National Minimum Information Standards for all Adults in Scotland for Assessment, Shared Care and Support Plan, Review and Carers Assessment and Support - Consultation on the Compendium of Standards

Minimum Standards for the Needs Assessment of All Adults

Introduction

Assessment is part of a wider process that includes care and support planning, resource access, monitoring and review. An assessment is undertaken to understand and document an individual's needs, to relate them to agency policies and priorities and to involve the person and/or their carer in identifying intended outcomes from any intervention. A well-documented assessment is a basis for ensuring a match between the needs of the individual and any interventions necessary to meet those needs.

In preparing these minimum standards the ARCG took account of existing Single Shared Assessment tools, guidance and processes for a variety of community care groups including: Older People, Mental Health, Dementia, Physical Disability including sensory impairment and brain injury, Learning Disability, and Substance Misuse. The standards reflect core information (but not specialist components) and assume assessment appropriate to level of need. These standards focus on the information about the needs of the person being assessed and are intended to be sufficiently adaptable to fit with different local business processes, particularly since they are designed for use by partners within multiple agencies

It may not be necessary to record all items for every person assessed, but the ability to record them is needed to comply with the standards. The content of a completed assessment will depend on the complexity of need.

Where Information Standards are shown here the actual method used locally for incorporating the standard into local tools is flexible. Where Data Standards are shown the format and codes specified should be adopted to achieve compliance.

Summary of minimum standards for Needs Assessment

The standards for needs assessment are listed under the following headings:

A. Person's perspective

B. Carer's perspective

C. Relationships

D. Vision, Hearing and Communication

E. Personal care and physical well-being

F. Mental health

G. Immediate environment and resources

H. Social and Cultural Life

I. Employment

J. Education, Training and Life Long Learning

K. Care and Protection

Standards denoted with the following symbol symbol graphic have related supplementary questions for completing an Indicator of Relative Need ( IoRN). These IoRN questions are detailed on pages 32- 35.

INFORMATION ABOUT SERVICE USER'S NEEDS

				Type of Standard
A. Person's perspective 1. Was the person involved in the assessment process Yes/No 2. If No, provide details If Yes, describe: 4. Problems and issues perceived and conveyed by the person 5. What is the person's understanding for the reason for this referral/assessment 6. Differences or disagreements				Information Standard
B. Unpaid Carer/s (previously known as 'Informal') 1. Is there an unpaid Carer (or Carers)? Yes/No If yes: 2. Was the unpaid carer involved in the assessment process? Yes/No 3. If No, provide details If Yes, describe 4. Problems and issues perceived and conveyed by the unpaid carer 5. What is the unpaid carers understanding of the reason for this referral/assessment 6. Is the unpaid carer happy to continue to support the person? 7. Differences or disagreements 8. Has the unpaid carer been offered assessment of needs? Yes/No 9. If No, provide details? 10. If Yes, was offer accepted? Yes/No 11. If main unpaid carer was not available would services (or additional services) be required? Yes/No 12. Level of Care provided by carer (or carers). Enter codes 0-4 against the period/s that apply Daytime Evening Overnight 0 None 1 Less frequently than daily. 2 Daily - once or twice during period. 3 Daily - more than twice during period. 4 Daily - continuously during period. 13. Are there any issues regarding current unpaid caring arrangements? Yes/No/Not Assessed 14. If Yes, describe specific issues.				Information Standard
Arrangements for young carers 1. Has a referral been made to children services? Yes/no? 2. If No, provide details.				Information Standard
C. Relationships Personal Relationships 1. Does the person have difficulty with key relationships? Yes/No/Not Assessed 2. If Yes, describe specific issues				Information Standard
Intimate Relationships 1. Has/does the person have difficulty with intimate relationships? Yes/No/Not Assessed 2. If Yes, describe specific issues including: Sexual health Sexual wellbeing				Information Standard
Service Provision arrangements 1. Are there any issues regarding service provision (previously referred to as formal caring arrangements)? Yes/No/Not Assessed 2. If Yes, describe specific issues				Information Standard
D. Vision, Hearing and Communication Hearing and Vision 1. Are there any issues? Yes/No 2. If Yes, describe specific concerns.				Information Standard
Communication 1. Are there any issues? Yes/No 2. If Yes, describe specific issues Speech Language Understanding Reading / writing Numeracy Use of telephone Other equipment (specify)				Information Standard
Personal care and physical well-being Relevant Medical Background including conditions that require ongoing care 1. Are there any relevant medical history/Learning Disabilities/ Physical Disabilities that require ongoing care? Yes/No/Unknown/Not Assessed 2. If Yes, provide details/conditions and source of information e.g. Mental Health Dementia Learning Disability (as per SCDS definitions) Physical Disability Acquired Brain Injury History of falls 3. If No, provide details. 4. If Unknown or Not Assessed detail any action taken to identify medical/mental health history. 5. Has the person had any hospital admissions within the last 12 months? Yes /No / Unknown/ Not Assessed 6. If Yes, provide details/conditions and source of information. 7. If No, detail source of information. 8. If Unknown or Not Assessed detail any action taken to identify hospital admissions. 9. Has the person attended any clinic/outpatient or treatment centre in the last 12 months? Yes /No / Unknown/Not Assessed 10. If Yes, provide details/conditions and source of information. 11. If No, provide details. 12. If Unknown or Not Assessed detail any action taken to identify any attendance at a clinic/outpatient or treatment centre.				Information Standard
Current physical health 1. Are there any current relevant health issues? Yes/No/Unknown/Not Assessed 2. If Yes, provide details and source of information including specific health issues. e.g. Skin care Allergies/Sensitivities Breathing difficulties 3. If Unknown or Not Assessed detail any action taken to identify current health issues.				Information Standard
Medication 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Taking medication Obtaining medication				Information Standard
Personal Care 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Managing personal appearance Washing Dressing				Information Standard
Eating, drinking and nutrition 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Does the person require the food to be placed in front of them to prompt them to eat?				Information Standard
Mobility 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Transferring from a position of lying down to sitting in a nearby chair Mobility on flat Mobility on stairs Mobility outdoors Falls				Information Standard
Substance Use 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Smoking Alcohol Drugs and solvents use (including prescribed drugs)				Information Standard
F Mental health Cognition 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Concentration Memory Orientation Wandering Awareness of danger				Information Standard
Emotional well-being 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Bereavement Emotional difficulties arising from life events General Mood Anxiety Motivation				Information Standard
Behaviour 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Agitation/Restlessness Disturbance/Disruption towards others Verbal Aggression Resistiveness or lack of co-operation Risk of harm to self or others				Information Standard
G Immediate environment and resources Domestic tasks/care of the home 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Food & drink preparation Use of heating Use of appliances or gas				Information Standard
Level and management of finances 1. Are there any issues? Yes/No/Refused to disclose/Not Assessed 2. If Yes, describe specific issues				Information Standard
Data Item	Description	Field Length	Format
Has the person been offered an income maximisation assessment?	Yes No.	1	Character	Data Standard
3. If the person has not been offered an income maximisation, provide details.				Information Standard
Accommodation 1. Are there any issues? Yes/No/ /Not Assessed 2. If Yes, describe specific issues e.g. Concerns regarding fabric of the building Physical security Safety hazards Equipment and adaptations Heating Summoning help Housing support				Information Standard
H Social and Cultural Life Social life and leisure activities 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues				Information Standard
Spiritual, religious, cultural matters 1. Are there any issues that are relevant to the provision of care? Yes/No/Not Assessed 2. If Yes, describe specific issues e.g. Requirements for worship or other religious observation Special dietary needs Arrangements for provision of care ( e.g. gender of carer				Information Standard
I Employment 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues				Information Standard
J Education, Training and Life Long Learning 1. Are there any issues? Yes/No/Not Assessed 2. If Yes, describe specific issues				Information Standard
K Care and Protection Abuse and neglect of person 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No. 4. If Yes, provide details				Information Standard
Other aspects of personal safety 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No. 4. If Yes, provide details				Information Standard
Public safety / harm to others 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No. 4. If Yes, provide details				Information Standard
Health and Safety at Work - Issues relating to anyone in direct contact 1. Are there any concerns / relevant history? Yes/No/Not Assessed 2. If Yes, describe specific issues 3. Have these concerns triggered a secondary process? Yes/No 4. If Yes, provide details				Information Standard
L Contact
Data Item	Description	Field Length	Format
Person informed who is single point of contact	Has the person been verbally informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments? Yes /No	1	Character	Data Standard
1. If the person has *not* been verbally informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments, provide details				Information Standard
Data Item	Description	Field Length	Format
Carer informed who is single point of contact	Has the carer been verbally informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments? Yes /No	1	Character	Data Standard
1. If the carer has *not* been verbally informed/given written advice as to who is the single point of contact to coordinate the contributions to assessments, provide details				Information Standard
Data Item	Description	Field Length	Format
Start Date of Assessment	The date on which an assessment of need commences. It is recognised that the process of assessment may be undertaken over a period of time.	10	CCYY-MM-DD	Data Standard
Data Item	Description	Field Length	Format
End Date of Assessment	The date on which an assessment of need concludes and needs are recorded. This should be the actual end date of assessment and not the proposed end date.	10	CCYY-MM-DD	Data Standard

IoRN Questionnaire

The Single Shared Assessment - Indicator of Relative Need ( SSA- IoRN) (previously known as the RUM) has been developed by ISD Scotland in partnership with the Scottish Government, Local Authorities, NHSScotland and other organisations. It is a standardised tool that uses information gathered from the SSA to place individuals over the age of 65 into groups according to their relative need. The main aim of the SSA- IoRN is to support the provision of better services for Scotland's older people through providing summary insights into the characteristics of people being assessed.

The IoRN is a standardised tool, which classifies people into one of 9 groups (A to I). It consists of a specific set of questions covering 5 characteristics i.e. activities of daily living, personal care, food and drink preparation, mental well-being and behaviour and bowel management. More detail on the use of the

questions and the algorithm are available at http://www.scotland.gov.uk/Topics/Health/care/JointFuture/SSAIoRN

Data Item	Description	Field Length	Format
When eating a meal, the person…	Eats without assistance. Eats without assistance using equipment. Eats with help, e.g. cutting up or pureeing food. Eats with encouragement, prompting or supervision. Requires complete assistance Receives nutrition by tube or Infusion.	1	Character
When transferring from bed to chair or wheelchair the person …	Transfers independently Transfers independently using equipment or adaptations Needs the assistance of one person Requires the encouragement, prompting or supervision of one person Needs the assistance of more than one person (with or without equipment) Does not transfer from bed to chair ( e.g. confined to bed)	1	Character
When using the toilet, the person …	Is independent Is independent with catheter or colostomy and equipment or adaptations Needs assistance Requires encouragement, prompting or supervision Requires complete assistance Does not use the toilet	1	Character
Is the person able to wash his/her hands and face?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person able to give himself/herself a complete wash, a bath or a shower?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person able to wash his/her hair?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person able to dress /undress himself /herself?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person able to prepare, cook and serve himself/herself a main meal?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person able to prepare, himself/herself a light snack ( e.g. sandwich)?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person able to prepare, himself/herself a hot drink ( e.g. a cup of tea)?	Without difficulty Without difficulty using equipment or an adaptation Has difficulty even if using equipment or adaptation Requires prompting, guidance, supervision or encouragement Cannot do without assistance from others	1	Character
Is the person agitated or restless?	Never, or less than three times in the last four weeks Three times or more in the last four weeks	1	Character
Has the person disturbed or disrupted other people?	Never, or less than three times in the last four weeks Three times or more in the last four weeks	1	Character
Is the person verbally aggressive?	Never, or less than three times in the last four weeks Three times or more in the last four weeks	1	Character
Is the person unco-operative or resistant to help with their care?	No Yes	1	Character
Has the person had difficulty with key relationships?	No Yes	1	Character
Has the person's behaviour constituted a risk of harm to themselves or to others?	No Yes	1	Character
Does the person require any of the following interventions or treatments relating to bowel management?	Provision of assistance, guidance, prompting or supervision to maintain bowel function: Never or less than once a week on average More than once a week on average	1	Character

Page updated: Thursday, December 13, 2007

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