chapter and Adult Safeguarding chapter).

Discharge planning should include information about post-hospital care, such as advice and information about community and voluntary sector organisations, housing options (such as home adaptations and possible alternative housing) and NHS or social care crisis response teams that can be contacted post-discharge.

Family members and unpaid carers providing care for the individual should be offered support where appropriate. For example, all unpaid carers may benefit from signposting to local carers’ support services, and they should be made aware of their right to an assessment for their own needs by their local authority. This includes young carers under the age of 18.

2.3 Discharge timing, location and support

Health and care professionals who are enabling hospital discharges to take place should work together with people and – where relevant – families and unpaid carers, to discharge them to the setting that best meets their needs. This process should be person-centred, strengths-based, and driven by choice, dignity and respect.

Most people being discharged go home without the need for ongoing support. Of those that remain, most people requiring supported discharges should be going home, with only a small proportion needing short-term bed-based intermediate care. Only in exceptional circumstances should someone be considered to need long-term care at the point of discharge. See Annex 3 of the Hospital Discharge and Community Support Guidance (Department of Health and Social Care) for further details about discharge pathways.

Support should extend beyond discharge itself. Local areas should have agreed protocols for collaborating with onward care providers about the individual’s hospital discharge through the transfer of care hub. Community health and care services, including GPs and social care providers, should:

  • communicate with the person and, where relevant, their unpaid carers to track and manage their recovery;
  • ensure that any change in the support needs of the person (or their carer) happens at an appropriate time.

People should be discharged to a familiar setting where possible, as they often respond well to the familiarity of their home environment when it is appropriate for supporting their needs. If required, they should receive rehabilitation or reablement support from NHS or social care services to enable them to regain their independence as far as possible. This can lead to a more accurate assessment of their future needs, once they have reached an improved point of recovery. Practitioners within acute and community health and local authorities should consider a range of factors when supporting the person and their family, unpaid carers or independent advocate to decide their care pathway and post-discharge support. This includes their preferences, existing provision of care, and whether unpaid carers are willing and able to support their recovery. Practitioners should be aware of young carers or young adult carers involved in unpaid support, working with them respectfully and appropriately and ensuring they have necessary support in place.

Discharging people to the most appropriate place to meet their needs requires active risk management across organisations to reach a reasonable balance between safety at all times, and independence (see Section 8, Specific Needs). Anyone requiring formal care and support to help them recover following hospital discharge should receive an initial safety and welfare check on the day of discharge to ensure basic safety and care needs are met and allow time for fuller assessments to take place as the person settles in their environment. This should be coordinated via the transfer of care hub. People should not have to make decisions about long-term care while they are in crisis or in an acute hospital bed.

Local areas should draw upon a range of short and medium-term interim care services, depending on the severity of a person’s needs. For example, some people may benefit from voluntary sector support, or very short term ‘hospital to home’ services to get them settled back home. Short-term (72-hour) reablement or live-in care services may also be useful to ensure people have care available while they settle at home, rather than being discharged to a community or care home bed, but these should be organised and agreed as affordable within existing budgets available to NHS commissioners and local authorities.

People with ongoing mental health needs, a learning disability, dementia, those in the last few months of life, and a range of other factors and conditions may require specialised support in the community to ensure their needs continue to be met. Children and young people facing the loss of a family member, and anyone facing the loss of a loved one due to suicide, should be informed about how they can access specialist bereavement support. The needs of homeless people will also need to be considered (see Section 8.5, Tailoring support to specific needs and circumstances). Local commissioning plans should include the provision of specialised support that meets the local population’s needs.

3. Structure, roles and responsibilities

3.1 Developing a discharge infrastructure

Discharging a person onto the right care pathway when they no longer need to remain in hospital requires a whole system approach. NHS organisations should work closely with adult social care, children’s social care, care providers, housing, the voluntary sector and others to ensure people’s care and treatment is timely, optimal and coordinated, while also minimising delays when they are ready to be discharged.

Senior level support from the NHS provider and the local authority should provide strategic leadership and oversight of the discharge process to monitor and eliminate the causes of unnecessary discharge delays, and ensure that the agreed hospital discharge procedures are being followed consistently.

NHS bodies, the local authority and other relevant partners should develop local protocols. These should set out each organisation’s role and how responsibilities should be exercised to ensure appropriate discussions and planning concerning a person’s short and long-term care options happen at the appropriate time in their recovery.

To ensure hospital discharge processes are effective, NHS bodies and the local authority should also ensure local recovery, rehabilitation and reablement services are commissioned effectively and sustainably, and meet the needs of their local population in the short and long term and are affordable within existing budgets available to NHS commissioners and local authorities. This may be provided as part of intermediate care services, and should be done in collaboration with relevant organisations, including the voluntary and community sector and care providers.

The support needs of specific populations should be considered when commissioning local services. This includes determining the type of specialist rehabilitation services needed for people with complex conditions, and ensuring appropriate social work provision and other specialist support is in place for people in complex, abusive or neglectful relationships. The involvement of advocacy should also be a key consideration where appropriate (see Independent Advocacy chapter). Local areas should also determine the best working arrangements for multi-disciplinary health and care teams who manage discharge from acute and community hospital settings, whether they choose to co-locate their staff, work together using virtual systems, or find other means of effective collaboration.

Commissioners should work with local voluntary and community sector organisations to develop and maintain capacity in the community to support people, including those who do not need specific reablement or rehabilitation, to retain links into the community and maintain their wellbeing.

3.2 Strategic planning

Health and social care systems based around a hospital should have an identified executive lead, employed by any partner in the system, to provide strategic oversight of the discharge process. They should ensure that appropriate procedures are followed, including the inclusion and support of carers, and that there are no avoidable delays to discharge.

Every local health and social care system should have a single coordinator who acts on behalf of the system to secure safe and timely discharge on the appropriate pathway for all individuals. This system leadership role can be employed by any partner in the system. Their primary function is to develop a shared system view of discharge, hold all parts of the system to account and drive the actions that should be taken as a system to address shared challenges. The single coordinator is accountable to the executive lead.

Every local health and social care system based around an acute hospital footprint should have a transfer of care hub whereby (physically and/or virtually) all relevant services across sectors (such as health, social care, housing and voluntary sector) are linked together. The transfer of care hub should coordinate care for people who require formal care and support after discharge from hospital, and any support for unpaid carers providing care. Hubs should be staffed by a small team, dedicated to ensuring people are discharged from hospital on the right pathways, with the right discharge information, and that they get the right onward care and support (if needed). Staff based in the transfer of care hub may also be the care givers and rehabilitation professionals for an individual. Decisions about what long-term support package is needed should not be taken on the hospital ward.

Case managers in transfer of care hubs should link relevant services to coordinate care and support the person. The case manager can be from any discipline (such as social care, primary care or therapies) depending on the needs of the person. They should also make arrangements for everyone leaving hospital with ongoing health and care needs to have an initial safety and welfare check on the day of discharge to ensure basic safety and care needs are met and allow time for fuller assessments to take place as the person settles.

Hospital multidisciplinary teams should describe – with input from the person and their unpaid carer, advocate, or relevant community-based professionals – the needs that require support after discharge before an assessment of their long-term needs. This could include non-clinical factors like their physical, social, psychological, financial and practical needs, including home adaptations and equipment. This could determine whether the person’s home is suitable for their needs upon discharge.

Multidisciplinary teams may include social workers, clinicians, therapists, mental health practitioners, pharmacists, care workers, dietitians, housing representatives, volunteer and community services and any other specialists needed to coordinate care for the individual. They should adopt strengths-based and person-centred planning, working together to plan care and carry out joint assessments. These teams should be aware of carers’ rights, and ensure carers are willing and able to care and that they have sufficient support to care safely. This helps to facilitate an integrated transition from hospital to the person’s usual place of residence. Safety should be ensured from the day of discharge. They should refer those requiring support to the transfer of care hub.

Hospital-based social workers have a vital role as members of a multi-disciplinary team, ensuring a person-centred and strengths-based approach is adopted during pre-admission, hospital stays and planned safe discharge. Their role in hospital and assessment settings is essential for people whose social circumstances are complex. These social workers should be experienced in supporting people to make informed choices, weighing up the risks and benefits of options. They should be familiar with mental health, mental capacity and safeguarding issues. They should also be knowledgeable about carers’ rights. They should understand the full options available to people in community settings in order to offer people the best choice and understanding of their recovery pathway.

It is critical that general practice and other primary care providers are directly linked into all discharge planning to ensure that health recovery support is available to the individual throughout their care journey.

Detailed guidance on accountability and roles can be found in Hospital Discharge Service: Action Cards.

4. Joint Accountability across Health and Social Care Leads to Better Outcomes

4.1 Cooperation duties

Section 82 of the NHS Act 2006 requires NHS bodies and local authorities to cooperate with one another to secure and advance the health and welfare of their local population. NHS bodies and local authorities must also comply with duties in the Care Act 2014, which requires them to co-operate with each other in the exercise of their respective care and support functions, including those relating to carers and young carers.

See Structure, Roles and Responsibilities, Hospital Discharge and Community Support Guidance (Department of Health and Social Care), planning, delivery and monitoring of discharge services, legal duties on health and social care bodies,

4.2 Escalation

Health and social care systems should have escalation mechanisms for people with concerns about care and support that are clearly communicated to people using services, their families, their unpaid carers and advocates, and service providers. These should clearly set out who is responsible for what and at which step of the process they should be engaged.

Concerns should be escalated via the locally agreed escalation mechanism, overseen by the single coordinator reporting to the executive lead. Areas will have flexibility over how this is implemented locally, but they should ensure mechanisms are agreed with all partners, and that there is a clearly identified responsible person at each stage of the discharge process.

Where a complaint needs to be raised against an NHS body, it should be made to them directly in the first instance. This can be done through the relevant body’s complaints department, or its Patient Advice and Liaison Service (PALS).

Where a complaint needs to be raised against a local authority or care provider, it should be made to them in the first instance. If this does not yield satisfactory results, or the complaint is not answered within a reasonable time, a complaint can be raised through the Local Government and Social Care Ombudsman.

People can also provide information to local Healthwatch organisations and the CQC, which may carry out a range of actions including inspecting the relevant body if it has the powers to do so.

5. Safe and Timely Discharges

Health and social care professionals should support and involve the person to be discharged in a safe and timely way to ensure they are only hospitalised for as long as they require hospital care. Discharging people once they no longer need acute care improves their outcomes and reduces the risk of medical complications such as deep-vein thrombosis, hospital acquired infections, and loss of independence.

No person should be discharged until it is safe to do so. This should include ensuring that, where relevant, any unpaid carers have been consulted on whether they are willing and able to provide care and support. Young carers should be offered independent advocacy support if they want it, to support them to consider how they will be impacted.

See also – the criteria to reside tool (see Annex D of the Hospital Discharge and Community Support Guidance (Department of Health and Social Care) supports clinical teams to have discussions and make decisions whether a person needs to stay in an acute bed to receive care.

6. Assessing for Long-Term Needs

People should be assessed for their long-term care needs following a period of recovery, rehabilitation and reablement (where required) when they are back in a familiar environment. The assessments should take place at a point of recovery when their long-term care needs are clearer.

Local authorities have duties to assess and meet people’s eligible care needs in relevant circumstances and these assessments should be conducted in a timely manner, in accordance with their Care Act 2014 duties. Best practice is for these assessments to be undertaken in a person’s home to determine long-term care needs.

If care, treatment or support is needed, the person should be fully involved in considering what form that might take and in weighing up the risks and benefits of the options that are available. This includes, if they require, consultation with family members and any carers who are willing and able to provide care and support. If they do not have any friends or family members to consult, an independent advocate should be consulted (see Independent Advocacy chapter).

Social care expertise is a central part of the process to determine people’s long-term care needs following a period of recovery and rehabilitation. It can maximise their independence, meet their needs and wishes and ensure they are fully aware of their options and the implications of each choice.

For people leaving the acute hospital environment it is best practice to screen for NHS Continuing Healthcare at the right time and in the right place for that individual (see NHS Continuing Healthcare chapter). In most cases this will be following discharge and after a period of recovery at home.

People with end of life needs will have additional considerations, which are set out in Section 8.1, Palliative and end of life care needs.

7. Active Risk Management

Multi-disciplinary discharge teams should work together when discharging people to manage risk carefully with the person and their unpaid carer, representative or advocate, as there can be negative consequences from decisions that are either too risk averse, or do not sufficiently identify the level of risk.

At one end of the scale, people may be discharged onto pathways which result in care being over-prescribed; and at the other end, individuals may not receive the care and support they need to recover. Any onward care providers should be included early in the person’s discharge planning. This allows more time for local capacity to be managed and for suitable support to be put in place. People’s care needs may also change, and there should be processes in place to ensure these needs are continuously reviewed and that the person is receiving appropriate support (see Section 4, Joint Accountability across Health and Social Care Leads to Better Outcomes).

Individuals and local factors will determine how best to manage risk. For example, in areas covering a broad geography, a virtual transfer of care hub may be one model that can facilitate multidisciplinary working to ensure information about individuals and any family or friends caring for them is shared effectively across organisations with their consent. Other areas may choose to co-locate key staff members from relevant organisations at a physical transfer of care hub, such as in a local acute hospital.

Alongside ensuring integrated working across health, housing, social care and other key organisations, assigning a single point of contact ensures that the individual or the family can communicate with professionals in a timely manner. Unpaid carers, in particular young carers and young adult carers, should be told how to communicate their concerns to professionals. This could be particularly crucial if there were a change in the person’s care needs post-discharge, such as their condition worsening. Supporting multidisciplinary working is also key to developing a shared approach to risk to support discharge. Huddles, trusted assessment, shadowing, and peer learning can all support this.

Health and social care professionals working in NHS bodies and local authorities should ensure that ‘safety netting’ is provided whereby the individual is provided with advice on discharge. The person should be given the contact details of their discharge team at the point of discharge and advised to make contact if they are concerned about anything. People should not be asked to see their GP or go to the emergency department following discharge, and they should only be followed up by a new team when the person’s relevant information has been handed over to the new team. Where appropriate, information provided to the person on discharge should be shared with their family, any unpaid carers and providers of onward care services. Where a young carer is identified, or any professionals responsible for care planning have concerns about this, the local authority has a duty to conduct a needs assessment, where it appears that the young person may need support.

8. Specific Needs

8.1 Palliative and end of life care needs

Consideration should also be given to people who have palliative care needs, including those who are nearing the end of their life (see End of Life chapter). Health and social care partners should work together to provide appropriate rehabilitation and reablement support from palliative and end of life specialist services and voluntary organisations. This may include support to maximise the individual’s independence or meet other personal goals.

People receiving palliative or end of life care should be supported to, where possible, recover from the incident that resulted in them being admitted to the acute hospital. They should receive appropriate and compassionate support from specialist organisations post-discharge to continue living the remainder of their time with dignity and as fully as possible. People who are recognised as likely to be in their last year of life may also benefit from further support such as benefits advice and equipment.

Systems should have regard to the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care for people where an appropriate clinician has decided that they have a primary health need arising from a rapidly deteriorating condition and the condition may be entering a terminal phase (see Continuing Healthcare NHS chapter).

Health and care providers should collaborate to minimise common issues that may disrupt end of life care during the interim care period. This includes access to medication and support, or trained professionals to administer them where necessary, and access to 24-hour nursing care and support to talk through the person’s wishes and preferences. Each person’s care journey should be anticipated and mapped out, including advanced care planning, to ensure they can move through a seamless pathway to end of life care, without unnecessary disruption.

8.2 Information sharing

See Case Recording Standards and Information Sharing chapter

One of the purposes of integrating health and social care is to ensure smoother care pathways with care joined up around a person’s life, needs and wishes, including an individual’s information and data being shared between relevant organisations with their consent. Relevant care information should be discussed and communicated in a timely manner to the individual and the people who will provide ongoing support, such as domiciliary care teams, GPs, unpaid carers, advocates and family members.

Health and care professionals (such as clinicians, social workers and therapists) should share appropriate information early to support a safe and timely discharge – for example about medication (including whether medication has changed since hospital admission) and immediate support needs, including transport and equipment required.

Local areas should work to establish information sharing protocols and mechanisms to enable data about the discharge process to be shared in a timely and effective manner to facilitate safe and timely discharges.

8.3. Planning and implementation of discharge

On discharge from hospital people who have new or additional needs should be offered choices of onward care and support to aid their recovery before any out of hospital assessment and arrangement of ongoing care and support (if needed). The choices offered should be suitable for their short-term recovery needs and available at the time of discharge.

Key to enabling choice while preventing delays is early and ongoing discharge planning conversations between healthcare professionals and people and their families and unpaid carers, following the principles of personalised care (see Personalisation chapter).

People in hospital should be supported to participate actively in making informed choices about their care, including, for people who fund their own care, the potential longer-term financial impact of different care options after discharge. These conversations should begin early in a hospital stay, and not when a person is ready to be discharged. This should also include, where appropriate, information about housing options (adaptation of the existing home and possible alternative housing, for example supported living).

Where there is disagreement between a person and their unpaid carers or family members, and the person is deemed by the appropriate professional to have capacity to make decisions relevant to their discharge, the person’s right to make these decisions should be respected.

Where a person wishes to return home and their family member or unpaid carer is unwilling or unable to provide the care needed, NHS bodies, local authorities and care providers should work together to assess and provide the appropriate health and care provision required to facilitate the individual’s choice, where possible, and enable a safe discharge.

If a person’s preferred care placement or package is not available once they are clinically ready for discharge, an available alternative or alternatives appropriate for their short-term recovery needs should be offered, while they await availability of their preferred choice. People do not have the right to remain in a hospital bed if they no longer require acute care, including to wait for their preferred option to become available.

8.4. Involving unpaid carers and family members in discharge decisions

Family members, friends and other unpaid carers play a vital role in the care of people who are discharged from hospital.

A determination should be made as early as possible in discharge planning – or following a period of recovery – about the status and views of any carers who provide care, including that they are willing and able to do so. This will need to be age appropriate if this is a young carer under the age of 18.

In delivering sound discharge planning, NHS bodies and local authorities will need robust systems to identify carers, including young carers, early in the process.

A carer’s assessment can be completed as soon as practicable after discharge (see Assessment chapter, Section 7, Carer’s assessment), but should be undertaken before caring responsibilities begin if this is a new caring duty or if there are increased care needs. If the assessment needs to take place prior to discharge it should be organised in a timely manner so as not to delay discharge from hospital. Under the Care Act 2014 the local authority must carry out an assessment where it appears that an adult carer may have needs for support at that time, or in the future, and to draw up a support plan for how these needs will be met. Should carers have substantial difficulty engaging in their own assessment, they should be referred for independent advocacy support (see Independent Advocacy chapter). Young carers in particular may benefit from independent advocacy support.

Recording carers’ details in electronic patient records can be one way to facilitate the identification and recognition of carers, particularly in cases where the person they are caring for has experienced repeat admissions. There is also the opportunity to identify the carer on their own patient record.

Practitioners should note that not all individuals who are (or will be) providing ongoing care will identify as a ‘carer’. If the person is nevertheless acting in the role of a ‘carer’, they should be regarded as one and involved in key conversations about the care needs of an individual after their discharge from hospital, or in having their own needs assessed. In other cases, the person being discharged may themselves have caring duties, such as a parent of child with a disability. Parents in this situation should be made aware of their right to an assessment of their needs and any additional services the local authority may need to put in place to support them in fulfilling their caring role for their child. This could include, for example, the provision of a short break or respite care to support the family.

Consideration should be given to identifying any children or young people in the household who have caring responsibilities, or may have new responsibilities at the point of discharge. This may include children or young people taking on a greater caring role in relation to a disabled sibling or other child in the family, as well as providing care to a parent following discharge.

Where a young carer is identified, or any professionals responsible for care planning have concerns that the person will be discharged into the care of a person under the age of 18, the local authority should be notified of this information. Upon notification, the local authority must carry out an assessment where it appears that the young person may need support or on request from the young carer or their parent. Any assessment should take into account the young carer’s age, understanding and family circumstances. Local authority assessments must also consider whether it is appropriate or excessive for the young carer to provide care for the person in question, in light of the young carer’s needs and wishes. The NHS has a duty to cooperate with local authorities in exercising these responsibilities.

There are instances where relationships are abusive: the individual or their carer may be abused, may abuse or be neglectful, or may have key information about abusive others. The Multi-Agency Safeguarding Adult Procedures for Knowsley should be followed where abuse, or risk of abuse, is identified, or staff members have concerns about abuse.

8.4 Mental capacity and advocacy

See Mental Capacity chapter

Mental capacity should be assessed on a decision-specific basis. If there is a reason to believe a person may lack the mental capacity to make relevant decisions about their discharge arrangements at the time the decisions need to be made, a capacity assessment should be carried out as part of the discharge planning process. Where the person is assessed to lack the relevant mental capacity to make a decision about discharge, a best interests decision must be made in line with the Mental Capacity Act 2005 and usual processes. No one should be discharged to somewhere assessed to be unsafe, and the decision maker must make the best interests decision.

Onward care and support options which are not suitable (for example, those not considered clinically appropriate) or available (for example, placements which are not available) at the time of hospital discharge should not be considered in either mental capacity assessments or ‘best interests’ decision making. Just as a person with capacity does not have a right to remain in a hospital bed if they no longer require acute care, neither is this an option for a person who lacks the mental capacity to make the discharge decision.

During discharge planning, health and care providers should continue to meet their responsibilities regarding Deprivation of Liberty Safeguards, where appropriate (see Deprivation of Liberty Safeguards chapter). This is especially the case for, but not limited to, people with a learning disability, dementia, acquired brain injury or people currently lacking capacity to make decisions about their mental health treatment. This includes carrying out a capacity assessment before a decision about discharge is made if there is reason to believe a person may lack the mental capacity to consent to their discharge arrangements which amount to a deprivation of liberty.

It may be appropriate for an independent advocate to support an individual during the discharge planning process, and in some cases this may be a legal requirement (see Independent Advocacy chapter). Referrals to independent advocacy services should be made as soon as discharge planning begins and ideally upon admission.

8.5. Tailoring support to specific needs and circumstances

Where there are ongoing health, housing or social care needs after discharge with different care options available, individuals (and, where relevant, their family, unpaid carers or advocates) should be empowered and supported to make the best choice for their individual circumstances.

Transfer of care hubs should incorporate appropriate safeguards for individuals who require this. For example, people who are homeless, at risk of homelessness or living in poor or unsuitable housing should be identified on admission to hospital. Individuals with a physical or learning disability and mental health needs have an increased probability of needing to use the social care system in their lifetime. Local areas should ensure that all legal responsibilities are met in relation to After-care in section 117 of the Mental Health Act 1983.

Health and social care professionals should follow an ongoing commitment to reducing health disparities and inequalities and consider the needs of groups that might need specialised support. This includes, but is not limited to, understanding issues relevant to people from black, Asian and minority ethnic groups, LGBTQI, faith or cultural needs, people living with disabilities, autistic people, older people, unpaid carers, people who do not speak English, and those with specific communication needs.

Any local changes to discharge arrangements should ensure that care providers are continuing to meet their responsibilities regarding Deprivation of Liberty Safeguards. This is especially the case for, but not limited to, people with a learning disability, dementia, acquired brain injury or people currently lacking capacity to make decisions about their mental health treatment.

For people where new mental health concerns have arisen, psychiatric liaison teams should be contacted by case managers in the first instance to review and assess as appropriate. A care co-ordinator or relevant mental health clinician should be involved in the discharge planning for people with a pre-existing mental health concern who are known to mental health services, to ensure their mental health needs are considered. They should ensure that the proposed onward care provider, if relevant, is fully aware of the person’s support needs. For those who are being discharged from an acute hospital following an episode of self-harm, the provider should consult NICE guidance on Self-Harm to ensure appropriate processes are being followed. Where individuals present with mental distress but do not meet the criteria for secondary mental health services, a preventative mental health offer should be available.

All people who are homeless or threatened with homelessness (see Homelessness chapter) should be identified on admission to hospital. During the hospital stay, the person should be referred by acute hospital staff to local authority homelessness or housing options teams, under the requirements of the Homelessness Reduction Act 2017, if the person consents. This duty to refer ensures services are working together effectively to prevent homelessness by ensuring peoples’ housing needs are considered when they come into contact with public authorities. People who are homeless or at risk of homelessness should not be excluded from short-term post-discharge recovery and support because of their housing status. Further guidance on supporting people who are homeless when being discharged from hospital can be found in the LGA and ADASS high impact change model for managing transfers of care and the accompanying support tool (see Managing Transfers of Care – A High Impact Change Model (LGA et al).

For people living in poor or unsuitable housing the local housing authority has a duty to provide any necessary adaptations (as determined by legislation and regulations underpinning the Disabled Facilities Grant System) and assess housing needs. The local authority also has the power to implement fast track and integrated systems for such provision.

Many people admitted to acute medical units have a condition which makes them frail (see Working with People Living with Frailty chapter). This is characterised as:

  • multiple physical, cognitive and functional impairments resulting in longer stay in hospital;
  • higher rates of hospital acquired harms such as deconditioning, falls, infection, delirium and adverse drug events.

Research suggests that the average 30-day readmission rates are around 20% in this group, but many can be prevented by comprehensive geriatric assessment and discharge planning that includes a specific focus on:

  • medicines reconciliation and optimisation;
  • patient and carer information, advice and support;
  • falls interventions (see Preventing Falls chapter);
  • provision of assistive technology to mitigate risk at home.

The default pathway for people with frailty should be home first, with intermediate care at home to regain functional ability after discharge. However, some people with more severe frailty may require a period of step-down bed-based care to support them to regain confidence and independence in a homelike environment. For those individuals, care should adopt a reablement approach, supported by the community intermediate care team in order to maximise recovery and delay progression to long term residential care.

9. Case Studies

The Hospital Discharge and Community Support Guidance (Department of Health and Social Care) provides two case studies about how two local areas have agreed funding to support best practice for their local hospital discharge services.

10. Further Reading

10.1 Relevant information

Hospital Discharge and Community Support Guidance (Department of Health and Social Care)

Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NICE)

Admission and Care of Residents in a Care Home during COVID-19 (DHSC) 

Professional Practice Guidance for Hospital Social Work with Adults during Covid-19 (BASW)

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CQC Quality Statements

Theme 1 – Working with people: Equity in experiences and outcomes

We statement

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

What people expect

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

1. Introduction

This chapter outlines the main points of the Equality Act 2010, and also how it relates to working with people with care and support needs, including safeguarding adults. The Act ensures there is consistency in what a local authority does to provide services in a fair environment and comply with the law. This includes all the people who use its services, their family and friends and other members of the public, staff, volunteers and partner agency staff.

2. Equality Act 2010

The Equality Act references ‘protected characteristics: all of which must be considered when implementing safeguarding procedures (see also Section 4.2, Protected characteristics). The Act covers both direct and indirect discrimination against people with these characteristics. These are:

  • age;
  • disability;
  • gender reassignment;
  • race;
  • religion or belief;
  • sex;
  • sexual orientation;
  • marriage and civil partnership;
  • pregnancy and maternity.

A local authority’s commitment to equality and diversity means that every person supported by it has their individual needs comprehensively addressed. They will be treated equally and without discrimination. This is regardless of any protected characteristics or another aspect that could result in them being discriminated against. The local authority is also committed to protecting individuals’ human rights. Failure to make reasonable adjustments in the care of a certain group with a protected characteristic (for example, a learning disability) may violate the Equality Act. It should have a process by which it considers how to promote equality.

3. Commitment to Equality, Diversity and Human Rights

The local authority should express its commitment to equality and diversity by:

  • respecting the ethnic, cultural and religious practices of people who use its services and making practical provision for them to be observed as appropriate;
  • reassuring people who use its services that their diverse backgrounds enhance the quality of experience of everyone who lives and works in any service provided by it;
  • protecting people’s human rights – treating them and their family and friends, fairly and with respect and dignity;
  • accepting adults who use its services as individuals;
  • supporting people to express their individuality and to follow their preferred lifestyle, also helping them to celebrate events, anniversaries or festivals which are important to them;
  • showing positive leadership and having management and human resources practices that actively demonstrate a commitment to the principles of equality and diversity;
  • developing an ethos throughout its services that reflects these values and principles;
  • expecting all staff to work to equality and diversity principles and policies and to behave at all times in non-discriminatory ways;
  • provide training, supervision and support to enable staff to do this;
  • having a code of conduct that makes any form of discriminatory behaviour unacceptable. This applies to both staff, people who use services and their family and friends, which is rigorously observed and monitored accordingly.

3.1 Human Rights

See also Appendix 1: Human Rights Legislation

‘Respecting diversity, promoting equality and ensuring human rights will help to ensure that everyone using health and social care services receives safe and good quality care.’ (Care Quality Commission)

The Care Quality Commission employs the commonly agreed ‘human rights principles’ in their inspection frameworks. These are sometimes called the FREDA principles:

  • fairness;
  • respect;
  • equality;
  • dignity; and
  • autonomy (choice and control).

These principles and standards should be at the heart of planning and delivery of care and in any required safeguarding processes involving adults with care and support needs and their family and friends. The local authority should also encourage and support its staff to develop knowledge and skills and, where relevant, provide organisational leadership and commitment to achieve human rights based approaches.

The local authority should encourage positive practice and a learning culture that promotes human rights. Staff must take swift action if they think someone’s human rights are being breached and speak to their line manager or designated adult safeguarding lead.

4. Guidance

4.1 Types of discrimination

All staff involved in the safeguarding process should be familiar with the following types of discrimination.

  • Direct discrimination occurs when a person is treated less favourably than others in similar circumstances on the grounds of race, colour, national or ethnic origins, sex, marital status, sexuality, disability, membership or non-membership of trade union, ‘spent convictions’ of ex-offenders, class, age, political or religious belief.
  • Discrimination by association applies to race, religion or belief, sexual orientation, age, disability, gender reassignment and sex. This is direct discrimination against someone because they associate with another person who possesses a protected characteristic (see Section 4.2, Protected characteristics below).
  • Perception discrimination is against an individual because others think they possess a particular protected characteristic. It applies even if the person does not actually possess that characteristic.
  • Indirect discrimination occurs when a condition or requirement is imposed which adversely affects one particular group considerably more than another.
  • Harassment is defined as unwanted, unreciprocated and / or uninvited comments, looks, actions, suggestions or physical contact that is found objectionable and offensive. Harassment is particularly liable to occur as part of sexual or racial discrimination.
  • Victimisation occurs when an employee is treated badly because they have made or supported a complaint or raised a grievance under the Equality Act, or because they are suspected of doing so. People are not protected from victimisation if they have maliciously made or supported an untrue complaint.

4.2 Protected characteristics

Under the Equality Act 2010 these are as follows.

  • Age: Where this is referred to, it refers to a person belonging to a particular age (for example 32 year olds) or range of ages (for example 18 – 30 year olds).
  • Disability: Under the Act, a person is disabled if they have a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities. The Act includes a protection from discrimination arising from disability. This states it is discrimination to treat a disabled person unfavourably because of something connected with their disability.
  • Gender reassignment: A transgender person is someone who proposes to, starts or has completed a process to change their gender. The Act does not require a person to be under medical supervision to be protected – so a woman who decides to live as a man but does not undergo any medical procedures would be covered. It is discrimination to treat transgender people less favourably because they propose to undergo, are undergoing or have undergone gender reassignment than they would be treated if they were ill or injured.
  • Marriage and civil partnership: In England and Wales marriage is not restricted to a union between a man and a woman and includes a marriage between a same-sex couple. Same-sex and mixed-sex couples can also have their relationships legally recognised as ‘civil partnerships’. Civil partners must not be treated less favourably than married couples (except where permitted by the Act). The Act protects employees who are married or in a civil partnership against discrimination.
  • Pregnancy and maternity: Pregnancy is the condition of being pregnant or expecting a baby. Maternity refers to the period after the birth. Protection against maternity discrimination is for 26 weeks after giving birth, and this includes treating a woman unfavourably because she is breastfeeding.
  • Race: Race refers to a group of people defined by their race, colour, and nationality (including citizenship) ethnic or national origins.
  • Religion or belief: Religion has the meaning usually given to it but belief includes religious and philosophical beliefs including lack of belief (for example atheism). Generally, a belief should affect life choices or the way a person lives for it to be included in the definition. In the Equality Act, religion includes any religion. It also includes a lack of religion.
  • Sex: Both men and women are protected under the Act.
  • Sexual orientation: Whether a person’s sexual attraction is towards their own sex, the opposite sex or to both sexes. The Act protects bisexual, gay, heterosexual and lesbian people.

5. Further Reading

5.1 Relevant information

Equality and Human Rights, Care Quality Commission

Equally outstanding: Equality and Human Rights – Good Practice Resource (CQC)

Social Work and Human Rights: A Practice Guide (BASW)

Culturally Appropriate Care (Care Quality Commission)

Appendix 1: Human Rights Legislation

See also Equality and Human Rights Commission 

  1. Human Rights Act 1998 Overview

The Human Rights Act 1998 (HRA) lays down the fundamental rights and freedoms to which everyone in the UK is entitled. The rights set out in the European Convention on Human Rights (ECHR) are incorporated in the HRA. It sets out people’s human rights in different ‘articles’, which are all taken from the ECHR. They are:

  • Article 2: Right to life;
  • Article 3: Freedom from torture and inhuman or degrading treatment;
  • Article 4: Freedom from slavery and forced labour;
  • Article 5: Right to liberty and security;
  • Article 6: Right to a fair trial;
  • Article 7: No punishment without law;
  • Article 8: Respect for private and family life, home and correspondence;
  • Article 9: Freedom of thought, belief and religion;
  • Article 10: Freedom of expression;
  • Article 11: Freedom of assembly and association;
  • Article 12: Right to marry and start a family;
  • Article 14: Protection from discrimination in respect of these rights and freedoms;
  • Protocol 1, Article 1: Right to peaceful enjoyment of property;
  • Protocol 1, Article 2: Right to education;
  • Protocol 1, Article 3: Right to participate in free elections;
  • Protocol 13, Article 1: Abolition of the death penalty.

Human rights law applies to public bodies and other organisations carrying out functions of a public nature. A number of these articles relate to working with adults with care and support needs, in particular Articles 2; 3; 5; 8.

The HRA can be breached in three ways by public bodies if they:

  • inflict explicit physical abuse or allow neglect of a person;
  • intervene in a person’s life unlawfully and disproportionately;
  • fail to intervene to protect a person from being abused or neglected by other persons.

2. Articles 2, 3, 5 and 8

2.1 Article 2 Right to Life

Article 2 applies in health and social care situations and requires an independent investigation into some deaths – coroner inquests – and may involve a breach of human rights with the state or public organisations implicated.

2.2 Article 3 Inhuman and Degrading Treatment

No one shall be subjected to torture or to inhuman or degrading treatment or punishment.

Degrading treatment would occur if it “humiliates or debases an individual showing a lack of respect for or diminishing his or her human dignity or arouses feelings of fear, anguish, or inferiority capable of breaking and individuals moral and physical resistance.” Pretty -v- UK [2002] 2FC 97

Article 3 is breached most frequently when public bodies carry out or are responsible for abusive care and treatment; that is allowing or ignoring actions when they should not have done so.

There is a positive duty under Article 3 for a public body to intervene when abuse is performed by one private individual against another person.

3. Article 5: Deprivation of Liberty

People who lack mental capacity are one of the categories when people can be deprived of their liberty (see Mental Capacity and Code of Practice chapter and Mental Capacity Act Deprivation of Liberty chapter). Legal procedures are set out in the Mental Capacity Act 2005 (MCA) and the Mental Health Act 1983 and should be followed. If they are not adhered to, it may lead to a breach of Article 5.

A deprivation of liberty under the MCA describes a best interest decision made in regard to a person who lacks mental capacity to decide about care, treatment or living arrangements. Such deprivations must be legally authorised under the provisions of the MCA (sections 4A-4B) or by order of the Court of Protection.

4. Article 8: Respect for private and family life, home and correspondence

Article 8 protects a person’s right to respect for their private life, their family life, their home and correspondence (for example, letters, telephone calls and emails).

4.1 Private life

A person has the right to live their life privately without government interference. This is a broad concept as interpreted by the courts, and covers areas such as:

  • sexual orientation;
  • lifestyle choices;
  • how someone chooses to look and dress;
  • the right for someone to control who sees and touches their body. In health services, for example, staff cannot leave someone undressed in a ward, or take a blood sample without the person’s permission;
  • the right to develop a personal identity;
  • to make friendships and other relationships;
  • a right to participate in essential economic, social, cultural and leisure activities. In some circumstances, public bodies, such as the local authority, may need to help someone enjoy their ability to participate in society;
  • the media and others being prevented from interfering in someone’s life.
  • personal information (including official records, photographs, letters, diaries and medical records) being kept securely and not shared without the person’s permission, except in certain circumstances (see Data Protection: Legislation and Guidance chapter).

4.2 Family life

People have the right to enjoy family relationships without interference from government. This includes the right to live with their family and, where this is not possible, the right to have regular contact. This includes couples who are not married, between an adopted child and adoptive parent and a foster carer and fostered child.

If a local authority makes an unjustified intervention in the life of person lacking mental capacity it may also breach Article 8- London Borough of Hillingdon v Neary [2011] EWHC 1377 (COP)

4.3 Home life

Everyone has a right to enjoy their existing home peacefully. Public bodies, therefore, should not stop a person from entering or living in their home without very good reason. They also cannot enter it without the person’s permission.

A right to home life does not mean, however, a right to be given housing.

4.4 Restrictions to Article 8

There are times when public bodies can interfere with someone’s right to respect for private and family life, home and correspondence. In such situations, the authority must be able to show that such action is lawful, necessary and proportionate in order to:

  • protect national security;
  • protect public safety;
  • protect the economy;
  • protect health or morals;
  • prevent disorder or crime; or
  • protect the rights and freedoms of other people.

Article 8 is not an absolute right. Interference with private life and family life is legally permissible but must be justified within the terms set out above.

A breach of Article 8 would occur if interventions are taken which are:

  • inconsistent with the relevant law;
  • consistent with the law but disproportionate and therefore unnecessary; or
  • for a purpose other than the criteria listed above.

5. Article 10 Freedom of Expression

Article 10 is the freedom to hold opinions and to receive and impart information and ideas without inference from the State. This right is not absolute but subject to several provisos. Restrictions can only be justified if they are for a specific purpose, for example:

  • public safety;
  • the prevention of disorder or crime;
  • the protection of health and morals;
  • the protection of the reputation or rights of others;
  • preventing the disclosure of confidential information.

The Care Act guidance warns local authorities against “abusive interventions that risk breaching the adult’s right to family life if not justified or proportionate“ Care and Support Statutory Guidance, Department of Health and Social Care, paragraph 14.98).

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CQC Quality Statement

Theme 4 – Leadership: Governance, management and sustainability

We statement

We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes and we share this securely with others when appropriate.

1. Introduction

Harassment and violence towards staff can have a direct effect on their health and safety. It can also affect standards of work, performance, confidence and morale of all staff.

Staff in roles most at risk are those who:

  • give a service;
  • are carers;
  • are in education;
  • are involved in cash transactions;
  • make deliveries / collections;
  • work with people who may exhibit controlling behaviour towards others;
  • represent authority.

Those committing acts of harassment and / or violence to staff may be adults with care and support needs, their family or friends or other members of the public. A person who commits such acts may be subject to a police investigation and criminal prosecution or other organisational sanctions, such as loss of service.

Managers and staff have a responsibility to abide by the policies and procedures of the service to:

  • limit incidents of harassment and violence;
  • respond to them appropriately;
  • protect themselves and their colleagues;
  • report the incident to the police with a view to prosecution, where appropriate.

2. What is Violence and Harassment?

2.1 Violence

Violence to staff is defined as abuse, threats or assaults in circumstances relating to their work. This includes:

  • verbal abuse;
  • offensive language;
  • discriminatory or derogatory remarks, for example those which are racist, sexist or homophobic in nature;
  • obscene gestures;
  • threatening behaviour;
  • stalking;
  • physical attacks;
  • spitting; and
  • throwing objects.

2.2 Harassment

Harassment is when a person causes alarm or distress to a member of staff; which can result in the victim being put in fear of violence. It can include repeated attempts to communicate with the member of staff, which are clearly unwanted and contact them in a way that the perpetrator expects to cause them distress or fear.

3. Assessing Risk from Violence and Aggression

The main factors that can create risk are:

  • mental health disorders;
  • impatience;
  • frustration;
  • anxiety;
  • resentment;
  • drink and / or drugs;
  • inherent aggression.

3.1 Violence risk assessments: staff responsibilities

Every adult who has a history of aggression / violence must have a care and support plan risk assessment. This should identify the risks and state the actions to be taken to minimise these risks. This should include family or friends who have such a known history, even if the adult themselves does not present a risk.

Information should be shared with other concerned organisations.

Systems in place to flag high risk cases should be activated.

Risk assessments should be regularly reviewed, care plans updated and actions taken to minimise risks.

Senior managers should be informed of risks and decisions documented and signed on case files.

3.2 Violence risk assessments: managers responsibilities

When carrying out a potential violence risk assessment, the following factors should be considered.

In the workplace:

  • work activities;
  • working conditions;
  • design of the work activities and surrounding environment;
  • frequency of situations that present a risk of workplace violence;
  • severity of the potential consequences to the member of staff who may be exposed to a risk;
  • information on workplace violence based on historical evidence and accurate information;
  • measures already in place to prevent workplace violence.

The wider working environment:

  • description of the department or area the manager or supervisor is in charge of;
  • history of violence in the department / service area;
  • activities in the department / service area that could expose workers to violence;
  • circumstances that might increase the risk of violence in the department / service area;
  • measures in place to address violence and the resources needed to implement them.

3.3  Recording

See Case Recording Standards and Information Sharing chapter

It is crucial for the safety and wellbeing of staff, adults and the protection of the organisation and wider community that risk assessments are fully documented. This includes clearly documented management oversight and decision making.

4. Management Responsibilities

Managers must assess the risk of both physical and non-physical assault to staff and take appropriate action to deal with it.

These steps may include:

  • providing suitable training and information;
  • improving the design of the working environment (such as physical security measures);
  • making changes to aspects of staff roles;
  • following the escalation policy of the organisation including reporting high risk cases of potential risk of violence and all incidents of actual physical and non-physical assault so that preventative action can be taken to ensure it is not repeated.

This will also help managers to check for patterns and so help predict the types of incidents that could occur.

Findings from all risk assessments should be communicated to all staff as appropriate, and arrangements put in place to monitor and review such assessments.

Mechanisms should be in place to share learning with staff and across the service.

4.1 Staff support

Depending on the seriousness of the incident, staff who have been the victim of harassment and / or violence should receive robust support from managers and the organisation’s human resources department as appropriate.

This may include:

  • debriefing by the line manager, as soon as possible following the incident;
  • supervision with the line manager for a more in-depth examination of the incident and any learning points that arise or further discussion with other colleagues including senior managers;
  • team discussion regarding the incident where appropriate to share learning and any change in practice required;
  • referral for counselling for the member of staff, where required;
  • support for the member of staff and the line manager, as required, in the case of any ongoing police investigation and subsequent prosecution or other internal organisational sanctions taken against the person perpetrating the harassment or violence.

Managers should also ensure that where the perpetrator is an adult who still uses the service, that steps are taken to discuss the situation with them, their behaviour, how they could have responded differently and referral to other agencies for support / interventions regarding behaviour management as appropriate.

5. Further Reading

5.1 Relevant chapter

Lone Working

5.2 Relevant information

Work Related Violence (Health and Safety Executive) 

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CQC Quality Statements

Theme 1 – Working with people: Equity in experiences and outcomes

We statement

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

What people expect

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

1. Introduction

Not all disabilities can be seen from a person’s outward appearance. Hidden disabilities are sometimes also called invisible disabilities and include, for example, mental and physical health problems and developmental disabilities.

Following their investigation of three complaints against London Councils, the Local Government and Social Care Ombudsman stated local authorities should check their procedures to avoid disadvantaging people with hidden disabilities.

In each of the three cases the local authorities did not do enough to help people use their services. This included not making reasonable adjustments to help a woman with autism to repay overpaid housing benefit, and not helping a man with severe dyslexia to deal with parking tickets and permits.

Whilst the focus of this chapter is local authorities, the information is relevant to all those working with adults with care and support needs. It outlines different types of hidden disabilities and how staff should be aware of and respond to such issues.

2. Types of Hidden Disability

Whilst there is now a better understanding of some of the conditions that constitute hidden disabilities, it is vital that all interactions with adults, including assessments, are conducted with hidden disabilities in mind. This is to ensure all relevant care and support issues that the adult has are identified, to ensure they receive the appropriate services relevant to their individual needs. This process is vital to ensure they are not discriminated against, as a result of a hidden disability being missed or reasonable adjustments not being made.

The lists below are not exhaustive; there will be other physical and mental health problems and other conditions that result in hidden disabilities.

2.1 Mental health

For many adults who suffer with mental health problems, their issues may not be immediately obvious and can be misunderstood. Without good working relationships and without a member of staff undertaking a comprehensive assessment with the adult, key aspects of the care and support that they require may be missed and their problems, therefore, could be compounded. Such issues may include depression, stress, bipolar disorder, psychotic and neurotic thought processes and suicidal thoughts.

2.2 Developmental disabilities

Other conditions which can be hidden include:

  • Dyslexia (development of literacy and language related skills affected);
  • Dyspraxia (perception, language and thought processes affected);
  • Attention Deficit Hyperactivity Disorder – ADHD (inattentiveness and hyperactivity-impulsivity);
  • Autistic spectrum disorder (communication, relationships with others affected);
  • Asperger’s syndrome (an autistic spectrum disorder).

Adults with such conditions have often developed ways of coping which may make it more difficult for staff to identify them as disabled. Even when someone can function well in many situations, this does not mean they are not disabled.

Issues to be aware of include:

  • communication issues (verbal and non-verbal);
  • understanding instructions;
  • the speed at which they process things; and
  • interpretation of social situations.

Some of these conditions may also co-exist with other hidden disabilities.

See Autism UK: What is Autism and Related Conditions for more information.

Adults with a learning disability or autism may have needs for care and support (within section 9 of the Care Act 2014 – the duty to assess – see Assessment chapter).

The Autism Act 2009 came into force in January 2010. Under the Act the Government has to publish and keep under review an Autism Strategy, as well as guidance for implementing the strategy which requires local authorities and NHS bodies to act (see Adult Autism Strategy: Supporting its Use (Department of Health and Social Care).

2.3 Physical health issues

Not all physical health problems are clearly visible. There are many conditions which can be hidden to include hearing and sight impairments, chronic fatigue syndrome / myalgic encephalomyelitis (ME), chronic pain and chronic illnesses such as fibromyalgia, epilepsy, diabetes, kidney failure and sleep disorders.

Such conditions should also be taken into consideration as a hidden disability.

2.4 Other issues for consideration

2.4.1 Mental capacity

See also Mental Capacity and Code of Practice chapter

Adult social care staff and other staff working with adults should be particularly mindful in considering mental capacity issues for adults with hidden disabilities when:

  • assessing needs and make care planning decisions;
  • conducting safeguarding enquiries;
  • when there is a dispute over ordinary residence.

2.4.2 Human rights

See also Equality, Diversity and Human Rights chapter

Article 3 of the Human Rights Act 1998 imposes a duty to take reasonable steps to provide effective protection to children and other vulnerable persons whom the state knows or ought reasonably to know, are being subject to inhuman or degrading treatment (see also Z v United Kingdom Application No 29392/95, (2001) CCLR 310, ECHR).

3. Equality Act 2010

See also Equality, Diversity and Human Rights chapter

It is essential that people with hidden disabilities are not either directly or indirectly discriminated against, that is they should have the same level of assessment, care and support planning, care and support services and other opportunities as those who do not have a disability.

“The Equality Act 2010 requires councils to anticipate the needs of people who may need to access their services. This means when councils are alerted to the fact someone might need to be treated in a different way, they should ask that person what adjustments are needed, and consider whether these are reasonable…. We recognise the significant challenges faced by public service providers in adapting their processes to the needs of people who may require adjustments, particularly where the services have been automated. But this is a duty councils must meet and needs they must anticipate.” Local Government and Social Care Ombudsman

4. Working with Adults who may have Hidden Disabilities

See also Information and Advice chapter and Assessment chapter.

Staff working with adults should be aware that they, or their carer, may have hidden disabilities, particularly those who are having contact with the service for the first time. It is important to not make quick judgements about a person based on initial communication. This is particularly relevant for staff in information and assessment and “front door” services.

Where there are communication issues or other factors are present that are not otherwise easily explained, staff should consider whether hidden disability / disabilities may be the cause and carry out further investigations as appropriate.

When a hidden disability is discussed with an adult and / or their carer, the member of staff should record both the discussion and the hidden disability in the adult’s case records (see Case Recording Standards and Information Sharing). Where the adult already has a care and support plan, this may mean a review is required (see Review of Care and Support Plans) and adjustments to the plan may be required to respond to the newly disclosed / diagnosed disability which may change the person’s eligible care needs within the care and support plan.

See Appendix 1: Case Study

5. Blue Badge Scheme

See also Hidden Disabilities

The Blue Badge scheme has been extended to include people with hidden disabilities, such as autism and mental health conditions, for example.

The criteria have been extended so that people are eligible who:

  • cannot undertake a journey without there being a risk of serious harm to their health or safety or that of any other person;
  • cannot undertake a journey without it causing them very considerable psychological distress;
  • have very considerable difficulty when walking (both the physical act and experience of walking).

This is particularly important for adults who find leaving their house a challenge. This may involve detailed preparations and sometimes overwhelming anxiety about plans going wrong or not being able to find parking spaces. Some autistic people might be unaware of road safety issues or become overwhelmed by busy or loud environments.

For further information see: Running a Blue Badge parking scheme: Guidance for local authorities (UK Government) 

6. Training and Awareness

Local authorities and other service providers should ensure they have a disability policy, ensure that staff are aware of hidden disabilities and know how to respond appropriately.  It should be addressed as part of general equal opportunities training.

7. Further Reading

7.1 Relevant chapters

Equality, Diversity and Human Rights

Assessment

Mental Capacity and Code of Practice

7.2 Relevant information

Councils need to check how they help People with Hidden Disabilities (Local Government and Social Care Ombudsman)

Appendix 1: Case Study

This case study refers to a situation in which the police restrained a young autistic man and failed to take special care: Commissioner of Police for the Metropolis -v-ZH [2013] EWCA Civ 69, 2013 16 CCLR 109

ZH suffered from severe autism and learning disabilities and became obsessed by the water at a local swimming pool. His carers knew if they attempted to touch to remove him that he would jump into the pool fully clothed. The police were called and informed that ZH was autistic but despite the warning they touched him whereupon he jumped into the pool. The police pulled ZH from the pool, restrained him before taking an agitated ZH to the police station. ZH sued the police.

The Court of Appeal held that the police had breached ZH’s human rights and were guilty of assault and false imprisonment and had breached the Disability Discrimination Act 1995. The police argued under the Mental Capacity Act 2005 that they were permitted to perform acts in relation to the care and treatment of persons lacking capacity where it was in their best interests. Their defence failed because their actions lacked reasonableness, practicability and appropriateness. The police should have consulted with the carers on how best to manage ZH’s behaviour and could not have held a reasonable belief that their actions were in ZH’s best interests.

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safe systems, pathways and transitions

We statement

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between services.

What people expect

When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place.

I feel safe and supported to understand and manage any risks.

1. Introduction

Sections 20 and 21 of the Criminal Justice and Courts Act 2015 are a part of the Government’s response to the public inquiry conducted by Sir Robert Francis QC into the events at Mid-Staffordshire NHS Foundation Trust (Report of the Mid Staffordshire NHS Foundation Trust  Public Inquiry – also known as the Francis Report).

There were already offences in relation to the ill-treatment and wilful neglect of adults receiving treatment for mental disorder (under the Mental Health Act 1983) and of those who lack mental capacity. However, there was previously no equivalent specific offence in relation to those being cared for who had full mental capacity (see Mental Capacity chapter). Under these sections of the Act, it is a criminal offence for an individual to ill treat or wilfully or deliberately neglect a person for whom they care, in their role of being a care worker.

‘Wilful’ means that the care worker has acted deliberately or recklessly in relation to the person who they are paid to care for.

‘Ill-treatment’ is also a deliberate act, where the individual knew that they were ill treating a person, or were being reckless as to whether they were.

Ill treatment and neglect are separate concepts. Ill treatment does not necessarily have to result in physical harm and can involve emotional and psychological damage – that the actions have caused or have the potential to cause to the adult and their family (see case law R v Newington1990, 91 Cr App R 254). It can also include a failure to protect the privacy and dignity of a vulnerable adult when the victim is unaware that they are being ill treated.

These offences apply to both organisations and individuals.

The Care Quality Commission (CQC) has a role to play as the regulator in setting standards and ensuring adults are safeguarded from abuse and improper treatment. CQC can prosecute registered care providers whom they have judged to have breached the standard. Criminal offences only apply to cases of wilful neglect where there is evidence of the worker or organisation acting or omitting to act deliberately, even though they know there is some risk to the adult as a consequence or because they do not care about that risk. Genuine errors or accidents by a care worker should not be caught within these offences.

2. Care Worker Offence

Under the Act a ‘care worker’ means an individual, who, is paid to provide health or social care. They may also be a director or be in a similar post within an organisation that provides health or social care.

‘Paid work’ means when a person is paid for carrying out care (see Appendix 1, Further Information, Paid work).

Health care includes all types of physical health or mental health care provided to adults. This also includes health care in relation to protecting or improving public health, and procedures that are similar to types of medical or surgical care but are not provided in connection with medical conditions which are excluded health care (see Excluded Healthcare) .

Social care includes all types of personal care, physical support and other practical assistance provided for people who need such care or assistance. This may because of:

  • age;
  • Illness;
  • disability;
  • pregnancy;
  • childbirth;
  • dependence on alcohol or drugs; or
  • any other similar circumstances.

This would not include a person who provided such care which was secondary to carrying out other activities.

A care worker found guilty of such an offence could receive a prison sentence of up to five years or a fine (or both); or for a less serious charge a prison sentence of up to 12 months or a fine (or both).

Unpaid family carers and friends cannot be charged with these offences. They may be investigated and charged under different legislation, however.

3. Care Provider Offence

The term ‘care provider’ means:

  • a corporation or association that provides and / or arranges health care (apart from excluded health care – see Section 2, above) or social care for an adult;
  • a person who is not the care provider, but provides health care or social care which has been arranged by the care provider, including where the individual does not provide care but supervises or manages those who do;
  • a director or similar post holder in an organisation which provides health care or social care;
  • a person who provides such care and employs or has arrangements with other people to assist them in providing such care.

A care provider commits an offence if:

  • a care worker who is caring for an individual (as part of the care provider’s arrangements) ill treats or wilfully neglects that individual;
  • if the care provider’s activities are managed or organised in a way which leads to a gross breach of a duty of care by the care provider to the individual who is ill-treated or neglected, and if that had not happened, the ill treatment or wilful neglect would not have occurred or would have been less likely to occur.

A person arranging for the provision of such care does not include someone who makes arrangements under which the provision of such care is secondary to carrying out other activities.

References made to providing or arranging the provision of health care or social care do not include making:

  • direct payments for community services and carers;
  • direct payments for health care;
  • direct payments for care and support.

4. The Duty of Candour

There is a requirement on health and social services to be open and honest with patients and service users when things go wrong. Professionals are expected to be candid with adults who use their services and their families when serious events occur and not obstruct fellow professionals who raise concerns.

The Francis Report recommends that healthcare providers must inform patients or other authorised persons as soon as practicable when they believe that the treatment of care provided has caused death or serious injury to that patient and provide information and explanation as the patient may reasonably request.

It also recommends a duty of candour on individual professionals to inform their employers where they believe or suspect that the treatment has caused death or injury. It is a criminal offence to obstruct a person in the performance of these duties or provide misleading information.

The Care Act includes a duty of candour as one of the requirements for providers registered with the CQC. All providers must act in open and transparent manner with adults who use their services and their families about their care and treatment.

There is also a requirement to notify and provide information and support to the adult or the person acting on their behalf where:

(i) an incident has resulted in or appears to have resulted in the death of an adult who uses the service ; or

(ii) caused severe harm or moderate harm or prolonged psychological harm to them.

The regulations also set out a notification requirement and it is a criminal offence for workers who commit breaches of the duty of candour.

5. Further Reading

5.1 Relevant information

Ill-treatment or Wilful Neglect Offences: Sections 20 to 25 of the Criminal Justice and Courts Act 2015

Appendix 1: Further Information

  1. Meaning of Wilful

The meaning of “wilful “has been developed in the case of R -v–Sheppard [1981) AC the House of Lords  held that a man “wilfully” fails to provide adequate medical attention for [P] if he either:

(a)  Deliberately does so knowing that there is some risk that P’s health may suffer unless he receives such attention; or

(b) Does so because he does not care whether P may in need of medical treatment, or not’

  1. Paid work

Paid work does not include:

  • payment in respect of the individual’s expenses;
  • payment to which the individual is entitled as a foster parent;
  • a benefit under social security legislation;
  • or a payment made under arrangements under Section 2 of the Employment and Training Act 1973 (arrangements to assist people to select, train for, obtain and retain employment).
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KNOWSLEY SPECIFIC INFORMATION

Preventing Homelessness and Rough Sleeping Strategy 2020-25

September 2023: A link has been added in Section 5.2, Other useful resources to Care and Support and Homelessness: Top Tips on the Role of Adult Social Care published by the LGA.

1. Introduction

The relationship between local housing and adult and social care departments can be complex because there are often legal and practical difficulties arising from circumstances where vulnerable adults and families fall below or between two legal frameworks. Their needs may not be sufficient to qualify them under the Care Act 2014 (CA) but they may also not meet the criteria for a positive housing decision because they do not have sufficient vulnerability to be assessed as being in ‘priority need’ (see Section 4.2.2, Section 189: Priority Need).

The CA allows the local authority to provide any type of accommodation which may be called ‘ordinary accommodation’, that is “accommodation in a care home or in premises of another type” where they would receive care and support services relevant for their assessed needs.

From an adult social care perspective, the local authority must not meet a person’s care and support needs by taking any action which is required – either by itself or another local authority – under the Housing Act 1996 (HA) or other housing related legislation. A local authority can provide ordinary accommodation under the CA when they are not under a duty to provide that person with accommodation under the HA.

Once the local authority has assessed an applicant’s needs as satisfying the relevant criteria, it must provide accommodation on a continuing basis so long as the need of the applicant remains as the same as originally assessed.

A local authority from an adult social care perspective may provide ordinary accommodation, and any other service within reason, to an adult whom it assesses as needing care and support under the CA; whether or not the local authority uses that power is for it to decide.

See also Appendix 1: Further Information, Accommodation.

2. Homelessness Service in Knowsley

See Knowsley Housing Solutions for further information

The Knowsley Housing Solutions Team provides Knowsley residents with specialist housing advice and support. They can offer advice and support, based on individual circumstances, if people are homeless or are worried about becoming homeless.

3. Safeguarding Concerns

Adults who are homeless may be vulnerable to abuse, whether they are rough sleeping, sofa surfing or in temporary accommodation. For example their lack of stable accommodation can leave them vulnerable to physical, emotional or sexual abuse, criminal exploitation and their possessions vulnerable to theft.

Staff who work with adults who are homeless should be aware of the increased possibility of safeguarding issues, be able to recognise the signs of potential abuse and to take action if they suspect that someone is being abused (see Knowsley Safeguarding Adults Procedures).

4. Homelessness Legislation

4.1 Housing Act 1996

The main legislation that addresses local authority duties in relation to people who are homeless is the Housing Act 1996. This states the legal requirements that underpin local authority action to prevent homelessness and provide assistance to people who are threatened with homeless or who are homeless.

In 2002, the legislation was amended through:

  • the Homelessness Act 2002 which means each local housing authority has a duty to undertake a review of homelessness and to develop and implement an effective strategy to deal with homelessness in consultation with both Social Services and other organisations; and
  • the Homelessness (Priority Need for Accommodation) (England) Order 2002 which extended the class of persons with a priority need for accommodation to six additional categories:
  • 16-17 years old;
  • 18-20 care leavers ;
  • vulnerable care leavers;
  • former members of the armed forces;
  • vulnerable former prisoner;
  • persons fleeing violence.

These were introduced to ensure a more strategic approach to tackling and preventing homelessness and to strengthen the assistance available to people who are homeless or threatened with homelessness by extending the priority need categories.

4.2 Homelessness Reduction Act 2017

The Homelessness Reduction Act 2017 (HRA) amended the Housing Act 1996.

One of the aims of the HRA is to ensure that all eligible households who are homeless or threatened with homelessness receive genuine and effective advice and assistance to help them secure accommodation. The HRA aims to widen access to homelessness advice and prevention services for all households who are experiencing homelessness or who are at risk of losing their home. It introduced a statutory duty to carry out assessments on all applicants, as well as duties to prevent and relieve homelessness in all cases.

Key sections in the Act are outlined below.

4.2.1 Section 179: Expanded the general duty to provide advice

Local housing authorities have a duty to ensure that advice and information on homelessness prevention and on how people can access help and support when homeless is made available free of charge. The HRA specifies the types of information that has to be made available and requires that advice and information has to be tailored to meet the needs of the following specific groups:

  1. people released from prison or youth detention accommodation;
  2. care leavers;
  3. former members of the regular armed forces;
  4. victims of domestic abuse;
  5. people leaving hospital;
  6. people living with a mental illness or impairment; and,
  7. any other group that the authority identify as being at particular risk of homelessness in their area.

The local authority can provide this advice themselves or arrange for other agencies to do it on their behalf.

4.2.2 Section 189: Priority Need

A person who is homeless and who approaches the local authority for assistance (known as an eligible applicant) has to fall into one of the priority need categories in order for the local authority to have a duty to obtain temporary accommodation for them. The following people have a priority need for accommodation:

  1. a pregnant woman or a person with whom she resides or might reasonably be expected to reside;
  2. a person with whom dependent children reside or might reasonably be expected to reside;
  3. a person who is homeless or threatened with homelessness as a result of an emergency such as flood, fire or other disaster;
  4. homeless 16 and 17 year olds;
  5. care leavers aged 18, 19 and 20;
  6. a person who is vulnerable as a result of old age, mental illness or handicap or physical disability or other special reason, or with whom such a person resides or might reasonably be expected to reside;
  7. people who are vulnerable as a result of time spent in care, the armed forces, prison or custody;
  8. people who are vulnerable because they have fled their home because of violence.

Such decisions can be controversial and can be subject to challenge and review, however.

The term ‘vulnerable’ is not defined in the legislation, therefore a considerable amount of case law considers how to define and interpret ‘vulnerable for example, Hotak v Southwark LBC; Kanu v Southwark LBC; Johnson v Solihull MBC [2015] UKSC 30. The Supreme Court judgment decided in these cases a homeless person is in priority need if he or she is vulnerable compared to the average person, not the average homeless person (Johnson vulnerability).

The test involves comparing the ability of the applicant to deal with the effects of being homeless with the ability of a hypothetical ordinary person to deal with the same situation. In order to be deemed vulnerable, the applicant must be:

  1. significantly more vulnerable than an ordinary person in need of accommodation; and
  2. likely to suffer greater harm in the same situation.

See also Appendix 1: Further Information, The vulnerability test.

Vulnerability in this context relates to a person’s vulnerability if they are not provided with accommodation, not their general ‘need of care and support’.

4.3.3 Section 189A: Assessments and Personalised Housing Plans where the person is homeless or threatened with homelessness

Local housing authorities must carry out an assessment where an eligible applicant is homeless or threatened with homelessness. This should identify what has caused the homelessness or threat of homelessness, the applicant’s housing needs and any support they need in order to be able obtain and stay in new accommodation.

Following the assessment, the local authority must work with them to develop a personalised housing plan. This should contain actions for the local authority to help them secure new suitable accommodation. A copy of the assessment and the plan must be given to the person, and both must be reviewed whilst the local authority continues to have any duty to them.

Practically, the local authority must try to agree a written list of the actions that each party will take. If they cannot be agreed, the local authority must produce a record of the reasons for the disagreement and detail what steps the local authority will take and those steps expected from the applicant. Until a point at which the local authority decides it does not owe a duty to the applicant, it has to keep the assessment under review, together with the appropriateness of any agreement reached or steps taken.

4.3.4 Section 189B: Relief Duty

The local authority has a duty to provide support and help to all eligible people who are homeless. This is met by helping a person secure suitable accommodation, where they have a reasonable possibility of staying for at least six months. The relief duty can remain in place for up to 56 days. If the applicant is still homeless at the end of this period the local authority must decide what further duty, if any, is owed to them.

The relief duty applies to all eligible applicants who are homeless; it is not conditional upon them being in a priority group.

The local authority can consider a person’s local connection when a relief duty is in place. If they do not have a local connection to the local authority and have a safe local connection to another local authority area, the local authority can decide to refer their case to the other area.

4.3.5 Duty to help to secure accommodation

Housing authorities have a number of duties and powers to secure accommodation for an applicant. The HRA introduces a duty of ‘help to secure’ accommodation for all applicants under prevention and relief duties. This does not mean that the housing authority has a duty to directly find and secure the accommodation, but involves them working with an applicant to agree reasonable steps that they and the local authority will take to identify and secure suitable accommodation.

The prevention or relief duty will be met if any type of suitable accommodation can be found when helping the applicant to secure accommodation. It can often be met by helping them to secure a tenancy; it can also be met by helping them to secure any type of suitable accommodation, including accommodation occupied under a licence.

The local authority can secure suitable accommodation in the following ways:

  • providing it themselves; or
  • arranging that the applicant obtains it from some other person; or
  • giving the applicant advice and assistance so that accommodation is available from some other person (in R v (Miah) v Tower Hamlets LBC [2014] EWHC 1029 advice to meet the duty then ends the duty).

The local authority must provide temporary accommodation for applicants who are in a priority need group whilst it performs the relief duty.

4.3.6 Section 191: Intentionally homeless

A person becomes intentionally homeless if they deliberately do something, or fail to do something that as a direct consequence means they no longer live in accommodation that was reasonable for them to stay in.

The local authority must be satisfied that all five elements of the intentional homeless (IH) test apply:

  1. What did the applicant do or fail to do?
  2. Did it lead to a loss of the accommodation as a consequence of an act or omission?
  3. Was there a termination or interruption in the occupation as distinct from a failure to take up accommodation?
  4. Was the accommodation available for the homeless person’s occupation?
  5. Would it have been reasonable for the homeless person to continue to occupy the accommodation?

A person will also be found to be intentionally homeless if they enter into any arrangement under which they are required to leave the accommodation which it would have been reasonable for them to continue live in, if the purpose of that arrangement was to enable them to claim assistance as a homeless person.

In considering whether a person deliberately becomes homeless the local authority has to ask whether the loss of accommodation would reasonably have been regarded as a likely consequence of that person’s deliberate conduct:

  • ‘deliberate’ relates to the act or omission;
  • ‘likely’ means a real or serious possibility;
  • the link between the act and the homelessness must be judged objectively;
  • the deliberate act must have contributed in some measure to the loss of the home.

There may be a number of causes of the homelessness, some of which may be ‘innocent’ but the applicant will still be IH if the local authority – on the balance of probabilities – is satisfied that homelessness was a likely consequence of a deliberate act. Examples are:

  • the applicant’s tenancy was not renewed by the landlord and was a reasonable result of the behaviour of not paying rent or withholding rent;
  • an applicant guilty of ASB or criminal behaviour is forced to leave their home because of i.e. threats. They are IH because the accommodation would have been reasonable to occupy but for ASB.

Where the homeless person took action or failed to act, there is a good faith test that has to be considered in regard to a deliberate act, that is, was the applicant acting honestly or were they genuinely ignorant of a relevant fact?

If it is decided that a person is intentionally homeless, this limits the duties and assistance the local authority can give them. At the most, if they are also in priority need, they will be provided with temporary accommodation for a reasonable period only. This period – usually around 28 days – is to allow them to make their own arrangements to secure alternative accommodation.

4.3.7 Section 195: The Prevention Duty

The local authority has a prevention duty to provide support and help to all eligible people who are threatened with becoming homeless within the next 56 days. This duty is often be met by providing assistance to enable a person to remain in their current home, where possible, however where this is not feasible it can be met by helping them move to another home in a planned way, without them becoming homeless.

This duty applies to all eligible applicants who are threatened with homelessness, it is not conditional upon the applicant being in a priority group and it does not require an applicant to have a local connection to the area. The duty remains in place for up to 56 days, although it can be longer, if required.

4.3.8 Section 195: A change to the meaning of ‘threatened with homelessness’

Under the HRA, households are considered to be threatened with homelessness if they are considered to be threatened with homelessness in the next 56 days. This period has been doubled from previous legislation in the HA, previously it was 28 days from date they presented for accommodation.

This is to require local authorities to intervene to provide assistance at an earlier stage, so there is increased opportunity to achieve a successful homelessness prevention outcome. The local authority is obliged to take reasonable steps to help the applicant secure that accommodation so it does not cease to be available for their occupation. In deciding the steps to take the authority must have regard to its own assessment.

4.3.9 Section 199: Local connection and a local connection for care leavers

An applicant has a local connection to an area if they are:

  1. normally resident in the area (usually for six of the past 12 months, or for three out of the past five years);
  2. employed in the area;
  3. have family associations to the area; or actual relationships are often considered more important than blood ties
  4. have other special circumstances that give them a connection.

A local connection is determined by the facts and circumstances at the date that the local authority completed its enquiries.

A young person owed leaving care duties under the Children Act 1989 will have a local connection to the area of the children services authority that owes them the duties.

Where a care leaver is aged under 21 and normally lives in a different area to that of a local authority that owes them leaving care duties, and has done for at least two years including some time before they turned 16, the young person will also have a local connection in that area.

4.3.10 Section 213B: Duty to Refer

The HRA introduced a duty to refer, which is placed on other public sector bodies, not the local housing authority. Social care services, including adult social care, are subject to this duty.

The aim of this duty is to help early identification of households who are homeless or threatened with homelessness, and to build on / develop joint working relationships between organisations in order to effectively prevent and relieve homelessness. The following organisations are subject to the duty to refer, and must refer people who they come into contact with, who are experiencing homelessness or who are threatened with becoming homeless:

  • prisons;
  • youth offender institutions;
  • secure training centres;
  • secure colleges;
  • youth offending teams;
  • the probation service;
  • Job Centre Plus;
  • social service authorities;
  • emergency departments;
  • urgent treatment centres;
  • hospitals in their function of providing inpatient care;
  • the Secretary for Defence in relation to former members of the regular armed forces.

The organisation must first have consent from the person they are going to refer. The person must then nominate a local authority in England where they want the referral to be sent. The referral itself will not mean a homelessness application has been made.

4.4 Summary of the main provisions of HRA

  1. The legislation introduces requirements for local housing authorities to carry out homelessness prevention work with all those persons who are eligible for help and threatened with homelessness.
  2. The HRA changes the point at which a person is classed as being threatened with homelessness from 28 days to 56 days.
  3. It makes changes to the way local authorities assess and the point in time in which a person becomes homeless or is threatened with homelessness. The HRA requires local housing authorities to carry out an assessment of the applicant’s needs and that the steps agreed between the local housing authority and the applicant are set out in writing in the form of a personalised plan.
  4. A duty is placed on local housing authorities to take steps for 56 days to relieve homelessness by helping any eligible homeless applicant to secure accommodation.
  5. A further duty was introduced that is owed to certain applicants who deliberately and unreasonably refuse to co-operate with local housing authorities.
  6. The legislation specifies that local agencies should refer those persons who are either homeless or at risk of being homeless to local housing authority teams.
  7. Provisions are made for certain care leavers to make it easier for them to show they have a local connection with both the area of the local authority responsible for them and the area in which they lived while in care if that was different.

4.5 Applying the Equality Act 2010 in re priority need and disability

The definition of disability in the Equality Act 2010 (EA) is “a person has a disability if s/he has a physical or mental impairment which has a substantial and long term adverse effect on that person’s ability”.

When making decisions about priority need under the EA, the local authority must ensure it has taken all steps to gather all relevant information relating to the applicant’s mental or physical disability.  Workers should undertake a full assessment interview with the applicant, focus on questions that relate to any physical or mental impairment and ask how the impairment might impact on them if s/he were to become or remain homeless.

The Supreme Court judgment stated that the EA is ‘engaged’ when making decisions on vulnerability where the applicant has a relevant protected characteristic: age; disability; gender; gender reassignment; pregnancy and maternity; race; religion or belief and sexual orientation. The court accepted that on priority need a protected characteristic will be a disability and these questions should be considered:

  1. What is the extent of the applicant’s disability?
  2. What is the likely effect of the disability on the applicant when taken together with that person’s other problems?
  3. Is the worker satisfied that relevant third party inquiries have been undertaken into any mental or physical impairment to demonstrate that the applicant meets the requirements set down by the EA?

If the applicant is found not to have a priority need category the reasons must be set out.

The local authority may find an applicant comes under the definition for the disability protected characteristic in a priority need, but does not automatically become eligible because they meet the definition.

If a local authority reaches a decision that on the evidence they are not vulnerable, despite coming under the disability protected characteristic, it must justify the decision as a proportionate means of achieving a legitimate aim, which is to meet the obligation set by the homeless legislation to decide when a person’s disability makes a person vulnerable under the EA.

5. Useful Resources

5.1 Homelessness Code of Guidance for Local Authorities

The Homelessness Code of Guidance for Local Authorities provides statutory guidance that all local authorities must consider when carrying out their duties relating to homelessness and preventing homelessness. The code is issued specifically for local authority members and staff, including social care services (see Section 4.3.10, Section 213B: Duty to Refer).

The guidance includes information on preventing and tackling homelessness, including joint working between housing and other services to secure accommodation and provide support. It also covers the duty to refer, although it was published prior to the implementation of the HRA.

5.2 Other useful resources

National Homelessness Advice Service NHAS: Useful information and resources for local authority staff, housing providers and members of the public. Requires a log in to access some resources.

Shelter Legal: Detailed and useful resources on homelessness applications, legal duties, security of tenure, rents, benefits etc.

Housing LIN (Learning and Improvement Network)

Integrated Health and Social Care for People Experiencing Homelessness (NICE)

Capacity and Housing Issues (39 Essex Chambers)

Care and Support and Homelessness: Top Tips on the Role of Adult Social Care (LGA)

Appendix 1: Further Information

1.1 Accommodation

In R v Kensington and Chelsea RLBC Ex p Kujtim [1999] CCLR 340 CA the Court of Appeal held that residential accommodation could include ‘ordinary’ housing accommodation. A duty to supply such accommodation arose where a person needed care and attention, including housing accommodation when it is not available. The need for care Is a precondition for this duty. Although CA uses the phrase ‘care and support’ instead of the term under the National Assistance Act 1948 (NAA) ’care and attention’, it has been held that the case law under the NAA still applies.

In R (SG) v Haringey LBC [2015] EWHC 2579 (Admin) it was held a local authority needs only provide under CA a response to an accommodation related need.

Deputy High Court Judge Bowers “The service provided in a non-home environment, would be rendered effectively useless if the claimant were homeless sand sleeping on the street”.

1.2 The vulnerability test

The Johnson vulnerability test is practically applied by asking the following questions:

  1. What are the person’s problems?
  2. What is the impact of those problems on them?
  3. What is their ability to manage their problems by themselves and with the help of others?
  4. Taking into account investigations from questions 1-3 how would they suffer more harm than an ordinary person without access to a home? i.e. would they suffer more harm than you or I if they were to become homeless?
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CQC Quality Statements

Theme 1 – Working with people: Equity in experiences and outcomes

We statement

We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.

What people expect

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

This is the Accessible Information Standard (NHS England). This aims to ensure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need from health and care services.

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Audio & Quick Read Summary

CQC Quality Statements

Theme 1 – Working with People: Assessing needs

We Statement

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

What people expect

I have care and support that is coordinated, and everyone works well together and with me.

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

1. Definition

The Mental Capacity Act 2005 (MCA) provides a framework to protect and restore power to those who may lack, or have reduced, capacity to make certain decisions at particular times. It places the adult at the centre of the decision making process.

‘Whenever the term ‘a person who lacks capacity’ is used, it means a person who lacks capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken.

This reflects the fact that people may lack capacity to make some decisions for themselves, but will have capacity to make other decisions. For example, they may have capacity to make small decisions about everyday issues such as what to wear or what to eat, but lack capacity to make more complex decisions about financial matters.

It also reflects the fact that a person who lacks capacity to make a decision for themselves at a certain time may be able to make that decision at a later date. This may be because they have an illness or condition that means their capacity changes. Alternatively, it may be because at the time the decision needs to be made, they are unconscious or barely conscious whether due to an accident or being under anaesthetic or their ability to make a decision may be affected by the influence of alcohol or drugs.

Finally, it reflects the fact that while some people may always lack capacity to make some types of decisions – for example, due to a condition or severe learning disability that has affected them from birth – others may learn new skills that enable them to gain capacity and make decisions for themselves’ (MCA 2005 Code of Practice, 2007: p3).

The Act legislates in relation to:

  • allowing adults to make as many decisions as they can for themselves;
  • enabling adults to make advance decisions about whether they would like future medical treatment;
  • allowing adults to appoint, in advance of losing mental capacity, another person to make decisions about personal welfare or property on their behalf at a future date;
  • allowing decisions concerning personal welfare or property and affairs to be made in the best interests of adults when they have not made any future plans and cannot make a decision at the time;
  • ensuring an NHS body or local authority will appoint an independent mental capacity advocate to support someone who cannot make a decision about serious medical treatment, or about hospital, care home or residential accommodation, when there are no family or friends to be consulted (see also Independent Mental Capacity Advocate Service);
  • providing protection against legal liability for carers who have honestly and reasonably sought to act in the person’s best interests;
  • providing clarity and safeguards around research in relation to those who lack capacity.

The MCA relates to people over the age of 16 years old. For the purposes of this manual, however, it only applies to those over the age of 18 years old, who are not children under the Children Act 1989 (before their 18th birthday).

2. Principles of the Mental Capacity Act

The following five principles apply for the purposes of the Act:

  • a person must be assumed to have capacity unless it is established that they lack capacity;
  • a person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success;
  • a person is not to be treated as unable to make a decision merely because they make an unwise or bad decision;
  • an act done or decision made, under the Act for or on behalf of a person who lack capacity must be done, or made, in their best interests;
  • before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

The five principles of the Act should inform all actions when working with a person who may lack or have reduced capacity and should be evidenced in taking decisions or actions on behalf of a person who may lack or have reduced capacity.

3. Excluded Decisions

There are certain decisions which can never be made on behalf of a person who lacks capacity to make those specific decisions. This is because they are either so personal to the individual concerned, or they are governed by other legislation.

Although the Act does not allow anyone to make a decision about the matters below on behalf of someone who lacks capacity to make such a decision for themselves (for example, consenting to have sexual relations), this does not prevent action being taken to protect a vulnerable person from abuse or exploitation.

3.1 Decisions concerning family relationships

Nothing in the MCA allows a decision to be made on someone else’s behalf on:

  • consenting to marriage or a civil partnership;
  • consenting to have sexual relations;
  • consenting to a decree of divorce on the basis of two years’ separation;
  • consenting to the dissolution of a civil partnership;
  • consenting to a child being placed for adoption or the making of an adoption order;
  • discharging parental responsibility for a child in matters not relating to the child’s property; or
  • giving consent under the Human Fertilisation and Embryology Act 1990.

3.2 Mental Health Act matters

Where a person who lacks capacity to consent is currently detained and being treated under the Mental Health Act 1983, nothing in the MCA authorises anyone to:

  • give the person treatment for mental disorder; or
  • consent to the person being given treatment for mental disorder.

3.3 Voting rights

Nothing allows a decision on voting – at an election for any public office or at a referendum – to be made on behalf of a person who lacks capacity to vote.

Unlawful killing or assisting suicide

Nothing in the MCA affects the law relating to murder, manslaughter or assisting suicide.

4. Determining Capacity

Anybody who claims an adult lacks capacity should provide proof.

They need to demonstrate, on the balance of probabilities, that the individual lacks capacity to make a particular decision, at the time it needs to be made. This means being able to demonstrate it is more likely than not that the person lacks capacity to make the decision in question.

4.1 Two stage test

To help determine if a person lacks capacity, the Act sets out a two stage test.

Stage 1: The Diagnostic Test

Does the person have an impairment of, or a disturbance in the functioning of, their mind or brain?

Stage 1 requires proof the person has an impairment or disturbance of the mind or brain. If a person does not have such an impairment or disturbance of the mind or brain, they will not lack capacity under the Act. Examples include:

  • conditions associated with some forms of mental illness;
  • dementia;
  • significant learning disabilities;
  • the long term effects of brain damage;
  • physical or medical conditions that cause confusion, drowsiness or loss of consciousness;
  • delirium;
  • concussion following a head injury; and
  • effects of alcohol or drug use.

Stage 2: The Functioning Test

Does the impairment or disturbance mean that the person is unable to make a specific decision when they need to?

The person must first be given all practical and appropriate support to help them make the decision for themselves. Stage 2 can only apply if all practical and appropriate support to help the person make the decision has failed.

4.2 Inability to make a decision

A person is considered unable to make a decision if they cannot:

  1. understand information about the decision to be made (‘relevant information’);
  2. retain that information in their mind;
  3. use or weigh that information as part of the decision making process; or
  4. communicate their decision (by talking, using sign language or any other means).

4.3 The causative nexus

Once you have identified an impairment or disturbance in the functioning of the mind or brain, it is important to decide whether the inability to make the decision is because of this impairment. This is known as the “causative nexus” (PC and NC v City of York Council [2013] EWCA Civ 478). Only where you can reasonably say that the person cannot make the decision because of the impairment of their mind can you say that they lack capacity to make the decision.

Assessors should also consider the case of SS v London Borough of Richmond upon Thames & South West London Clinical Commissioning Group [2021] in which Mr Justice Hayden, Vice President of the Court of Protection highlighted: SS v London Borough of Richmond Upon Thames & Anor [2021] EWCOP 31 (30 April 2021) (bailii.org)

I hope Dr N will not think me too pedantic if I make the observation that “patient failed capacity assessment” strikes me as awkwardly expressed. It is not a test that an individual passes or fails, it is an evaluation of whether the presumption of capacity has been rebutted and if so, for what reason.

5. Recording

The two stage test should be used as a framework for recording the assessment of mental capacity, so that evidence for decision making is clear.

6. Making Decisions on behalf of someone who lacks Capacity

If, having taken all practical steps to assist someone, it is concluded that a decision should be made for them, that decision must be made in that person’s best interests. It must also be considered whether there is another way of making the decision which might not affect the person’s rights and freedom of action as much (known as the ‘least restrictive alternative’ principle).

6.1 Decision makers

Different people may be required to make decisions or act on behalf of someone who lacks capacity to make decisions for themselves. The person making the decision is known as the ‘decision maker’, and it is their responsibility to determine what would be in the best interests of the person who lacks capacity.

Determining who the decision maker is depends on the decision and the context, and not on the circumstances of the individual. For most day to day actions or decisions, the decision maker will be the carer most directly involved with the person at the time. Family members and informal carers will be decision makers for actions that they undertake. A care assistant will be the decision maker if the decision is, for instance, about what clothes to put on that morning.

Professionals are the decision makers for actions for which they are responsible. A doctor or other health professional will be the decision maker about someone’s capacity for the treatment they are prescribing, or initiating a care pathway. A nurse will be the decision maker about the treatment or care that they are delivering or administering. A social care professional will be the decision maker about a move into residential care or commissioning a package of care.

In some cases, the same person may make different types of decision for someone who lacks capacity. For example, a carer may carry out certain acts in caring for the person on a daily basis, but if they are also an attorney, appointed under a Lasting Powers of Attorney, they may also make specific decisions concerning the person’s property and affairs or personal welfare.

A decision may also, at times, be made jointly by a number of people. For example, when a care plan for a person who lacks capacity is being developed, different healthcare or social care staff might be involved in making decisions or recommendations about their care package. Alternatively, the decision may be made by one practitioner within the team. A different member of the team may then implement that decision, based on what the team has ascertained to be in the person’s best interests.

6.2 Lasting Powers of Attorney, Court Appointed Deputy and the Public Guardian

A Lasting Powers of Attorney (LPA) allows an adult to appoint an attorney to act on their behalf if they should lose capacity in the future and allows them to empower an attorney to make health and welfare decisions.

A Court Appointed Deputy is appointed by the Court of Protection. Depending on the terms of their appointment, deputies can take decisions on welfare, healthcare and financial matters as authorised by the Court of Protection but they are not able to refuse consent to life sustaining treatment. Deputies are only appointed if the Court cannot make a one off decision to resolve the issues.

The MCA created a public body and an official to support the statutory framework:

  • The Court of Protection has jurisdiction relating to the whole Act, with its own procedures and nominated judges;
  • A Public Guardian, supported by the Office of the Public Guardian (OPG). The OPG is the registering authority for LPA’s and deputies. It supervises deputies appointed by the Court and provides information to help the Court make decisions. It also works with other agencies, for example the police and adult social care, to respond to any concerns raised about the way in which an attorney or deputy is operating.

6.3 Independent Mental Capacity Advocates

See Independent Mental Capacity Advocate Service.

The MCA also included another key provision to protect people who lack capacity. Independent Mental Capacity Advocates (IMCA) are those appointed to support a person who lacks capacity but has no one to speak for them. They have to be involved where decisions are being made about serious medical treatment or a change in the adult’s accommodation where it is provided, or arranged, by the NHS or a local authority. The IMCA makes representations about the person’s wishes, feelings, beliefs and values, and brings to the attention of the decision maker all relevant factors to the case. IMCA services are provided by organisations that are independent of the NHS and local authorities.

6.4 Forward Planning

Considering the possibility of losing mental capacity and registering a Lasting Power of Attorney is usually associated with people getting older. But it would be wise to consider such decisions and act on them much earlier in life, in case of unexpected illness or an accident that results in a temporary or permanent loss of capacity.

Using a LPA is not necessarily limited to circumstances where an adult’s capacity is diminished. Due to a physical illness that renders a person (the donor) unable to leave the house for example, a LPA who is registered in relation to property and financial affairs can carry out financial transactions on their behalf and with their permission. In the absence of a registered LPA the alternative would be to borrow the money which could attract charges, or to apply to the Court of Protection.

Although a LPA cannot be used until it has been fully registered and confirmation received, they can be registered before capacity is lost which means that they could be used immediately if it should become necessary.

7. Best Interests

The Mental Capacity Act sets out a checklist of things to consider when deciding what’s in a person’s best interests. People should:

  • not make assumptions on the basis of age, appearance, condition or behaviour;
  • consider all the relevant circumstances;
  • consider whether or when the person will have capacity to make the decision;
  • support the person’s participation in any acts or decisions made for them;
  • not make a decision about life sustaining treatment ‘motivated by a desire to bring about his (or her) death’;
  • consider the person’s expressed wishes and feelings, beliefs and values;
  • take into account the views of others with an interest in the person’s welfare, their carers and those appointed to act on their behalf.

8. Further Reading

8.1 Relevant chapters

Deprivation of Liberty Safeguards

Best Interests

Independent Mental Capacity Advocate Service

Assessment

8.2 Relevant information

Mental Capacity Act 2005 Code of Practice

Decision-Making and Mental Capacity (NICE)

Assessment and Recording of Capacity (39 Essex Chambers)

Mental Capacity Toolkit (University of Bournemouth 

Mental Capacity Act (MCA): e-Learning course (SCIE)

Fluctuating Capacity in Context (39 Essex Chambers) 

ePractice

Now complete the 5 minute ePractice Quiz to test your understanding and provide evidence for CPD.

1. Using the Mental Capacity Act is it possible to complete one assessment to decide that a person is not able to make any decisions?(Required)
2. The Mental Capacity Act sets out five guiding principles.(Required)
Please tick which are correct the from the following list:
3. When assessing a person’s capacity to make a certain decision there is a two stage test to be followed.
3.1 Stage One – Diagnostic Test. Is this about:(Required)
3.2 Stage Two – The Functioning Test. Is this about:(Required)
4. The person who is the decision maker is responsible for making the decisions in the best interests of a person who is deemed to lack capacity. Is the decision maker always a social worker?(Required)
5. Once a person is assessed as lacking capacity to make decisions about their health and welfare, is the only way to make decisions on that person’s behalf is using the best interests framework:(Required)
6. Even when a person may not have the capacity to understand the decision being made, some decisions regarding personal matters cannot be made on their behalf using the MCA.(Required)
Please tick the answers below which highlight the decisions that are excluded from the MCA and best interests framework:
7. The Independent Mental Capacity Advocate (IMCA) is a role that can be undertaken by:(Required)
Please tick all correct options.

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CQC We and I Statements

Theme 1 – Working with People: Assessing needs

We statement

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

I statements

I have care and support that is coordinated, and everyone works well together and with me.

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

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CQC Quality Statement

Theme 4 – Leadership: Governance, management and sustainability

We statement

We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes and we share this securely with others when appropriate.

1. Introduction

This chapter is a summary of the Professional Capabilities Framework (PCF) guidance, which is the structure of social work skills professional development in England.

It was first published in 2012, and updated in 2018.

This is a full version of the Professional Capabilities Framework and Guidance.

The Framework includes:

  • alignment between PCF 2018 and the Knowledge and Skills Statements (KSS) in the British Association of Social Work (BASW), the Department of Health and Social Care (DHSC) and the Department for Education (DfE);
  • definition of the PCF 2018;
  • capabilities;
  • PCF 2018 graphic;
  • super domains – purpose, practice, impact;
  • domain descriptors;
  • level descriptors.

These are outlined below.

2. Alignment with Knowledge and Skills Statements

The PCF outlines the framework of capabilities and professional development. It is linked to the structure of Knowledge and Skills Statements (KSS) so that the two frameworks can be used in conjunction with each other.

‘The KSS set out what a social worker should know, and be able to do, in specific practice settings, in specific roles and at different levels of seniority. The KSS map onto the Practice domains of the PCF (Knowledge, Critical Reflection and Analysis, Interventions and Skills) and should help guide everyday practice’.

This is the full Statement on the PCF and KSS

3. Definition of the PCF

The PCF is the framework for social work practice and learning in England and performs the following functions:

  • sets out nine common domains of capability for social workers;
  • promotes and underpins social work for all social workers across all specialisms and roles;
  • supports social workers to meet requirements of the professional regulator;
  • describes the range of roles within the social work professions;
  • supports employers, workforce leads, managers and supervisors as well as individual social worker, sin developing social work careers and ongoing professional learning;
  • is aligned with the International Federation of Social Workers’ (IFSW) global definition of social work through the BASW Code of Ethics for social workers across the UK.

Specialist knowledge, skills or learning content that may be needed in particular work contexts or roles is not described by the PCF.

4. Capabilities

Capabilities are ‘An integration of knowledge, skills, personal qualities, behaviour, understanding and values used appropriately, effectively and confidently, not just in familiar and highly focused specialist contexts but in response to new, complex and changing circumstances’ (Adapted from Stephenson, 1992)

The capabilities described in the PCF provide the basis and rationale for social work practice.

The nine levels of capability outlined in the PCF guides social workers to develop their skill to deal with situations of increasing risk, ambiguity and complexity.

The PCF Fan Graphic

5. Super Domains

There are three super, overarching domains which cut across all other areas. These are:

  • purpose – why we do what we do as social workers, our values, ethics and how we approach our work;
  • practice – what we do – specific skills, knowledge, interventions and critical analytical abilities we develop;
  • impact – ow we make a difference and how we know we make a difference. Ability to bring about change through practice, leadership, and professionalism.

5.1 Domain descriptors

The domain descriptors describe key areas of social work practice and were refreshed in 2018 following wide consultation.

  • Professionalism;
  • Values and Ethics;
  • Diversity and Equality;
  • Rights, Justice and Economic Well Being;
  • Knowledge;
  • Critical Reflection and Analysis;
  • Intervention and Skills;
  • Contexts and Organisations;
  • Professional Leadership.

5.2 Level descriptors

Level descriptor outline levels of post within social work and were also refreshed in 2018 following consultation.  These are:

  • Pre-qualifying levels:
  • Point of entry training;
  • Readiness for practice;
  • End of first placement;
  • End of second placement;
  • Newly qualified social worker (ASYE);
  • Social worker;
  • Experienced social worker;
  • Advanced social worker;
  • Advanced social work practitioner;
  • Advanced social work educator;
  • Social work managers/team or practice leads;
  • Strategic social worker;
  • Strategic social work practitioner;
  • Strategic social work educator;
  • Strategic social work managers / leaders.

6. Further Reading

6.1 Relevant chapters

Social Workers Supervision Policy

Workplanning and Appraisal

6.2 Relevant information

Professional Capabilities Framework and Guidance

Professional Standards and Professional Standards Guidance (Social Work England)

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CQC Quality Statements

Theme 3 – How the local authority ensures safety in the system: Safeguarding

We statement

We work with people to understand what being safe means to them as well as our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.

What people expect

I feel safe and supported to understand and manage any risks.

March 2023: This chapter has been rewritten to reflect the latest version of the Modern Slavery Statutory Guidance, published by the Home Office.

1. Introduction: What is Modern Slavery?

Modern slavery is a serious and often hidden crime where people are exploited by criminals, usually for profit. It includes human trafficking, slavery, servitude and forced labour.

In all types of modern slavery a victim is, or is intended to be, used or exploited for someone else’s gain, with no respect for their human rights. Criminals involved in modern slavery can be people working alone, those running small businesses or part of a wider organised crime network.

Adult victims will usually be coerced or forced into modern slavery, by using threats, force, deception, or abusing their position of power over victims. However, vulnerable adults (and children) cannot give their informed consent to be in such a position and therefore exploitation – even without any type of coercion – could still be modern slavery.

The scale of modern slavery in the UK is significant. Modern slavery crimes are being committed throughout the country and there have been increases in the number of victims identified every year. In 2021, the Home Office received 3,190 reports of adult potential victims via the Duty to Refer process (see Section 5, National Referral Mechanism and the Duty to Refer) compared to 2,175 in 2020. The most commonly referred nationalities in 2021 were Albanian (14%), Eritrean (12%) and UK (11%).

Modern slavery can be difficult to spot and often goes unreported. Staff working in social care, health, local authorities and any other role which comes into contact with the public could potentially see signs of modern slavery. Staff should be trained to:

  • understand the signs or indicators of modern slavery;
  • know how to take appropriate action; and
  • provide possible victims with protection and support, based upon their individual needs. It is essential that professionals recognise that those who were previously victims of modern slavery (known as survivors) may be at risk of re-trafficking and further harm and take action to prevent this. This is because they may be found by their previous exploiters or coerced by new exploiters.

Multi-agency working is vital to ensure that victims are identified, protected and safeguarded.

Modern slavery is an adult safeguarding concern, and the local authority has legal duties to provide support for suspected or known victims. Under the Modern Slavery Act 2015, all modern slavery offences are punishable by a maximum sentence of life imprisonment. For modern slavery concerns regarding children, please see the Knowsley Safeguarding Children Partnership Procedures.

2. Types of Modern Slavery

Modern slavery includes the following:

  • human trafficking;
  • slavery, servitude and forced or compulsory labour.

2.1 Human trafficking

Human trafficking is where a victim is forced or deceived into a situation where they are then exploited. It involves the movement of people for exploitation and can occur across international borders or within a country.

The Council of Europe Convention on Action against Trafficking in Human Beings defines ‘human trafficking’ as:

the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs.

Human trafficking involves three basic elements:

  1. action;
  2. means; and
  3. purpose of exploitation.

It should be seen as a process involving a number of actions which are all connected, rather than a single act at a particular point in time, as noted in the table below:

Elements of human trafficking in adults What this means
Action recruitment, transportation, transfer, harbouring or receipt, which includes an element of movement whether national or cross-border;
Means threat or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability;
Exploitation for example, sexual exploitation, forced labour or domestic servitude, slavery, financial exploitation, removal of organs (see below for more detail)

(taken from Modern Slavery Statutory Guidance: How to Identify and Support Victims, Home Office)

To be considered as human trafficking, a victim must be trafficked for the purposes of exploitation. This can be:

  • sexual exploitation: in most cases of human trafficking for sexual exploitation purposes victims will be female, but there are also male victims. Rape and violence are common, and victims are often tricked and given false promises of good jobs and economic opportunities;
  • forced or compulsory labour: victims have to work for little or no pay and their employers will not let them leave or find another job. If they are foreign nationals, their passports may be taken by their exploiters so they cannot return home. They may also be forced to live in terrible conditions. Forced labour can take place in any sector of the labour market, including manufacturing, food preparation and processing, agriculture, hospitality, nail bars and hand car washes;
  • forced criminality / criminal exploitation: victims are forced to commit illegal activities, including pick pocketing, shop lifting, begging, growing and cultivating cannabis, being exploited across different areas of the country – know as ‘county lines’, benefit fraud, sham marriage and other crimes. The Modern Slavery Act states that victims who have been forced into criminality should not be prosecuted;
  • removal of organs: victims are trafficked for their internal organs (typically kidneys or the liver) to be taken (‘harvested’) to be transplanted in other people (who usually pay for the new organs);
  • domestic servitude: victims work in a household where they may be ill-treated, humiliated, made to work long and tiring hours, forced to work and live in very difficult conditions or forced to work for little or no pay. Sometimes, someone who is a victim of forced marriage can also be a victim of domestic servitude.

2.2 Slavery, servitude and forced or compulsory labour

As well as trafficking, modern slavery also covers cases of slavery, servitude and forced or compulsory labour. Some people may not be victims of human trafficking because they have not moved out of their local area, but can still be victims of modern slavery.

Slavery, servitude and forced labour are illegal in the UK.

For a person to be a victim of slavery, servitude and forced labour there must have been:

  • the means (being held, either physically or through threat – for example, threat or use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability);
  • a service (a person has to have provided a service for the benefit of others – for example, begging, sexual services, manual labour, domestic service).

3. Identifying Victims

It can be difficult to identify victims of modern slavery; they are often reluctant to come forward, may not recognise themselves as victims or, because they are scared, they may tell their stories with obvious mistakes or having left some information out.

Some adults are more vulnerable to becoming victims of modern slavery, including:

  • young men and women;
  • pregnant women;
  • former victims of modern slavery (including people who do not consent to enter the National Referral Mechanism, see Section 5), who may be at risk of being re-trafficked;
  • people who are homeless or at risk of becoming homeless;
  • people with drug and alcohol issues;
  • people who have learning difficulties, disabilities, communication difficulties, chronic developmental or mental health disorders or other health issues;
  • people who have experienced abuse before;
  • people in some deprived / poor areas where there are few job opportunities are more likely to be recruited by traffickers, pretending to be recruitment agencies / genuine employers;
  • people struggling with debt;
  • people who have lost family or suffered family breakdown or have limited support networks;
  • people with criminal records who employers may not want to take on;
  • illegal immigrants who are not allowed to work and therefore do not have an income;
  • older people who are lonely and do not have much money;
  • people who speak no or very little English and / or cannot read or write in their own language;
  • overseas domestic workers.

3.1 Signs to look out for

Victims of modern slavery can be found anywhere. However, there are certain industries where they are more likely to be found such as nail bars, car washes, food preparation / processing factories, domestic service, farming and fishing, building sites and the sex industry.

The Modern Slavery Statutory Guidance (Home Office) provides the following indicators:

3.1.1 General indicators

Victims may:
Believe that they must work against their will Have false identity or travel documents for example a passport (or none at all)
Be unable to leave their work or home environment Be found in or connected to a type of location or venue likely to be used for exploiting people
Show signs that their movements are being controlled / feel that they cannot leave Be unfamiliar with the local language
Be subjected to violence or threats of violence against themselves or against their family members and loved ones Not know their home or work address
Show fear or anxiety Allow others to speak for them when addressed directly
Have injuries that appear to be the result of an assault Be forced, threatened or deceived into working in poor conditions
Not be allowed to have the money they have earned Be disciplined / controlled through punishment
Be distrustful of the authorities Receive little or no payment
 Be afraid of telling anyone their immigration status Work very long hours over long periods
Come from a place where human trafficking victims are known to come from Live in poor or substandard accommodations
Have had the fees for their transport to the country of destination paid for by organisers of human trafficking, who they must pay back by working or providing services Have no access to medical care
Have no or not much contact with other people Only be allowed to have limited contact with their families or with people outside of their immediate environment
Be unable to speak freely with others Believe that they must work until they have paid off the debt they are told they owe
Be dependent on their ‘bosses’ / facilitators Have believe the false promises of their bosses / facilitators.

3.1.2 Physical indicators

  • Physical injuries – with no clear explanation as to how or when they got the injuries or which are either not treated or only partly treated, or there may be lots of / unusual scars or broken bones which have healed.
  • Work related injuries – often through having poor or no personal protective equipment and health and safety arrangements.
  • Physical consequences of living in captivity, neglect or poor environmental conditions – for example, infections including tuberculosis (TB), chest infections or skin infections, malnutrition and vitamin deficiencies or anaemia.
  • Dental problems – from physical abuse and / or not being able to see a dentist.
  • Worsening of existing long term medical conditions – these may be untreated (or poorly treated) conditions such as diabetes or high blood pressure.
  • Being disfigured – cutting, burning, or branding someone’s skin may be used as punishment or a way to show that an exploiter ‘owns’ the person.
  • Pain after a surgical operation – infection or scarring from organ harvesting, particularly of a kidney.

3.1.3 Psychological indicators

  • Expression – they may seem in fear or anxious.
  • Depression – they may have a lack of interest in getting involved in activities, in socialising with other people or appear to feel hopelessness.
  • Attachment and identity issues – they can become detached from other people or become over-dependent (or both). This can include being dependent on their exploiters.
  • Unable to control emotions – for example they may often swing between sadness, forgiveness, anger, aggression, frustration and / or emotional detachment or emotional withdrawal.
  • Difficulties with relationships – they may have difficulty trusting others (either have a lack of trust or be too trusting) which causes difficulties in their relationships and difficulties assessing warning signs in their relationships.
  • Loss of independence – for example they may have difficulty in making simple decisions, tendency to give in to the views / desires of others.

 3.1.4 Situational and environmental indicators

  • Exploiters keep victims’ passports or identity documents, contracts, any payslips, bank information or health records.
  • They have a lack of information about their rights as a visitor in the UK or a lack of knowledge about the area in which they live in the UK.
  • They act as if they are being coerced or controlled by another person.
  • They may go missing for periods.
  • They may be fearful and emotional about their family or dependents.
  • They may have limited spoken English, for example only being able to talk about being exploited and not being able to have any other topic of conversation.
  • They may be limited in where they can go (victims may not be ‘locked up’ but are not able to move around freely) or being held in isolation.
  • They may have their wages withheld (including deductions from wages).
  • Debt bondage – they may have to work until they have paid off a debt to the traffickers / exploiters.
  • They may have abusive working and / or living conditions, including having to work a lot of overtime.

3.2 Impact on victims

Victims of modern slavery are forced, threatened or deceived into situations of humiliation and being under the control of their exploiters, which undermines their personal identity and sense of self. The impact of these experiences can be devastating.

It is important for all professionals to understand the specific vulnerability of victims of modern slavery and use practical, trauma-informed methods of working which are based upon basic principles of dignity, compassion and respect and which recognise the impact of trauma on the emotional, psychological and social wellbeing of people.

Victim’s voices must always be heard, and their rights respected.

4. Reporting Concerns

4.1 Taking action

When responding to concerns of modern slavery,  the safety, protection and support of the potential victim must be the first priority. They may need emergency medical care. Only independent interpreters should be used. Never use any other adults who are with potential victims, as they may (unknown to the member of staff) be associated with the exploiters and therefore may not tell the truth about the person’s situation.

4.1.1 Immediate risk of harm

If it is suspected that someone is in immediate danger, the police should be contacted on 999.

4.1.2 No immediate risk of harm

There are a number of options that can be taken:

  • the police can be contacted on 101;
  • the Modern Slavery helpline can be contacted: 0800 0121 700.

4.1.3 Adult Social Care

Victims of modern slavery are often adults who are at risk of, or who are experiencing, abuse or neglect, particularly when they have been rescued from a situation of exploitation. In this instance, it should be considered whether a Section 42 (safeguarding) enquiry is required. When making a safeguarding referral, the cooperation of the adult victim should be requested, taking into account their needs and wishes.

Even where an adult has been removed from a harmful situation, they can be at risk of re-victimisation. Even if there is no immediate risk relating to safety or the person’s welfare, it is important to discuss any concerns with the safeguarding adults team.

4.2 Seeking advice

Advice about what action to take can be sought from your manager, the safeguarding adults team, the local police public protection unit (contactable via the police switchboard) or the Modern Slavery Helpline.

5. National Referral Mechanism and the Duty to Refer

For further guidance and the online referral forms see:

The National Referral Mechanism (NRM) provides a framework for identifying and referring potential modern slavery victims and ensuring they receive appropriate support.

Support for adult victims may include:

  • access to legal aid for immigration advice;
  • access to short-term Government-funded support through the Modern Slavery Victim Care Contract (accommodation, material assistance, translation and interpretation services, counselling, advice, etc);
  • outreach support if already in local authority accommodation or asylum accommodation;
  • assistance to return to their home country if not a UK national.

5.1 Referral or Duty to Notify

An online referral system is used for making referrals into the NRM and also for Duty to Notify (DtN) referrals.

Referrals into the NRM can only be made by staff who work for designated ‘first responder’ organisation – this includes local authorities (see Appendix 1 below).

Whether a DtN referral or referral into the NRM is made depends on obtaining the consent of the adult victim.

For an adult to be referred to the NRM, they must provide informed consent. This means they should understand what the NRM is, what support it can provide, and what the possible outcomes are if they are referred.

It should be presumed that an individual has the mental capacity to make a decision about whether to consent to entering the NRM. When there may be concern about a person’s mental capacity to make a decision about whether or not to consent to entering the NRM, steps should be taken to try to support them to make the decision. Where a person does not have the capacity to consent, a best interests decision should be taken. Before a decision is taken in the best interests of an individual, it is vital to consult with any other agencies involved in the care and support of the individual. See Mental Capacity chapter.

If the adult does not consent to a NRM referral, a DtN referral should always still be made, using the online referral form.

5.2 Support for potential victims who do not consent

Adult potential victims who choose not to enter the NRM may still be eligible for other state support. They may still be:

  • in immediate risk of harm, in which case the police should be contacted by calling 999;
  • eligible for housing support through the local authority or for other support from the government where they have recourse to public funds;
  • entitled to make a claim for asylum or another type of immigration status or stay in asylum support if they have an active claim (where the person does not have the right to reside in the UK);
  • able to receive emergency medical care;
  • at risk of further exploitation, see Section 4.1.3, Adult Social Care.

6. Further Reading

6.1 Relevant information

Modern Slavery and Exploitation Helpline – free confidential advice in over 200 languages

Modern Slavery Statutory Guidance – How to Identify and Support Victims (Home Office) 

Modern Slavery Training Resource Page (Home Office) 

Modern Slavery Resources (Home Office)

 

Appendix 1: NRM First Responder Organisations and Responsibilities

In England and Wales, a ‘first responder organisation’ is an authority that is authorised to refer a potential victim of modern slavery into the National Referral Mechanism. The current statutory and non-statutory first responder organisations are:

  • police forces;
  • certain parts of the Home Office; UK Visas and Immigration, Border Force, Immigration Enforcement and National Crime Agency;
  • local authorities;
  • Gangmasters and Labour Abuse Authority (GLAA);
  • Salvation Army;
  • Migrant Help;
  • Medaille Trust;
  • Kalayaan;
  • Barnardo’s;
  • Unseen;
  • NSPCC (CTAC);
  • BAWSO;
  • New Pathways;
  • Refugee Council.

First responder organisations have the following responsibilities – it is for the organisation to decide how it will discharge these responsibilities:

  • identify potential victims of modern slavery and recognise the indicators of modern slavery;
  • gather information in order to understand what has happened to victims;
  • refer victims into the NRM via the online process (in England and Wales this includes notifying the Home Office if an adult victim doesn’t consent to being referred – DtN);
  • provide a point of contact for the competent authority to assist with the Reasonable and Conclusive Grounds decisions and to request a reconsideration where a first responder believes it is appropriate to do so.
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CQC Quality Statement

Theme 4 – Leadership: Governance, management and sustainability

We statement

We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes and we share this securely with others when appropriate.

1. Introduction

Data protection legislation should not be seen as an obstacle to sharing information, but as a framework of best practice which helps to ensure that when the local authority uses, records and shares information it does so safely and in a way which is transparent and in line with the law.

The local authority collects, uses, stores and retains (for specified time periods) information about people with whom it works. This includes:

  • adults and their families who use the service, including their families and any children, and those who no longer in receipt of services;
  • current, past and prospective staff; and
  • current, past and prospective staff; and
  • suppliers.

When processing data in this way, the local authority must comply with the requirements of the Data Protection Act 2018 (DPA) and the UK General Data Protection Regulation (UK GDPR) (see Section 2, Legislation).

It must also ensure, through its procedures and working practices, that all employees, contractors, consultants, suppliers and partners who have access to any personal data held by or on its behalf, are fully aware of and abide by their duties and responsibilities under data protection legislation. Any contracts with service providers must be clear about the different parties’ responsibilities for data processing and information sharing.

Personal information must be handled and dealt with in accordance with data protection legislation however it is collected, recorded, stored and used, and whether it be on paper, on computer or digital records or recorded in any other way.

In addition, the local authority may also be required to collect and use information in order to comply with the requirements of central government, such as in the case of a Safeguarding Adults Review or Care Quality Commission inspection.

2. Legislation

2.1 Data Protection Act 2018

The Data Protection Act 2018 aims to ensure that UK data protection legislation keeps pace with technological changes, and the impact these have had on the collection and use of personal data.

The Act provides additional functions and clarification of the role of the Information Commissioner and the Information Commissioner’s Office.

2.2 UK General Data Protection Regulation

The UK General Data Protection Regulation (UK GDPR) (see UK GDPR: Guidance and Resources, Information Commissioner’s Office).

The UK GDPR:

  • gives individuals greater control of their data by improving consent processes; and
  • introduced the ‘right to be forgotten’ which enables the data subject to have their data ‘forgotten’ once it is no longer being used for the purpose which it was collected. This is not an absolute right, however; it applies only to data held at the time the request is received. It does not apply to data that may be created in the future.

If staff receive a query about the collection or processing of personal data, they should contact the Knowlsey Information Governance team for advice.

3. Principles of Data Protection: Article 5 GDPR

Anyone processing personal data must comply with the principles laid down in the DPA and UK GDPR.  These are legally enforceable and require that when personal data is processed (see also Section 3.2, What is personal data under Article 4?) it must be:

  • lawful and fair and carried out in a transparent manner in relation to the data subject. (lawfulness, fairness and transparency principle);
  • specified, explicit and legitimate and not further processed for other purposes incompatible with those purposes (purpose limitation principle);
  • adequate, relevant and not excessive to what is necessary in relation to the purposes for which data is processed (the data minimisation principle);
  • accurate and kept up to date (the accuracy principle);
  • kept for no longer than is necessary for the purposes for which the personal data is processed (the storage limitation principle); and
  • stored in a way that ensures appropriate security including protection against unauthorised or unlawful processing and accidental loss, destruction or damage, using appropriate technical or organisational measures (the integrity and confidentiality principle and the accountability principle).

3.1 Handling personal data and sensitive personal data

The DPA outlines conditions for the processing of personal data, and makes a distinction between personal data and sensitive personal data.

Personal data is any information relating to a living person who can be identified or who is identifiable, directly from that information, or who can be indirectly identified from that information in combination with other information.

3.2 What is personal data under Article 4 GDPR?

Personal data is:

  • any information relating to an identified or identifiable natural person such as;
    • a name;
    • an identification number;
    • location data;
    • an online identifier such as an IP address or cookies; or
    • an email address.

3.3 Special categories of data (sensitive personal data):  GDPR Article 9

Special category data is personal data that needs more protection because it is sensitive. It includes personal data which reveals:

  • racial or ethnic origin;
  • political opinion;
  • religious or other beliefs;
  • trade union membership;
  • physical or mental health or conditions;
  • sexual life or sexual orientation.

3.4 Identifying a lawful basis for sharing information

Article 6 of the UK GDPR providers practitioners with a number of lawful bases for sharing information. At least one of these must apply whenever personal data is processed,

Where practitioners need to process and share special category data (sensitive personal data), they need to identify both a lawful basis for processing under Article 6 of the UK GDPR and a special category condition for processing in compliance with Article 9 (see Information Commissioner’s Office, Lawful basis for processing).

4. Data Protection Practice

The local authority must:

  • observe fully conditions regarding the fair collection and use of personal information;
  • meet its legal obligations to specify the purpose for which information is used;
  • collect and process appropriate information and only to the extent that it is needed to fulfil operational needs or to comply with any legal requirements;
  • ensure the quality of information used;
  • apply strict checks to determine the length of time information is held;
  • take appropriate technical and organisational security measures to safeguard personal information;
  • ensure that personal information is not transferred abroad without suitable safeguards;
  • ensure that the rights of people about whom the information is held can be fully exercised under data protection legislation. These include:
    • the right to be informed that processing is being undertaken;
    • the right of access to one’s personal information within the statutory timescale;
    • the right to prevent processing in certain circumstances;
    • the right to correct, rectify, block or erase information regarded as wrong information.

In addition, the local authority should ensure that:

  • there is someone with specific responsibility for data protection;
  • everyone managing and handling personal information understands that they are contractually responsible for following good data protection practice;
  • everyone managing and handling personal information is appropriately trained to do so;
  • everyone managing and handling personal information is appropriately supervised;
  • anyone wanting to make enquiries about handling personal information, whether a member of staff or a member of the public, knows what to do;
  • queries about handling personal information are promptly and courteously dealt with;
  • methods of handling personal information are regularly assessed and evaluated;
  • performance with handling personal information is regularly assessed and evaluated;
  • data sharing is carried out under a written agreement, setting out the scope and limits of the sharing. Any disclosure of personal data will be in compliance with approved procedures.

All employees should be aware of the local authority’s data protection policy and of their duties and responsibilities under the DPA.

All managers and staff will take steps to ensure that personal data is kept secure at all times against unauthorised or unlawful loss or disclosure and in particular will ensure that:

  • paper files and other records or documents containing personal / sensitive data are kept in a secure environment;
  • personal data held on computers and computer systems is protected by the use of secure passwords, which where possible have forced changes periodically;
  • passwords must not be easily compromised and must not be shared with others;
  • personal data must only be accessible to team members with appropriate access levels;
  • data in all forms must be disposed of by secure means in accordance with local policies.

All contractors, consultants, suppliers and partners must:

  • ensure that they and all of their staff who have access to personal data held or processed for or on behalf of the local authority, are aware of this policy and are fully trained in and are aware of their duties and responsibilities under data protection legislation. Any breach of any provision of the legislation will be deemed as being a breach of any contract between the local authority and that individual, partner or firm (see Report a Breach, Information Commissioner’s Office);
  • allow data protection audits by the local authority of data held on its behalf (if requested);
  • indemnify the local authority against any prosecutions, claims, proceedings, actions or payments of compensation or damages, without limitation.

All contractors and suppliers who use personal information supplied by the local authority will be required to confirm that they abide by the requirements of data protection legislation in relation to such information supplied by the local authority.

The local authority must also:

  • ensure data subjects are given greater control of their data by improving consent processes. Consent must be freely given, specific, informed and give a clear indication of their wishes. This must be provided by a statement or clear affirmative action, signifying the individual’s agreement to the processing of their personal data;
  • must ensure that data subjects have the ‘right to be forgotten’ which enables them to have their data ‘forgotten’. This is not an absolute right, however; it only applies to information which is data held at the time the request is received. It does not apply to data that may be created in the future.
  • keep a record of data operations (mapping data flow within the local authority) and activities and assess if it has the necessary data processing agreements in place, and take action to remedy if not;
  • carry out data protection impact assessments (DPIAs) on its products and systems;
  • designate a data protection officer (DPO) for the local authority;
  • review processes for the collection of personal data;
  • be aware of the duty to notify the Information Commissioner’s Office of a data breach (the relevant supervisory authority);
  • ensure ‘privacy by design’ and ‘privacy by default’ in new products (such as a new case recording system) and assess whether existing products used by the local authority meets the new data protection standards and take action accordingly to ensure compliance.

5. Redaction of Third Party Data

Before sharing information, the local authority must redact (or remove) personal data relating to third parties, to protect their privacy. For example, where social work records include references to other people, such as the adult’s family and friends, it is like some of this information will need to be withheld (redacted) before the record can be shared.

Under the Data Protection Act, it is for each local authority to weigh up how ‘reasonable’ it is to share another person’s information in each case (for example it may be reasonable to share information about another family members’ health condition if is likely to be hereditary). The Act is clear however that any person who appears in records because they were employed to provide care or received payment for providing a service, or acted in an official capacity, should not be treated as ‘third party’. This means that the names and information of social workers and other professionals should not be redacted.

6. Rights of the Data Subject

Any person whose information is being processes by the local authority has the following rights:

  1. to be informed of data processing (for example a privacy notice);
  2.  to be able to access information free of charge (also known as a Subject Access Request) – there is a one month time limit for the local authority to respond to any request;
  3. to have inaccuracies corrected;
  4. to have information erased (although this is not an absolute right);
  5. to restrict processing;
  6. to have data portability;
  7. intervention in respect of automated decision making;
  8. to be able to withdraw consent;
  9. to complain to the Information Commissioner’s Office (ICO).

6.1 Right to be informed (section 44 DPA)

A person whose information is being processed should have access to a privacy notice (available on the council website), setting out:

  1. lawful basis for processing;
  2. contact details for the Data Protection Officer (DPO);
  3. what information will be processed;
  4. who it will be shared with and why;
  5. how long it will be held;
  6. details of rights;
  7. how to complain.

6.2 Rectification (Section 46 DPA)

A person whose information is being processed has the following rights:

  • to rectify or correct inaccurate information;
  • if information is incomplete it must be completed;
  • rectification or correction can be achieved by the provision of a supplementary statement;
  • where the rectification is of information maintained for the purposes of evidence, instead if rectifying, the processing should be restricted;
  • be informed in writing if request has been granted and if not the reasons for this.

7. Action if there is a Data Breach

A breach of security which can be either accidental, deliberate or unlawful and can involve:

  • destruction;
  • loss;
  • alteration;
  • unauthorised disclosure;
  • unauthorised access.

A breach covers accidental and deliberate causes and is more than just losing personal data.

7.1 Examples of data breaches

These are commonly occurring breaches:

  • access by an unauthorised party, including a third party;
  • deliberate or accidental action (or inaction) by a controller or processor;
  • sending personal data to an incorrect recipient;
  • computing devices containing personal data being lost or stolen;
  • alteration of personal data without permission; and
  • loss of availability of personal data.

7.2 What constitutes a serious data breach?

A serious data breach:

  • is where it is likely to result in a risk to the rights and freedoms of individuals. If unaddressed such a breach is likely to have a significant detrimental effect on individuals – for example, result in discrimination, damage to reputation, risk of physical harm, financial loss, loss of confidentiality or any other significant economic or social disadvantage;
  • must be assessed on a case by case basis;
  • must consider these factors: detriment / nature of data / volume (detriment includes emotional distress as well as both physical and financial damage).

All serious data breaches must be reported to the ICO within 72 hours of becoming aware of the breach. See UK GDPR Data Breach Reporting (ICO) for further information.

8. Further Reading

8.1 Relevant chapters

Information Sharing and Confidentiality

Case Recording

8.2 Relevant information

Guide to Data Protection: for Organisations (Information Commissioner’s Office)

Working from Home (Information Commissioner’s Office) 

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1. Introduction

The Mental Health Act (MHA) is the current law which provides legal powers for the admission, detention and treatment of a person against their will in respect of mental illness. Where a person is detained against their will this is commonly known as ‘being sectioned’.

The MHA is an extensive legislative framework about which this chapter provides an introduction and basic details of the most commonly known and used sections within the adult social care remit.

The MHA1983 was reformed in 2007 which saw a number of key changes to the original Act which placed a larger focus on public protection and risk management. The 2007 amendments were exactly that and the main body of the 1983 Act remains in place, as such the MHA may be referred to as the Mental Health Act 1983 (2007). See Appendix 1: 2007 Amendments to the 1983 Act for information about changes to the original legislation.

2. Who does the Mental Health Act 1983 apply to?

The MHA provides ways of assessing, treating and caring for people who have a serious mental disorder that puts them or other people at risk. It sets out when:

  • people with mental disorders can be detained in hospital for assessment or treatment;
  • people who are detained can be given treatment for their mental disorder without their consent (it also sets out the safeguards people must get in this situation); and
  • people with mental disorders can be made subject to guardianship or after-care, under supervision to protect them or other people.

Most of the MHA does not distinguish between people who have the mental capacity to make decisions and those who do not. Many people covered by the MHA have the capacity to make decisions for themselves.

Decision makers will need to decide whether to use either the MHA or MCA to meet the needs of people with mental health problems who lack capacity to make decisions about their own treatment. Where someone with a mental health disorder is subject to a Community Treatment Order (CTO) or Guardianship under the MHA, and lacks capacity, they may have a Deprivation of Liberty Safeguard in place; otherwise a person cannot be subject to the two frameworks at the same time. See Interface between the Mental Capacity Act 2005 and the Mental Health Act 1983.

3. Parts of the Act

The Mental Health Act 1983 is split into ten parts:

  1. The Application of the Act;
  2. Compulsory Admission to Hospital and Guardianship;
  3. Patients Concerned in Criminal Proceedings or Under Sentence;
  4. Consent to Treatment;
  5. Treatment of Community Patients not Recalled to Hospital;
  6. Mental Health Review Tribunals;
  7. Removal and Return of Patients Within the United Kingdom;
  8. Management of Property and Affairs of Patients;
  9. Miscellaneous Functions of Local Authorities and Secretary of State;
  10. Offences; and also
  11. Miscellaneous and Supplementary.

These parts are the ones most commonly used and key to adult social care practice:

  • Compulsory Admission to Hospital and Guardianship;
  • Miscellaneous Functions of Local Authorities and Secretary of State;
  • Miscellaneous and Supplementary

Further detail about each section is outlined below.

4. Part 2: Compulsory Admission to Hospital and Guardianship

4.1. Section 2 Admission for Assessment

This allows for:

  • a person to be detained in hospital for assessment of their mental health;
  • treatment to be forcibly administered as part of the assessment period (excluding use of Electro-Convulsive Therapy – ECT);
  • a detention period of up to 28 days, however discharge can be arranged sooner.

Section 2 cannot be renewed. If further detention is required beyond the 28 day period, assessment under section 3 should be considered. In certain cases where there may be issues relating to a person’s nearest relative, Section 2 can be extended by the powers of the Court until such decision regarding the nearest relative are resolved.

4.1.1 Criteria

For a person to be detained under section 2 they must have:

  • been assessed by two doctors – one of whom must be section 12 approved. It is preferable that at least one of the doctors involved in the assessment has previous acquaintance with the person being assessed;
  • both doctors need to be of the opinion that compulsory admission is required and must complete a medical recommendation;
  • there must be no longer than five clear days between each of the medical assessments, for example if an examination is completed on a Monday, the five days are not inclusive of this day (meaning Tuesday to Saturday are clear days therefore Sunday is the last possible day for the second medical examination);
  • the Approved Mental Health Professional (AMHP) must be in agreement with the two doctors’ recommendations and have completed a valid application for admission;
  • the AMHP must complete the application for admission within 14 days of the latter dated medical recommendation;
  • a person’s nearest relative is also able to make an application for admission.

4.1.2 Appeal

Patients have the right to appeal against the detention within the first 14 days.

4.2 Section 3: Admission for treatment

For a person to be detained under section 3 the criteria for section 2 must all be met. Section 3 can be used where a person is well known to mental health services and it is clear what illness is to be treated and therefore no assessment period is required.

Alternatively, it may be used due to the need for continued detention after the 28 day period of section 2.

4.2.1 Provisions

The Act allows the following provisions:

  • a person to be detained in hospital for treatment of their mental health. Appropriate medical treatment must be available;
  • forcible administration of treatment (excluding use of ECT. Where there is non-compliance with medication this will need to be reviewed by a second opinion appointed doctor (SOAD) after three months.;
  • a detention period of up to six months, after which it can be renewed for a further six months and on a 12 monthly basis thereafter.

4.2.2 Appeal

Patients have the right to appeal against the detention within the first six months.

Please also see Section 117 Aftercare.

4.3 Section 4 – Admission for Assessment in case of emergency

4.3.1 Criteria

Section 4 is used in emergency situations where is it deemed not practicable to arrange two doctors and assess under section 2.

Unlike assessment for sections 2 and 3 there needs only to be one doctor involved – preferably one whom previous acquaintance. An AMHP is still required to make an application.

4.3.2 Provisions

The Act allows the following provisions:

  • detention period of up to 72 hours following which further assessment by a second doctor should be arranged and the decision made whether to detain under section 2 or to arrange discharge;
  • treatment can be refused, however where there is concern regarding capacity to consent, treatment can be provided in the best interests of the individual detained. It can also be provided where it is necessary to prevent harm to themselves or to others.

4.3.3 Appeal

There is no right of appeal against section 4.

4.4 Section 5: Application in respect of a patient already in hospital (holding powers)

The Act:

  • provides powers to doctors and nurses to prevent a person from leaving hospital where by doing so there may be a risk posed to the individual themselves or to others as a result of the individuals mental health;
  • may be used to prevent informal patients from leaving a mental health ward or prevent a person from leaving a general ward where they may be receiving treatment for a physical condition.

There are two parts to section 5 which are outlined below.

4.4.1 Section 5(2)

This is often referred to as doctor’s holding powers. The provisions are:

  • it gives the doctor in charge of the individuals the power to detain for up to 72 hours;
  • further assessment by an AMHP and second doctor should be arranged as soon as possible and the decision made whether to detain under a section of the M HA or to arrange discharge;
  • section 5(2) cannot be renewed.

4.4.2 Section 5(4)

This is often referred to as nurse’s holding powers. The provisions are:

  • it gives certain nurses the power to detain for up to six hours;
  • a doctor should be requested to attend as soon as possible;
  • section 5(4) ends when the doctor arrives. The doctor must assess if the person can be transferred onto section 5(2) or whether the person can remain on an informal basis;
  • section 5(4) cannot be renewed.

4.5 Section 7: Application of Guardianship Order

Guardianship gives someone (usually a local authority social care department) the exclusive right to decide where a person should live. However in doing so they cannot unlawfully deprive the person of their liberty. Where restrictions amount to a deprivation, authorities should seek to apply for a DoLS authorisation to run concurrent with the Guardianship Order (see Deprivation of Liberty Safeguards).

The guardian can also require the person to attend for treatment, work, training or education at specific times and places, and they can demand that a doctor, approved social worker or another relevant person have access to the person wherever they live.

Guardianship can apply whether or not the person has the capacity to make decisions about care and treatment.

It does not give anyone the right to treat the person without their permission or to consent to treatment on their behalf (see also Interface between Mental Capacity Act and Mental Health Act).

4.6 Section 17: Leave of absence from hospital

The Act makes the following provisions:

  • the Responsible Clinician (RC) to grant a detained patient leave of absence from hospital;
  • leave can be provided as escorted or unescorted and the time allowed is controlled by the RC;
  • leave can be used to allow a person to have home leave including overnight stays and can often be useful to trial how a person is likely to function in the community when discharged from hospital.

A person is still a detained patient when section 17 is in place.

4.7 Section 17A: Community Treatment Orders

Community Treatment Orders (CTO’s) are used to support people in the community that have mental health needs and require continued treatment under supervision.

The aim of the community treatment or was to reduce the number of ‘revolving door’ patients who would typically become non-compliant with treatment once discharged from hospital, and as a result experience deterioration in their mental state often resulting in further admission.

The provisions are:

  • CTO’s can only be used where a person is detained under section 3, 37, 45A, 47 or 48;
  • a CTO allows for conditions to be attached to a person’s discharge;
  • any individual considered for a CTO should have a degree of understanding in relation to the conditions attached as they must comply with these conditions in order to avoid recall to hospital;
  • CTO timeframes mirror those of Section 3, that is six months, six months, annual;
  • an AMHP needs to be in agreement with the proposal of a CTO before it can be enforced.

4.8 Section 26: Nearest Relative

The MHA provides safeguards to those who are detained, one of these being the role of the nearest relative (NR).

The NR is different from next of kin and is identified using the list below;

  • husband, wife or civil partner;
  • son or daughter;
  • father or mother;
  • brother or sister;
  • grandparent;
  • grandchild;
  • uncle or aunt;
  • niece or nephew.

Determining a person’s NR can at times be complex, however to simplify it whoever appears first in the above list in defaults to the role.

The NR must be over 18 (unless husband, wife or civil partner) and where there are both parties available, for example mother and father, the eldest would fulfil the role.

The NR has the right to request that a MHA assessment is completed; they are able to make an application for detention and can also request that their relative is discharged from hospital.

An identified NR can be displaced by the courts if it is deemed that they are unsuitable. The NR is also able to delegate the role and function.

Part 9: Miscellaneous Functions of Local Authorities and the Secretary of State

5.1 Section 117 Aftercare: Introduction

See also Section 117 Aftercare

Section 117 of the Mental Health Act 1983 (2007) imposes a duty upon local authorities and Integrated Care Boards to provide aftercare services for anybody who has been detained under Sections 3, 37, 45A, 47 or 48 of the Mental Health Act (MHA). This includes patients granted leave of absence under section 17 and patients being discharged on community treatment orders (CTOs). The Care Act 2014 implemented some changes to the MHA (see Section 7, Care Act Amendments to Aftercare under the Mental Health Act 1983).

As Section 117 enforces a duty on the local health authority and adult social care services to provide care to meet eligible needs, Section 117 needs that arise directly because of or from the person’s mental disorder and are likely to prevent a deterioration in their condition and therefore lead to a readmission. If a person has additional social care needs, such as a physical disability, that do not arise because of a mental disorder, the usual social care eligibility criteria under the Care and Support Statutory Guidance would need to be applied to these needs.

If, at any point, it becomes apparent that a person who is be eligible for Section 117 aftercare has been paying for services, they can reclaim these payments as long as with clear evidence is provided of their detention.

6. Part 11: Miscellaneous and Supplementary

6.1 Section 135: Warrant to search and remove to a place of safety

6.1.1 Section 135 (1)

The provisions are:

  • professionals have the power of entry to a person’s private dwelling for the purpose of assessment under the MHA;
  • for entry to be gained by force if required under the powers of a warrant issued by the county court;
  • for a person to be removed to a place of safety for the purpose of assessment or where appropriate, remain in their own home.
  • an AMHP, a police officer and a doctor is required to be present for the execution of a 135 (1) warrant.

6.1.2 Section 135 (2)

The provisions are:

  • for forcible entry if required to access a person who is liable to be detained under the MHA or who need to be retaken to hospital (for example if they have gone absent without leave from the ward when detained and have returned home and refusing to allow entry);
  • a warrant is again required to act out these powers of entry, however an AMHP or doctor is not required to execute the warrant under this section.

6.1.3 Section 136: Removal of mentally disordered persons without a warrant – police powers of detention

The provisions are:

  • section 136 is an emergency power which allows police officers to remove a person from a public place to a place of safety for the purpose of further assessment under the MHA where there are concerns that a person may be suffering from mental illness and in need of immediate care and / or control. The timeframes of section 136 were reduced from 72 to 24 hours in December 2017;
  • if a person is initially seen by a doctor before the AMHP has coordinated a full assessment and it is deemed that there is no evidence of mental illness, the person must be discharged from the 136 immediately;
  • a person can be discharged with or without follow up from services once assessed or may be detained under the MHA.

7. Further Reading

7.1 Relevant chapters

Interface between the Mental Capacity Act 2005 and the Mental Health Act 1983

Section 117 Aftercare

Defining Mental Disorder

Ordinary Residence

7.2 Relevant information

Mental Health Act 1983

Mental Health Act 1983 Code of Practice

Appendix 1: 2007 Amendments to the Mental Health Act 1983

1. Key amendments

The key amendments to the Act were as follows.

The Fundamental Principles – Section 118 of the Act says that the Code of Practice (which was given legal stature as part of the reform) must provide a statement of principles to inform all decision making within the remit of the mental health act.

Chapter 1 of the Code of Practice for England outlines the following guiding principles:

  • purpose principle;
  • least restriction principle;
  • respect principle;
  • participation principle;
  • effectiveness, efficiency and equity principle.

Section 1: Definition of mental disorder – The definition of mental disorder in Section 1 of the Act was split into 4 classifications; psychopathic disorder, mental illness, mental impairment and severe mental impairment.

The 2007 Act broadened the term of mental disorder as below:

“mental disorder” means any disorder or disability of the mind.

Prior to the changes to the Act there were grounds to detain those with Learning Disability under mental impairment and severe mental impairment. The amendment now makes clear that the disability itself does not meet the criteria for detention unless it is:

“associated with abnormally aggressive or seriously irresponsible conduct on his part”

2. Professional roles

The role of the Approved Social Worker (ASW) was opened up to healthcare professionals including nurses, occupational therapists and psychologists. It was renamed the Approved Mental Health Professional (AMHP).

The role of the Responsible Medical Officer (RMO) became that of the Responsible Clinician (RC).

Supervised Discharge /Community treatment Orders – Section 25A Supervised Discharge of the 1983 Act was abolished other than for those already subject to it and was replaced with the introduction of section 17A Community Treatment Orders (CTO’s).

Introduction of Appropriate Medical Treatment – The 1983 Act stated that treatment had to be likely to be effective upon a person’s condition which allowed for a greater degree of detentions to take place, whereas the Act now concurs that treatment is only to be provided where there is purpose outlining that the purpose of any treatment is to:

“alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations” (section 145).

The definition of medical treatment was also changed itself to outline that medical treatment can be provided in the absence of medical supervision.

Those of 16 and 17 years of age and Parental Responsibility – The 2007 Act introduced the notion that any person aged 16 or 17 who is deemed to have capacity cannot be detained on basis of parental consent – outlined in section 131 MHA.

Appendix 2: The Policing and Crime Act 2017

Further to the 2007 Amendments to the MHA 1983, the introduction of the Policing and Crime Act 2017 has more recently had an impact on the application of the Act. The

Guidance for the implementation of changes to police powers and places of safety provisions in the mental health act 1983 published by the Home Office and Department of Health usefully outlines these changes as below:

  • section 136 powers may now be exercised anywhere other than in a private dwelling;
  • it is now unlawful to use a police station as a place of safety for anyone under the age of 18 in any circumstances;
  • a police station can now only be used as a place of safety for adults in specific circumstances, which are set out in regulations;
  • the previous maximum detention period of up to 72 hours has been reduced to 24 hours (unless a doctor certifies that an extension of up to 12 hours is necessary);
  • before exercising a section 136 power police officers must, where practicable, consult one of the health professionals listed in section 136(1C), or in regulations made under that provision;
  • a person subject to section 135 or 136 can be kept at, as well as removed to, a place of safety. Therefore, where a section 135 warrant has been executed, a person may be kept at their home (if it is a place of safety) for the purposes of an assessment rather than being removed to another place of safety;
  • a new search power allows police officers to search persons subject to section 135 or 136 powers for protective purposes.
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CQC Quality Statements

Theme 1 – Working with People: Assessing needs

We statement

We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

What people expect

I have care and support that is coordinated, and everyone works well together and with me.

I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.

1. Introduction

If a person has been assessed as lacking capacity, any action taken or any decision made or on behalf of that person, must be made in their best interests. This is the fourth principle of the five principles of the Mental Capacity Act 2005 (MCA) (see Mental Capacity).

The person who has to make the decision is known as the ‘decision maker’. The decision maker is usually the person closest to the decision, that is a clinician for healthcare decisions, social worker for social care decisions and a carer for day to day care decisions.

2. What are ‘Best Interests’?

The law requires a number of factors to be considered when deciding what is in the best interests of a person who lacks capacity. The checklist below details these factors. This list is not exhaustive and the MCA Code of Practice should be referred to for more details.

  • It is important not to make assumptions about someone’s best interests merely on the basis of their age, appearance, condition or any aspect of their behaviour.
  • The decision maker must consider all the relevant circumstances relating to the decision in question.
  • The decision maker must consider whether the person is likely to regain capacity (for example after receiving medical treatment). If they are likely to, can the decision or act wait until then?
  • The decision maker must involve the person as fully as possible in the decision that is being made on their behalf.
  • If the decision concerns the provision or withdrawal of life sustaining treatment the decision maker must not be motivated by a desire to bring about the person’s death.

The decision maker must in particular consider:

  • the person’s past and present wishes and feelings (in particular if these have been written down);
  • any beliefs and values of the person (for example religious, cultural or moral) that would be likely to influence the decision in question and any other relevant factors.

As far as possible, the decision maker must consult other people if it is appropriate to do so and take into account their views as to what would be in the best interests of the person lacks mental capacity, especially:

  • anyone previously named by the person lacking capacity as someone to be consulted;
  • carers, close relatives or close friends or anyone else interested in the person’s welfare;
  • any attorney appointed under a Lasting Power of Attorney (LPA);
  • any deputy appointed by the Court of Protection to make decisions for the person;
  • the Independent Mental Capacity Advocate (IMCA), if appointed (see Independent Mental Capacity Advocate Service chapter).

The decision maker must take the above steps, amongst others, and weigh up the above factors when deciding what decision or course of action is in the person’s best interests.

For decisions about serious medical treatment or certain changes of accommodation and where there is no one who fits into any of the above categories, the decision maker may need to instruct an IMCA.

3. Where there is a Dispute about Best Interests

Family and friends may not always agree about what is in the best interests of an individual. Case records should record any details of disputes, must clearly demonstrate that decisions have been based on all available evidence and have taken into account all the conflicting views. If there is a dispute, the following courses of action can help in determining what is in a person’s best interests:

  • involve an advocate who is independent of all the parties involved;
  • get a second opinion;
  • hold a formal or informal case conference;
  • go to mediation;
  • as a last resort, an application could be made to the Court of Protection for a ruling.

4. Recording

Comprehensive recording is key in all cases, but particularly in safeguarding adults cases which are likely to be the most complex and present the highest levels of risk. In such cases, full records of best interest decision making should be kept, including:

  • how the decision about the person’s best interests was reached;
  • the reasons for reaching the decision;
  • who was consulted to help decide the best interests;
  • what particular factors were taken into account;
  • if written requests from person concerned were not followed, why not;
  • the content and results of any disputes;
  • what has been decided in the person’s best interests and reasons for that decision.

People lacking mental capacity have the same rights as those with capacity to have their outcomes realised. Although it may be challenging, a good best interest decision reflects the wishes, feelings, values and needs of the person.

This can also be included as an outcome measure on the safeguarding adult return forms.

5. Further Reading

5.1 Relevant chapter

Mental Capacity

5.2 Relevant Information

Determining and Recording Best Interests (39 Essex Chambers)

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September 2023: A new section 1, Advance Care Planning, has been added to reflect guidance contained in ‘Universal principles for advance care planning’ which was published in response to the Care Quality Commission report ‘Protect, Connect, Respect – decisions about living and dying well’.

1. Advance Care Planning

Advance Care Planning (ACP) is a process of discussions which an adult can choose to have with their care providers about their preferences and priorities for their future care, while they have the mental capacity to be able to have such meaningful conversations. The process, which is person-centred and likely to involve a number of conversations over time, should include whoever the adult wishes to involve, including family members or friends.

The process will enable the adult to feel more involved in their care and treatment and gives them the opportunity to reflect and share with those involved what matters most to them.

The result of these discussions may include the adult deciding one, or more, of the following:

1.1 Universal principles

The following are the universal principles of ACP and describe ‘what good looks like’ in advance care planning:

  1. The adult is central to developing and agreeing their advance care plan including deciding who else should be involved in the process.
  2. The adult has personalised conversations about their future care, focused on what matters to them and their needs.
  3. The adult agrees the outcomes of their advance care planning conversation through a shared decision making process in partnership with relevant professionals.
  4. The adult has an advance care plan which records what matters to them and their preferences and decisions about future care and treatment, that they can share with others.
  5. They have the opportunity, and are encouraged, to review and revise their advance care plan.
  6. Anyone involved in the adult’s advance care planning process is able to speak up if they feel that these universal principles are not being followed.

2. Advance Statements

An advance statement is a written statement that sets down a person’s preferences, wishes, beliefs and values regarding their future care. Its aim is to provide a guide to anyone who might have to make decisions in the person’s best interests if they lose the ability to make or communicate decisions.

A health or social care professional making a best interests decision on behalf of an adult who lacks mental capacity must take into account any advance statement that has been made, as laid down in the Mental Capacity Act (MCA). However, the advance statement is an expression of the person’s preferences and is not legally binding for a health or social care professional.

It may be difficult to challenge a healthcare professional’s decision to disregard the adult’s wishes, because they can argue they have  considered the advance statement but were acting in the person’s best interests (see Best Interests chapter).

3. Advance Decision to Refuse Treatment

An advance decision is different from an advance statement. An advance decision is a document which contains a statement that stands even if the person’s life is at risk, such as where the person has refused life sustaining (continuing) treatment. This is laid out in the MCA.

The advance decision is designed to express the desires of a person who may later lack mental capacity to refuse all or some medical treatment, and overrides the best interests test. It is legally binding provided the criteria described in the MCA are met.

In relation to refusal of treatment, the advance decision must be:

  • can only apply to refusal of treatment;
  • must be written;
  • must be made when the person has capacity;
  • must be made by a person who is over the age of 18 years and it has been witnessed.

The MCA says the advance decision is not applicable to life sustaining treatment unless:

“it contins a statement … that it is to apply … even if the life is at risk” when the refusal relates to life sustaining treatment (MCA Part 1 section 25(5) (a)). The advance decision is not binding if the circumstances it describes are not explicit.

An advance decision is not applicable to life sustaining treatment if:

  • the treatment is not the treatment specified in the advance decision;
  • any circumstances specified in the advance decision are not present;
  • there are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of they made the advance decision and which would have affected their decision had they anticipated them (MCA Part 1 Section 25 (4)).

An advance decision is not valid if the person:

  • withdraws the advance decision when they have mental capacity;
  • has created a lasting health and welfare Power of Attorney after the advance decision was made which gives the attorney power to make decisions regarding life sustaining treatment (see Section 5, Lasting Powers of Attorney, Court Appointed Deputy, Court of Protection and Office of the Public Guardian);
  • has done something which is clearly inconsistent with the decision.

Practitioners should be clear that advance decisions are different from advance statements.

3.1 End of life

At end of life, the best interest test applies when a patient does not have the mental capacity to make their own decisions (see Best Interests chapter). This can be a result of losing mental capacity (see Mental Capacity and Code of Practice chapter), or through a loss of consciousness (temporary or permanent). It will cover decisions relating to palliative care (in the case of serious or life-threatening disease) and withdrawing treatment.

In the absence of a legitimate advance decision or health and welfare Lasting Power of Attorney (LPA), the decision on which treatments should or should not be provided should be made by the healthcare professionals, not the person’s relatives.

The healthcare professional must decide what is in the person’s best interests, taking all the relevant medical and non-medical circumstances into account.

4. Do Not Resuscitate

See also Advance Decision to Refuse Treatment (NHS) 

DNACPR stands for do not attempt cardiopulmonary resuscitation. DNACPR is sometimes called DNAR (do not attempt resuscitation) or DNR (do not resuscitate) but they all refer to the same thing.

Everyone has the right to refuse CPR if they do not want to be resuscitated, if they stop breathing or their heart stops beating.

Where a do not resuscitate decision has been made in advance, it will recorded on a special form and kept in the person’s medical records. A DNACPR order is not permanent; it can be changed at any time.

People’s views and wishes may also be recorded in their LPA (see Section 5, Lasting Powers of Attorney, Court Appointed Deputy, Court of Protection and Office of the Public Guardian below) or advance decision documents (see Section 3, Advance Decisions).

People who have a serious illness or are undergoing surgery that could cause respiratory or cardiac arrest, should be asked by a member of the medical team about their wishes regarding CPR if they have not previously made their wishes known. This should take place before they have surgery.

People should always be advised to discuss such decisions with their family or other carers, so that it is not a surprise to them should the situation arise.

If the person does not have the mental capacity to decide about CPR when a decision needs to be made (see Mental Capacity and Code of Practice chapter) and have not made an advance decision to refuse treatment, the healthcare team should consult with their next of kin about the person’s wishes so a decision can be made in their best interests (see Best Interests chapter).

Medical staff have a legal duty to consult and involve patients in a decision to place a ‘Do Not Resuscitate’ (DNR) order on a their medical notes. Patients should always be involved in a DNR decision. There must be a convincing reason not to involve the patient, otherwise a failure to consult with them may breach their human rights. Causing potential distress to a patient is not a good enough reason not to consult with them.

5. Lasting Powers of Attorney, Court Appointed Deputy, Court of Protection and Office of the Public Guardian

5.1 Lasting Power of Attorney

Any person who has the mental capacity to understand the nature and implications of doing so may appoint another person/s to look after their affairs on their behalf. This power may be changed by the donor (the person) at any time.

A Lasting Power of Attorney (LPA) is a legal document which allows an adult to appoint an attorney/s to act on their behalf if they should lose mental capacity in the future. It enables the person to instruct an attorney to make decisions about their property and affairs and / or health and welfare decisions. Attorneys, in this case, can be family members or friends, who have to be registered with the Office of the Public Guardian. See Make, Register or End a Lasting Power of Attorney (gov.uk)

5.2 A Court Appointed Deputy and the Court of Protection

A Court Appointed Deputy is appointed by the Court of Protection (CoP). The Court of Protection has the the authority to make decisions on financial or welfare matters for people who cannot make decisions at the time they need to be made (because they lack mental capacity). Depending on the terms of their appointment, Court Appointed Deputies can take decisions on welfare, healthcare and financial matters as authorised by the CoP but they are not able to refuse consent to life sustaining treatment (see Section 2, Advance Decision to Refuse Treatment).

Any decisions made by the CoP can be challenged; for example where it is believed that a deputy is not acting in the best interests of the person they are representing and there are safeguarding concerns as a result.

5.3 Office of the Public Guardian

The Office of the Public Guardian (OPG) is the body which registers authority for LPA’s and court appointed deputies. It supervises deputies appointed by the CoP and provides information to help it make decisions. The OPG also works with other agencies, for example the police and adult social care, to respond to any concerns raised about the way in which an attorney or deputy is behaving.

5.4 Abuse by an Attorney or Deputy

If someone has concerns about the actions of an attorney who is a registered LPA or a deputy appointed by the CoP, they should contact the OPG. The OPG can investigate the actions of a deputy or attorney and can also refer concerns to other relevant agencies. For more information, see Report a Concern about an Attorney, Deputy or Guardian (gov.uk).

6. Further Reading

6.1 Relevant chapters

Mental Capacity

Best Interests

6.2 Relevant information

Court of Protection

Office of the Public Guardian

Universal Principles for Advance Care Planning (NHS)

Advance Decisions (Living Will) 

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This chapter provides information for staff about how to keep safe, both professionally and personally, when using social media.

KNOWSLEY SPECIFIC INFORMATION 

Knowsley Council Social Media Protocol

RELEVANT INFORMATION

Standards of conduct, performance and ethics, Health and Care Professions Council

1. Introduction

This guidance provides information about how to minimise risk to yourself, and others, whilst using social media sites.

As a social care professional the onus is upon you to protect yourself from allegations of wrongdoing online and whilst using digital technology, in order to avoid potentially inappropriate or damaging situations. As your role involves direct work with individuals and families in challenging and stressful situations, there is a risk that people with whom your service works may, at times, post information about staff or the service that is erroneous, libellous and / or upsetting.

It is vital therefore that, in order to protect the reputation of the organisation and staff, the response is always professional, proportionate and measured.

In such situations, managers may need to respond to and take action against those posting such material; guidance is provided below to help protect all staff and volunteers working with the public.

2. Steps to Minimise Risk

2.1 Privacy settings and passwords

Check your privacy settings across all social networks. This can be done by going to ‘Settings’ and reviewing the current privacy settings. Updating privacy settings is vital to being able to protect yourself online and is just as important as keeping a credit card safe, for example.

The privacy settings of some social media sites can be set up to send posts just to particular groups, such as close friends, rather than all ‘friends’. Such options are worth considering when thinking about sharing information that you would not necessarily want all people to know.

Remember some information cannot be hidden however tight privacy settings. Names and profile images will always be visible on Facebook for example, so choose images or photos carefully.

By logging out of your social networks and then searching for yourself you can see how your profile appears to the public.

Regularly update your passwords. Do not use the same one across all social media accounts. This will help avoid someone hacking into your account and posting inappropriate status updates or images.

2.2 Connect wisely

Many people have far more friends on social media than they know personally. But it is wise only to connect with people that you know and trust. Even people you know, however, may post comments or share material that you do not like or agree with.

In such cases think about whether to ‘unfriend’ that person rather than be associated with someone whose views you do not share or you maybe seen by others as not trying to counteract.

If it is someone you know and like, discuss their posts with them if you find it uncomfortable.

Not all social media sites operate for the same purpose. Consider the purpose of the site, and act accordingly. For example, LinkedIn is for professional connections. It is not wise, therefore, to accept requests to connect if the message contains suspicious text or the person seems to have no connections, location, education or vocation similar to you.

2.3 Post, share and access wisely

2.3.1 Personal information

Think carefully before you post photos and text.

If you would not say it in public or to your manager, or want them to see certain images, you should not put it on social media however tight your privacy settings. Online friends can share or repost / re-tweet your updates, so you can lose control of what you say and display.

Remember, some things are best only shared in person or by telephone or even not at all, not via social media including email.

It is illegal to access or download material that promotes or depicts criminal behaviour. Do not access any illegal or inappropriate websites on your personal computer or mobile phone, not even for personal or professional research purposes. This includes illegal or inappropriate images of children, some pornography or extremist websites.

Photos and texts sent to mobile phones and tablets can also be shared by others, so be careful what you send to others or what images you allow people to take of you. Sometimes images are accompanied by personal information, including name, address and links to their social media profiles. Distributing certain private images or films may be an offence under the Criminal Justice and Courts Act 2015. It applies both on and offline, and to images which are shared electronically or more traditionally so includes uploading of images on the internet, sharing by text and email, or showing someone a physical or electronic image.

Be careful using social media whilst under the influence of alcohol or if you are feeling upset or distressed in any way. Whilst your own posts can be edited the next day, there is often not much that can be done about other people’s replies.

Take care when in contact with others via web cam internet sites (for example chat rooms, message boards, social networking sites and newsgroups). Avoid inappropriate communication with individuals you think may be under 18, or those with who you may be in a position of trust. Avoid inappropriate communication with those who you do not know. Adults can pose as children using interactive technology; likewise some children can pose as adults.

2.3.2 Professional Information

See also Standards of conduct, performance and ethics, Health and Care Professions Council, 2016

Posting information in relation to service users with whom you work, or their family or friends, is not permissible. This is a potential breach of the Data Protection Act 2018 (see Information Sharing and Confidentiality), and even where it is not strictly illegal it is professionally unethical and may result in disciplinary action being taken. For example, families have seen and subsequently made formal complaints about social workers who – whilst not disclosing any personal information – have posted comments following court cases which have found in the local authority’s favour.

Posting information about work colleagues of any grade, whilst not illegal, is inadvisable. It can damage working relationships and cause difficulties in the office environment. Again, it may lead to disciplinary action being taken.

If in the course of your work you see an adult or child who you think may have physical injuries or signs of abuse or neglect, seek advice from your manager or designated safeguarding manager before taking photographs for evidential purposes on a mobile phone or tablet, and record the guidance they give you. This is to avoid unnecessary allegations being levelled at you where your actions could be misinterpreted. If the advice is not to take photographs, mark the site of the injuries on a body map, make a written record and refer your concerns in the usual way.

Consider the implications of out of office hours discussions with colleagues via social media about contentious issues such as politics, for example. Working relationships can sometimes be adversely affected by such disagreements.

2.4 Review content

If you have used social media accounts over a number of years, it may be useful to review earlier entries to see if there is any content you posted when you were younger that you would not now post. If so, it would be best to delete it.

Monitor what others post about you, as this also contributes to your social media profile even if you did not post it yourself. If you are not happy with being tagged in a particular photo or status update, contact the person or organisation concerned via messaging or email (rather than via a public discussion) and politely ask them to remove it, explaining why.

Getting content taken down by the social media company can be difficult and may have to involve the police, which should only be reserved for extreme cases.

2.5 Act wisely

Whilst you should always share personal information with caution, in particular do not give email addresses or mobile telephone numbers to anyone who is, or has been, a service user or members of their family. If you wish to keep in contact with any such person, only use work emails or telephone numbers to communicate with them. Discuss your intention with your line manager in advance, and seek their advice.

Ensure you adhere to your organisation’s Acceptable Use Policy / IT and email procedures. If you breach any part of them, report it voluntarily immediately to your manager or designated other, as per the procedures.

If there is any incident related to this guidance, which causes you concern, report it immediately to your line manager. Document it as soon as possible, according to your workplace procedures.

4. In Summary

Use common sense and professional judgement at all times to avoid circumstances which are, or as importantly could be viewed by others, to be inappropriate.

Remember, computers, tablets and mobile phone technology may be the virtual world, but they very much impact on real life. Treat people the same through electronic communications as you would on a personal basis.

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– End –

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RELEVANT INFORMATION

Moving and Handling in Health and Social Care, Health and Safety Executive

This chapter is adapted from the above guidance.

1. Introduction

Moving and handling people, property and equipment is a common feature of daily working practices for many members of staff. Poor moving and handling practice can result in:

  • back pain and musculoskeletal disorders;
  • moving and handling accidents – which can injure both the person being moved and the employee;
  • discomfort, injury and lack of dignity for the adult being moved.

Employers must reduce the risk of injury to staff and adults using care services by:

  • avoiding manual handling tasks that could result in injury, where practicable;
  • assessing the risks from moving and handling that cannot be avoided;
  • putting measures in place to reduce the risk, where reasonably practicable

Staff must:

  • follow appropriate procedures and use the equipment provided
  • inform line managers of any problems
  • take reasonable care to ensure that their actions when involved in moving and handling tasks do not put themselves or others at risk.

2. Moving and Handling Risk Assessments

Moving and handling risk assessments help identify where injuries and problems could potentially occur and how to prevent them. The person carrying out the assessments must be trained and competent to identify and address the risks from moving and handling activities.

A moving and handling assessment should include:

  • consideration of the person’s needs and ability, task, load and environment;
  • identify what is needed to reduce the risk for all the tasks identified;
  • record the assessment and controls necessary in the adult’s individual care and support plan;
  • periodic review of the plan, as well as if the adult’s needs change;
  • arrangements to monitor handling activities;
  • ensuring competence of staff, equipment provision and management arrangements.

2.1 Identifying Risk

Activities that may increase risk may include assisting with:

  • person transfers;
  • treatment;
  • daily activities (such as bathing) with adults with specific needs.

Stresses and strains arising from adopting awkward or static postures when caring for and treating people should be addressed during the risk assessment.

Risk assessment should be part of a wider needs assessment process to achieve the best outcome. Health and safety issues will then be identified and built into the complete care package.

2.2 Individual risk assessments

The assessment should be person-centred and involve the service user where possible, or their family, in decisions about how their needs are to be met. This can reassure the adult about the safety and comfort of any equipment to be provided, and how it will help to ensure their safety and that of the staff who work with them.

The outcomes of the risk assessment and the inclusion of the findings in the adult’s care and support plan (see Care and Support Planning chapter) should be documented in their case records (see Case Recording chapter).

The risk assessment should include information about the adult’s moving and handling needs detailing whether the requirements are during the day, at night, or both specifying:

  • what the adult is able/unable to do independently;
  • the extent of their ability to support their own weight;
  • other relevant factors, for example pain, disability, fatigue, tissue viability or tendency to fall;
  • the extent to which they can participate in/co-operate with transfers, whether specialist equipment is required and the number of staff needed to perform a transfer;
  • whether they need assistance to reposition themselves / sit up when in bed/chair, and if not how this will be achieved;
  • specific equipment that is required and the type;
  • arrangements for reducing the risk and dealing with falls where the adult is assessed as at risk.

Some adults may become upset or agitated when being moved, particularly if they do not feel safe or reassured. Others, though willing to assist at the start, may become frightened during the manoeuvre and are unable to continue. These are situations where injury to the adult, staff or both parties may be more likely to arise. Training may prevent injury occurring in such circumstances.

3. Monitoring and Review

Risk assessments should be reviewed periodically and whenever circumstances change to ensure they remain current. This should also form part of the adult’s care and support plan review (see Review of Care and Support Plans chapter).

There should also be arrangements in place to ensure that moving and handling activities are monitored to ensure that correct procedures, techniques and equipment are being used.

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CQC Quality Statements

Theme 1 – Working with People: Supporting people to live healthier lives

We Statement

We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce future needs for care and support.

What people expect

I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally. I am supported to plan ahead for important changes in my life that I can anticipate.

1. Who are Self-Funders?

Self-funders are adults who arrange and pay for their own care in full. This may be funded from their own finances, or another private source such as a family member. It includes people who receive direct payments who can choose how to spend their payments to meet their care and support needs.

2. Local Authority Duties

A local authority has a duty to meet the needs of all adults who are assessed as having eligible needs (see Eligibility chapter). There are two exceptions to this:

  1. when the person is a self-funder and does not want the local authority to meet their needs;
  2. where a person lacks mental capacity and there is a person authorised or in a position to arrange their relevant care and support.

If the local authority – having carried out a financial assessment (see Charging and Financial Assessment chapter) – is satisfied that the adult who wants to self-fund has financial resources that are over the financial limit (£23,250), the adult can ask the local authority to meet their needs. The local authority would charge for meeting the adult’s needs, as they have above the capital limit. It can also charge a fee for arranging the provision of care and support for the adult.

During the passage of the Care Bill, the government described this an “important and ground-breaking right” for self-funders to ask the local authority to arrange care and support on their behalf.

3. Local Authority Discretion

Where the self-funder asks the local authority to meet their eligible need for care home accommodation, the local authority may chose to do that but it is does not have to. Where the adult’s needs are to be met by some other type of care and support and not care home accommodation, the local authority must meet those eligible needs.

It was intended that the duty on local authorities to also meet the eligible needs of self-funders in a care home would be implemented on 1st April 2015. However, this reform (along with other financial reforms) has been delayed.

4. Mental Capacity

The exception outlined above in Section 2, Local Authority Duties does not necessarily apply to those adults lacking mental capacity.

Where an adult who lacks capacity to make such a request to the local authority has finances above the financial limit, it may be made by someone else acting on their behalf. The person making the request on behalf of the adult can only do so if this was in the adult’s best interests (see Mental Capacity Act and Code of Practice chapter).

The person or other interested party or the local authority could then arrange for the payment of the local authority’s charge through a deputyship.

5. Financial Differences in Who makes the Arrangement

If an adult or a family member makes the arrangements with a care home, the adult will pay the market rate for the bed in the residential accommodation.

A local authority, acting on behalf of the adult who has fallen below the capital limit, will probably be able to negotiate a lower rate with the care home than the adult who is a self-funder. This is often due to the local authority being able to ‘block book’ beds, which will not be available to the person who is self-funding.  The local authority will also have framework agreements with various providers in their area through which they can purchase the same services but often at a reduced rate.

6. Further Reading

6.1 Relevant chapters

Assessment

Care and Support Planning

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Technology that promotes independence at home. Aids such as pendant alarms and sensors, for example, can detect if the person has fallen or there are other hazards such as smoke, floods or gas leaks. They alert a monitoring centre where operators arrange for someone to come to the person’s home or contact family, a doctor or emergency services. See also assistive technology.

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