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ADASS South West England

Carers' Eligibility

Report

April 2015

Carers' Eligibility April 2015

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Report

1 Introduction A Carers Eligibility Workshop commissioned by ADASS in the South West for local authorities in that region took place on 29 April 2015 at Bishops Hull House, Taunton. It attracted 29 participants from 13 council areas. The objectives of the workshop were:

To develop understanding of the Care Act eligibility framework relating to carers

To identify key principles involved in applying the eligibility criteria To have practical opportunity to apply criteria to case scenarios To identify key learning points that can be shared with colleagues

across the region

2 Context For the 60% of us that at one stage or another will be a carer, there are clear benefits that come from the Care Act:

The right not just to assessment but also to an eligibility determination and to a service

The council’s obligation to supply information and advice, and to signpost

The replacement of restrictive terms from ‘old’ legislation like ‘regular’ and ‘substantial’

The Act will also boost provision of preventative and well-being services in local markets.

There are though, huge challenges that relate to funding and the concern that unless the Act is properly funded it will alleviate little of the burden on unpaid carers. We have to take into account the effective 26% reduction (£3.5b) in adult social care over 4 years – 12% reduction in cash, 14 % increase in demand. It would seem that austerity will remain with us for some time to come. New rights come, of course, at a cost, and some councils are going down the route of charging carers, a trend that may gather momentum should demand for carer support outstrip resources

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available. Many have provision to charge in their policies. Lots are reviewing charging approaches.

A second challenge is that carers and practitioners might continue to think there is no point in a full assessment – 2013 research from York University found practitioners routinely offered full assessment but this often declined and practitioners did not pursue the issue.

There are also issues relating to how eligibility arrangements will be applied and how arbitrary application of criteria will be. These were the focus of the workshop.

3 Key IssuesAt the start of the workshop participants were asked to identify what are the key issues for them on carer eligibility. ADASS had indicated the concern of Directors in the region to maximise consistency and this focus was recognised by people at the workshop. Other key issues raised were:

What ‘meeting eligible needs’ means – what does ‘good’ look like? Comparing and contrasting Care Act requirements with old provision Implications of eligibility for self-funders Value of using agreed wording across region How best to avoid legal challenge? Prevention: how might ‘pausing assessments’ apply to carers? How to

incorporate all tiers of prevention? How to balance meeting well-being of individual with existing

resources? How to meet ‘unmeetable’ expectations? Securing resources to ensure that carers needs are an ‘equal’ priority?

Issues involved in delegating decision-making about eligibility Dealing with the ‘maintaining a habitable home environment’ outcome

area? How to establish impact of this domain on the caring role? Does it include cleaning?

What is ‘necessary care’? Definitions? How to address when cared for person does not want re-ablement?

What is ‘significant impact’? Where cared for person is in residential care might carer still be

eligible? Where cared for person discharged from service – might carer still be

eligible? Where does entitlement to respite care end? How much should people

have? Application to self-funders? Should carer be given an indicative personal budget before the support

plan?

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Does our local ‘matrix’ work as well as it should?

4 Your starter for 10Small groups looked at a number of brief scenarios reflecting issues relating to carer eligibility. They were asked to reach speedy conclusions - and where unable to reach a decision on the information provided, to indicate what else they would need to know. The scenarios were:

1. Fred travels 200 miles to spend a few hours chatting with his aunt every couple of months. She appreciates his visit. Is this ‘necessary’ care?

2. Carer prepares breakfast for neighbour who prepares other meals herself. Is this necessary care?

3. Caring for my uncle at weekends means I have no time to redecorate my house – so can I ask for help with hiring a decorator? Is this an allowable ‘outcome’?

4. Carer is a volunteer from the local church – can such a carer be eligible?

5. A home carer from a private agency supports Mrs. X five mornings per week, then goes in at weekends – in her own time, and without pay – when no formal care is contracted. Might she be eligible for support?

6. Mrs. Y has support from a neighbour who is a single parent to a very demanding child and – in addition – is trying to study for an OU degree. She needs support to do all she needs to do, and would probably need support even without Mrs. Y. Might she be eligible for support?

7. Carer has suffered from chronic arthritis for many years. She has only known and supported Mr Z for 6 months. Her health is getting in the way of care. Would she meet the deterioration in physical health criterion?

8. Carer gets tired because she cares many hours a week for her mother, but nevertheless gets a real sense of fulfilment from this. Can care be seen as having an impact on her well being?

9. Carer calls in on Mr B each evening to make sure that he is ready for bed. She then has to walk home through dark city streets. She does not feel safe doing this and want money to pay for a taxi. Does she meet the outcomes criterion?

5 Eligibility within Care Act 2014There are three key legal ‘offers’ for carers in the Care Act 2014:

Section 10 of Act:

Creates a single duty to undertake a carer’s assessment on the basis of appearance of need for support. There is no longer a need to provide

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substantial amount of care on a regular basis. So the threshold for assessment is lower

Section 20 of Act:

Creates a legal obligation to meet a carer’s needs for support so long as the cared for person is ordinarily resident in the Local Authority area. This new entitlement replaces the previous discretionary power.

Section 13of Act:

Requires councils to determine if someone has eligible needs following assessment. It provides for regulations, which set out eligibility criteria. This requirement is new in law though not in policy. This requirement is our focus here.

A carer meets the eligibility criteria if:

His/her needs are caused by providing necessary care for an adult

AND, as a result:

His/her health is at risk

Or he/she is unable to achieve specified outcomes

AND, as a consequence, there is or is likely to be a significant impact on the carer’s well-being

6 8 stepsWe broke these three elements down into an 8-step approach:

1. Is this person a carer?2. Does the carer have a need for support?3. Is the carer providing necessary care?4. Do needs relate to carer providing this care?5. Is the carer’s physical or mental health – as a result – deteriorating or at

risk of deterioration?6. Is the carer – as a result – unable to achieve one or more of the

outcomes designated in regulations?7. As a consequence is there, or is there likely to be, an impact on the

carer’s well being?8. Is this impact significant

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6.1 Is this person a carer?

Carers covered by the Care Act are adults who provide or intend to provide care for someone – an adult 18+, or a disabled young person in transition. Or it could be a young carer of an adult who is in transition.

Any level of care might be involved and it no longer has to be regular or substantial. But you might want to ask how realistic it is – as in the quiz – where a carer visits once in a blue moon.

The carer would not usually be a volunteer or paid/contracted person (see Guidance paras 6.16-17). But councils do have the discretion to regard such people as carers for eligibility purposes and may do so where, for example, a paid carer is also providing paid care, say, at weekends; and where volunteers such as church visitors are providing support etc.

6.2 Does the carer have a need for support?

Reminds us of need to assess first and not to assume that the carer has needs. Where assessment indicates that the carer has a need for support now or in future you must consider eligibility

Carer needs may fluctuate just like needs of the person cared for; this may relate, say, to their own health, or other commitments. Hence it is important to consider an individual’s needs over an appropriate period of time to ensure that these have all been accounted for when eligibility is being determined.

6.3 Is the carer providing necessary care?

Is this care? Care can be practical + emotional – it is not defined beyond this there are suggestions that it can incorporate ‘care about’ as well as ‘care for’. But what are the boundaries to this? N.B. the carer must be willing to provide + continue to provide care

Is this necessary care? Guidance para 6.124 says: “The carer must also be providing “necessary” care. If the carer is providing care and support for needs which the person cared for is capable of meeting themselves, the carer may not be providing necessary support. In such cases, local authorities should provide information and advice to the adult and carer about how the adult can use their own strengths or services available in the community to meet their needs”.

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Guidance and Skills for Care/SCIE training material suggest you might want to check.1. What would be impact if care stopped?2. Could they provide this care for themselves? If yes, provide

information and advice as appropriate.3. Are required activities ones that the individual requiring support

should be able to carry out as part of normal daily life but is unable to do so?

4. Is the carer over-involved and supplying support that is not strictly necessary? The person cared for may have become used to support that he or she does not really need.

5. Is carer duplicating care already supplied by others because, e.g., the carer is anxious about the person cared for, or does not feel that formal support is provided at sufficient frequency, for long enough, or with an appropriate caring ethos?

Can include care provided to support needs that are not eligible. Person cared for does not have to have eligible needs. E.g. may be unable to meet only one outcome. N.B. we should determine carer eligibility without considering if the persona cared for has eligible needs.

The Guidance relating to ‘necessary care’ has been called unhelpful. This paragraph was inserted post consultation. The risk is that it will be narrowly interpreted. So if cared for not eligible this might be seen to offer ‘wriggle room’ that by definition care supplied by carer is not necessary care.

But the carer does not have to provide care – need to be mindful that if carer not covering certain tasks the council might have to step in anyway.

6.4 Do needs relate to carer providing this care?

Do needs result from something other than caring? Consider, for instance, the scenario described in “Starter for 10’ question 6 where Mrs Y’s neighbour faces considerable demands in child care and education.

6.5 Is carer’s physical or mental health – as a result – deteriorating, or at risk of deterioration?

Clearly lots of carers will themselves have health conditions that do not arise from caring. The test here is whether physical or mental health conditions are deteriorating – or likely to deteriorate – as a result of providing care.

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We should keep to the forefront of our minds the drastic impact that health can have on a carer’s capacity to care. Carers at Breaking Point1 last year suggested that: 63% suffered from depression as a result of caring 90% said they were stressed 79% reported anxiety 50% of those at breaking point suffered physical injury or seen

deterioration in health

Or

6.6 Is carer – as a result – unable to achieve one or more of the outcomes designated in regulations?

The outcomes specified in The Care and Support (Eligibility Criteria) Regulations 2014, which are used to determine eligibility are set out below. These are not of course really outcomes - more life domains:

Carrying out any caring responsibilities for a child Providing care to other persons for whom the carer provides care Maintaining a suitable home environment Managing and maintaining nutrition Developing and maintaining family or other personal relationships Engaging in work, training, education or volunteering Making use of necessary facilities or services in the local

community Engaging in recreational activities

The carer must be:

Unable to achieve one of these without assistance; or be Able to achieve but only with pain, distress, anxiety; or be Able to achieve but in so doing endanger or likely to endanger health of

carer and/or cared for

A key issue here is whether the carer would be able to achieve the outcome if there were no caring responsibilities? If ‘no’ then the carer would not be eligible.

N.B. some key domains that you might have thought would be included in the list of outcomes – such as safety – is not actually included.

1 Carers at Breaking Point Carers UK 2014

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6.7 As a consequence is there, or is there likely to be, an impact on the carer’s well being?

‘Wellbeing’ is a broad concept. It is described as relating to the following 9 areas in particular (as set out in guidance):

Personal dignity (including treatment of the individual with respect) Physical and mental health and emotional wellbeing Protection from abuse and neglect Control by the individual over their day-to-day life (including over care

and support provided and the way they are provided) Participation in work, education, training or recreation Social and economic wellbeing Domestic, family and personal domains Suitability of the individual’s living accommodation The individual’s contribution to society

Note that Guidance uses the words ‘including’ and ‘in particular’ so these areas of well-being are not exclusive and there may be others (such as choice).

The need is to consider what is important to the individual. Wellbeing is personal – it means different things to different people. Eligibility is not an absolute, and the carer is best placed to judge.

6.8 Is this impact significant?

The word ‘significant’ is not defined and we are encouraged to adopt its ‘everyday meaning’

It could mean an impact of some size on one area, or a cumulative impact, or a domino effect

‘Significant’ - by definition - means variation. As SCIE says: “A given situation could have a ‘significant impact’ on one individual but not on another. Therefore, professional judgement and analysis of the information gathered in the assessment are crucial to establishing whether there is indeed ‘significant impact’ on the individual’s wellbeing”.

But this leaves the potential for narrow, restrictive definitions.

6.9 Some other issues

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DISCRETION – the local authority has discretion to operate beyond these criteria

ORDINARY RESIDENCE - for carers the responsible local authority will be the one where the adult for whom they care is ordinarily resident. However, there may be some cases where the carer provides care for more than one person in different local authority areas - those authorities should consider how best to cooperate on and share the provision of support.

REPLACEMENT CARE - situations where the carer is supported by replacement care for the cared for person would be chargeable to the latter even where the latter is not eligible. Should the latter refuse to pay for such care the local authority would be in a difficult situation. One option would be to waive charges.

6.10 Record-keeping and informing Individuals

The slide below reminds of need to keep a written record of what is decided (and why) and to give this to the carer, with advice/information where the carer is not deemed eligible.

7 How to make an Eligibility Determination

http://www.scie.org.uk/care-act-2014/assessment-and-eligibility/eligibility/eligibility-determination.asp

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Section 6 (above) raises various problems that flow from interpretation. Some additional lines of thought are set out below.

The Act calls on us to apply ‘everyday’ meaning for the word ‘significant’; and personalised understanding of concepts like ‘well-being’ and ‘necessary’. SCIE suggests that making an eligibility determination is about using evidence, reflecting upon it, and using professional judgement and experience as in the diagram shown above.

The problem is that exercise of professional judgement by different professionals might lead to unacceptable levels of variation in interpretation. This – on the one hand – may leave a council exposed to challenge. Or - on the other hand – it may give scope (if the council is so minded) to adopt narrow definitions that serve to exclude people from eligibility.

7.1 Interpreting statues and applying criteria

There are a number of rules of interpretation typically followed by courts that we can usefully take into account:

Plain meaning or literal view, taking the statute word for word. But what is the plain meaning of ‘significant’, ‘necessary’ etc? Be mindful that civil servants may deliberately draft in ambiguity to achieve a political ‘fix’

‘Mischief’ rule - what was the ‘mischief’ not covered by previous law which parliament has sought to remedy when it passed this law? As far as carers are concerned the mischief of previous provision might be seen to be that carers had a right to be offered carers needs assessment only where they were providing regular and substantial care for someone over the age of 18

‘Golden’ rule - can depart from normal meaning to avoid an ‘absurd’ result

Purposive - what was the intention of parliament? Integrated/contextual - respect words but don't stick religiously to them -

interpret in context in which they appear

So assessors might ask whether there is a clear ordinary meaning that should be attached to words in the Act, and, if not, consider what legislators were trying to achieve.

7.2 Looking for consistency

Councils will want to achieve consistency in reasoning – to ensure equality of treatment, reduce fragmentation, ensure that carers know what they can




reasonably expect, and to ensure a level of replicability and predictability in practice.

Typically the law offers two key ways to achieve this:

Using arguments based on precedent - earlier decisions being followed in a later case because cases are broadly the same.

Using arguments based on analogy - because later case is similar. Analogies will vary in strength, cannot bind, and must be used alongside other reasons where there are insufficient facts that support direct use of a precedent.

The need is for a systematic approach and for on going learning and avoiding common concerns and biases.

The Care and Support (Eligibility Criteria) Regulations 2014 require assessors to think causally when determining eligibility. Deciding whether unachieved outcomes constitute a significant impact on a person’s wellbeing has to be a “plausible but ultimately tentative judgement”. If it is felt that there is not enough information to make an eligibility determination, assessment should be resumed.

The points made in sections 7.1 and 7.2 do not, of course, take away from the need for assessors to exercise professional judgement, nor should they be seen as encouragement to the risk averse. The Care Act calls for strong negotiation, and offers good opportunities for social workers and other professional groups to re-claim their skill base, and to root what they do in evidence-informed practice. But professional judgement should be augmented by a disciplined approach to interpretation and consistency.




8 Scenarios exerciseThe workshop looked at 8 scenarios and considered each against the template in section 6 (above). Scenarios, together with a summary of key issues and conclusions reached at the workshop, are reproduced below:

SCENARIO 1 ElsieElsie is 78 years old and has been a carer for her husband George for a number of years. George has a diagnosis of Bi Polar Disorder and has suffered from x4 heart attacks and a small stoke. When George becomes elated in mood he presents as over talkative, spending money including purchasing a car without first discussing this with his wife (which he would usually do) becomes disinhibited and can be verbally aggressive to Elsie although there is no history of physical aggression. George continues to attend the Heart club for on-going cardiac rehabilitation. He has been under the care of CMHT for several years and responded well to medication to treat his Bi-polar illness.

Elsie was assessed as a carer, she advised that she carries out all domestic chores in the household, manages George’s medication and manages all appointments on the calendar and attends these with George. She describes supporting George as being very stressful and feels that caring for George affects her emotional and mental health. She describes not sleeping well and feeling ‘drained’ all the time. Elsie also suffers from osteoporosis, which causes her significant pain. The outcome of the assessment identified services to provide emotional support to Elsie and enable her to have a break from her caring role and Elsie registering with the local Carers in Crisis scheme in order to provide her with an ‘emergency back-up plan’ which she found reassuring.

After a significant period of stability in George’s mental health, he was discharged from CMHT back to the care of his GP. Elsie continues to provide significant support for George and continues to find the situation stressful and difficult.

Would Elsie continue to be eligible to access carers’ services?2

1. Is this person a carer (as envisaged by the Act)?Yes

2. Does the carer have a need for support?Yes Role stressful & difficult. Needs breaks from care. Fluctuating needs.

3. Is the carer providing necessary care?Yes/Probably. Managing medication. Emotional support.

2 Case study from Bournemouth




4. Do needs relate to carer providing this care?Yes

5. Is carer’s physical or mental health – as a result – deteriorating, or at risk of deterioration?

Yes – stress, not sleeping, drained. But N.B. osteoporosis not connected to caring role.

6. Or is the carer – as a result – unable to achieve one or more of the outcomes designated in regulations?

Yes – 3, probably 5, 8

7. As a consequence is there, or is there likely to be, an impact on the carer’s well being?

Yes – emotional well being, control over day to day life

8. Is this impact significant?Yes – she feels it’s very stressful

9. Eligibility decision - Eligible

10. Any other important issues raised?N.B. George may no longer have eligible needs, but ‘necessary’ care does not hinge on that. What kind of break would best support?




SCENARIO 2 Mrs SMr S lives with his wife in a two-storey house. He was working when he had a stroke. Following his stroke Mr S has experienced left sided weakness, in both his leg and arm and hemianopia (reduced visual field, mainly affecting awareness of left side visual field). Mr S has been working with Physiotherapists and Occupational Therapists within the hospital. He is able to walk without support and distance and stamina continues to improve. It has been advised that Mr S has supervision on the stairs, encouragement to use two rails and to slow his actions and monitor feet/hand positioning. Mr S can be impulsive at times when mobilising and needs prompting to slow his actions.

Mr S needs prompting and supervision with all activities of daily living, including personal care. Mrs S was assisting in this role, however, feels that the conflict in prompting and correcting techniques is affecting their personal relationship.

Since returning home, Mr and Mrs S have found the impact of his new level of needs in the home environment has added stress on their relationship.

Mrs S wrote on the referral:'I now have to manage all financial affairs, correspondence, as my husband is unable to read and can no longer use a computer. He has a very limited attention span and concentration. He is unable to manage complex tasks. His memory has also been affected; we are self-funding and unable to afford services'.

'He needs help with getting dressed, taking medication, preparing food, keeping safe i.e. locking doors, switching off gas, persistent confusion with time and routine'.

'My husband frequently wakes during the night and is confused and gets up thinking it is morning. He needs care at all times’.

'My husband is often very depressed/unable to make any sequence activity. Unable to make medical appointments - dental - GP or make any family social arrangements’.

'Has difficulty with certain foods, coughs badly - swallow reflex affected, needs supervision. Cannot prepare hot food'.

'I do all shopping, housework, laundry and cleaning as he is unable to sequence, even minor tasks’.

'My husband is unable to make telephone calls or write letters. Sometimes he is too depressed to make small talk with neighbours even’.




'My husband is unable to be left alone for more than 1 hour max. He gets anxious, has little concept of time so thinks he has been left for much longer. He gets anxious if I am in another part of the house too.'3


2. Does the carer have a need for support?Highly likely though not too clear what the need is

3. Is the carer providing necessary care?Yes – if provides all care listed – appears to do everything for him

4. Do needs relate to carer providing this care?Yes – care affecting relationship and causing conflict


Probably – stress on relationship, unable to leave alone, waking nights


Yes – 5,6,7,8


Yes – control over day to day life

8. Is this impact significant?Yes

9. Eligibility decisionEligible

10. Any other important issues raised?Self-funding and note that cannot afford care. Need to explore why this is. Assessment for Mr S plus possibly financial assessment to check costs. Self-funders often worry about spending. If Mr S refusing care could use systematic approach to try to resolve issue – MCA, visits, multi agency.Mrs S needs a break, but any replacement care would be chargeable to Mr S

3 Bristol




SCENARIO 3 MargaretMargaret aged 73 has been caring for her husband Ken aged 82 for 10 years. Ken has limited mobility due to a stroke some years ago making it difficult for him to get out of the home, undertake household chores, including maintenance of the home, gardening etc. He is, however, able to cope with his own personal care needs at the current time. They live in a static home park where there are strict park rules about the upkeep of the outside of the home and surrounding gardens and Margaret is getting very anxious and worried about the deteriorating condition of the area outside their home, in particular the fences and garden. Margaret is still very active and a keen gardener so wants to carry on doing as much of the garden as she can. However she is feeling extremely anxious and stressed about the fact they do not have the income to buy in some handyman help4.

1. Is this person a carer (as envisaged by the Act)?Yes (though this is assumed as no ‘duties’ shown)

2. Does the carer have a need for support?Yes – for handyman support, and help with anxiety & stress

3. Is the carer providing necessary care?Offers practical support relating to home but more information needed to confirm this

4. Do needs relate to carer providing this care?No – need for assistance with exterior of property would be there even if she had no caring role


Extremely anxious and stressed as a result of issues relating to upkeep of property but this not apparently linked to caring role


Outcomes 3 and possibly 7 & 8 affected but these not related to caring


Impact on emotional well being – but not obviously a result of caring

4 Devon - Developed by PSSRU at London School of Economics and Political Science in the ‘criteria study’ they undertook in the run up to the Care Act.Fernández J-L, Snell T (2014) Impact of the June 2013 draft eligibility regulations on social care in England: a vignette-based study of care managers' assessments




8. Is this impact significant?Arguments that it may or may not be but not relevant because of above

9. Eligibility decisionNot eligible

10. Any other important issues raised?Needs signposting to support with garden and alternative ways of meeting needs. May need advice about suitable housing for the future. Benefits check may help. Likely that assessor would have diverted before assessing eligibility – pause for prevention.




SCENARIO 4 Nandi Nandi is the mother of a son aged 19 and two girls both aged 14. Her son has Asperger Syndrome and he finds it difficult to socialise with his peers and clings to Nandi for company. He loves playing golf but won’t pursue the interest as he is reluctant to leave the home without family support. Although he will occasionally go out with his sisters, Nandi will often find she needs to take him out to the park, to the cinema etc. in order to keep him occupied and active.

She is finding this support relentless and exhausting and feels that it is putting a strain on her and she is feeling very anxious and stressed. Her husband works shifts at the local airport and is often not able to give Nandi much support with her children. Nandi also works part time and is finding the school holiday periods particularly challenging.

Nandi’s two daughters often have to find ways of entertaining their brother whilst she is at work, and she worries about the effect this is having on them. She would love to have a break on her own away from the family to get some time to herself5.


2. Does the carer have a need for support?Yes – child care, relationships, work

3. Is the carer providing necessary care?Yes – son’s needs relating to Asperger’s

4. Do needs relate to carer providing this care?Yes – no time for self


Yes – strain, anxiety, stress – finds it relentless and exhausting


Yes – 1, 5, 6, 7, 8 – child care, work, recreation, relationships


Emotional well being, no time for self, impact on work

5 (Ibid)




8. Is this impact significant?Yes – relentless, exhausting


10. Any other important issues raised?Cared for person needs provision in own right – does he need an assessment? ? Direct Payment to support golf. ? Respite during school holidays, or short breaks at other times. How much dependency has he created? Contribution of Asperger’s services?Young Carer’s assessment for sisters.Nandi could be parent carer under children’s legislation as son could be under transition until 25.Husband: need to know more about his position, possibility of flexible working. Does he need carer’s assessment too?




SCENARIO 5 JohnJohn cares for his son, Peter, who is aged 19 and has bipolar disorder. John’s wife died some years ago so John is Peter’s main carer. Peter’s condition is reasonably stable at the current time due to medication. But there are periods when his condition deteriorates, particularly when he is not taking his medication properly.

John feels he constantly has to monitor Peter’s medication and provide emotional support so John decided some months ago to give up his job at a local IT company. Although he is now close at hand to support Peter, John is feeling the financial pressure and feels isolated and depressed.

John would like to start his own IT business from home, but needs to attend some courses to bring him fully up to date. He also wants to join the local tennis club so that he can keep active and start mixing with other people6.

1. Is this person a carer (as envisaged by the Act)?Yes. But cared for person has fluctuating needs. Provides emotional support and maintains stability.

2. Does the carer have a need for support?Yes. Financial, isolation, depression (? Health needs, referral to GP). His needs fluctuate as well.

3. Is the carer providing necessary care?Yes – medication (but might Meds be covered differently?) Caring ensures mental health condition stable.

4. Do needs relate to carer providing this care?Yes – had to give up job as a result


Yes – depression


Yes – 6, 7, 8


Yes – participation in work, economic well-being, contribution to society.

6 Devon (Ibid)




8. Is this impact significant?Yes – unable to work

9. Eligibility decisionEligible – but this may reduce in future

10. Any other important issues raised?Various possible interventions for John: Job Centre +, reduced rate leisure, CBT, Benefits Check, Back to work support, Business start up advice, replacement care for son. What stops him joining tennis club? Is it just money? Pause to ask what does a good/bad day look like?Value in re-assessing son’s needs to reduce pressure on John; build resilience; support him being with others.




SCENARIO 6 Wayne’s familyWayne is 14 years old and he lives with his mother, two much younger sisters and an 18-year-old brother. His father died when he was 11. His brother has Down’s Syndrome and Wayne often finds himself having to keep an eye on all of his siblings particularly when his mother is at work. He finds it very hard as he feels the pressure of ‘being the man of the house’ even though he is the younger brother.

He is finding his GCSE Year 10 tough because he keeps thinking of his brother and sisters safety and worries that they are OK whenever he is at school. He stays in the house a lot in case his siblings damage things or hurt themselves if left alone, he has to help his brother with medication, and remind him to do certain things. He also feels he has to support his mother who is often very stressed after work. He feels he is behind on his schoolwork in part due to the fact he has no access to a computer at home. He is reluctant to stay behind and catch up work at school as he feels he should get home.

He sometimes has a hard time at school because his friends think his brother is ‘weird’ and tease him about it. He is often unable to go out to join in with activities with his friends so feels different to everyone else. He would love to join the local football club but his mother says they can’t afford the registration fee7.

1. Is this person a carer (as envisaged by the Act)?Wayne’s mother could be regarded as a carer under the Care Act, but with older son being in transition she is a parent carer.Wayne appears to be a young carer. Young carers are covered by the Children and Families Act 2014 / Children Act 1989 though the Care Act will apply where they are in transition to being adult carers (this would not apply to Wayne at this stage).

2. Does the carer have a need for support?Yes – for mother and Wayne, and also important to check if Wayne and sisters are children in need. Carer assessment needed for mother.

3. Is the carer providing necessary care?Yes – keeping safe from harm; helping with medication. Have brother’s needs been assessed? Is he receiving care from outside the family?

4. Do needs relate to carer providing this care?Yes: Wayne isolated; anxious when leaving siblings; school attendance and exams; unable to take part in recreation. . Mother stressed; financial issues

7 Devon (ibid)





Wayne anxious, stressed, ‘older than his years’. Mother ‘very stressed’ after work.


Mother - care impacting on wider outcome areas such as her parenting role, working lifeWayne: education, recreation, relationships – 1, 5, 6, 7, 8


Yes. Is caring role inappropriate?



10. Any other important issues raised?We included this scenario to take account of our roles in identifying children who are providing care and in referring to Children’s Services where a young carer’s assessment appears appropriate; and when assessing an adult, or a carer where it appears that a child is involved in providing care in considering the impact of the person’s needs on the young carer’s wellbeing, welfare, education and development; and whether any of the caring responsibilities the young carer is undertaking are inappropriate. (See Guidance 6.68 - 6.73)Value of whole family approach as needs are affecting the whole unit.Access to activities, clubs, computer.Are there safeguarding issues?




SCENARIO 7 ‘93 Year Old’A carer we work with cares for her 93 year old mother who has vascular dementia and can be verbally abusive, particularly to people she does not know. The carer’s health is impacted by the constancy of the caring role. She feels that she is unable to leave the house or take exercise, and as a result of this she feels that she is becoming overweight. The carer has not had a meaningful break away from the caring role in over 3 years. The carer really wants to go away for a weekend with an old school friend. However the only person that the ‘cared for’ person will allow to be with her if this happens is the carer’s son. The carer’s son works full time and would want some re-imbursement for doing this. The carer’s son lives in the same home as his sister, the main carer, and her mother.

In the support plan of the carer assessment we stated that because the carer could not achieve some of the outcomes and they were having a significant impact upon her heath and well being, she needed a break. We therefore asked for a one-off payment of £400 so that the carer could remunerate her son, whilst she took a meaningful break away from her caring role to have some rest and to think objectively about her caring role. The response from the local authority was that ‘it is unusual to request a one-off payment; can you ask instead for a sitting service or a holiday grant!’ I am in discussion with the council regarding this8.

1. Is this person a carer (as envisaged by the Act)?Yes – full time

2. Does the carer have a need for support?Yes. No other support if she drops out. Can’t leave house. Isolated. Needs break, chance for exercise.

3. Is the carer providing necessary care?Probably – need to establish full extent of role. Has cared for person been assessed?

4. Do needs relate to carer providing this care?Yes


Yes – mental strain from no breaks in caring; overweight.


Yes – 5, 7, 8

8 Wiltshire





Yes – physical health; emotional well-being; control over day-to-day life; recreation.


9. Eligibility decisionEligible. Best way to sustainably meet needs is the key issue here.

10. Any other important issues raised?Need for whole family approach. Stress outcomes rather than service – meet what she wants rather than fit into existing service. Carer has right to say how needs would best be met. Son can be paid. Direct Payment might allow regular support.Replacement care costs whether to pay for son or other carer – cared for person chargeable for this. Refer to GP re weight, challenging behaviour. Training to cope with behaviour?




SCENARIO 8 Penny Queenie is a 90-year-old White British woman who lives on her own in one bedroomed flat. Her flat is supported housing and is run by a registered social landlord RSL. There is a call-in warden that checks once a day and she has a pendant alarm in situ.

Queenie was born in the UK however immigrated to Australia in the early 1970s to be with her partner but returned to live in England in the mid-1990s to be near her only daughter, Penny. Penny lives about 1 mile from her mum. Queenie used to like to ballroom dancing and has always enjoyed a daily walk. She often spends time with her daughter Penny, often going shopping, on day trips and eating out. She is a cheerful and positive person and enjoys a laugh.

However it is clear to both Queenie and Penny that her memory is not as good as it used to be. She is beginning to forget daily routines and sometimes gets lost when she goes on her regular walks to town.

Penny looks after her 3-year-old grandson to her youngest daughter the first three days of the week. On these days she lives with her daughter who is divorced and has a history of depression. It is only a two-bedroom house and Penny sleeps on the sofa. Penny does not drive so she gets around on buses and her pushbike. Penny’s daughter lives 15 miles from her mum and grandmother.

Penny is very anxious about her mum while she is looking after her grandchild. As well at the beginning of the week looking after her grandchild, Penny has been staying with her mum at the second end of the week. Often staying at night which, again, involves sleeping on the sofa.

Penny has become very upset as when her mum got undressed the other day she saw that her mum has lost a lot of weight. She has also observed that her mum is no longer able to wash and dress herself without a great deal of difficulty and pain.

Penny has also observed that Queenie is also unable to put her eye drops in for her Glaucoma. Queenie is getting very anxious about her physical health saying she has very bad muscular pain and is also beginning to get anxious at night and suffer from bad dreams. Queenie is becoming increasingly tearful and also worried that she will eventually go blind.

Penny does all of her mums laundry, shopping and cleaning and also personal admin. Queenies granddaughter visits on a Saturday and takes her grandmother and mum out.

Penny has recently divorced from her husband and is also living in RSL supported housing flat. Penny has had a number of falls off her bike and has Osteoarthritis.




Penny does not know where to go to get some advice about her mum and is very much worried about Queenies well-being9.


2. Does the carer have a need for support?Yes probably – though Penny is not saying she needs support. Need for assessment of carer and Queenie

3. Is the carer providing necessary care?Yes – but unclear what might be otherwise provided were Queenie’s needs assessed.

4. Do needs relate to carer providing this care?Worry, anxiety. Pulled in two directions. But unclear what breadth and depth of needs might be at this stage.


Emotional well-being. Tired. Sleeping arrangements may worsen existing osteoarthritis.


Needs to be assessed but probably 1, 2, 3, 5, 8


Yes probably – emotional well-being, control over day-to-day life, social well-being.


9. Eligibility decisionYes, depending on needs assessment

10. Any other important issues raised?Need for assessment and care for cared for person. Value of GP contact for Queenie and Penny. Sofa bed. Staged approach starting with assessment of Queenie. Simple things are likely to improve quality of life.

9 Case Study written by IPC



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