Carer’s name:      	Carer’s ID:      	Main assessor:      	
Carer’s Assessment – Question Set                                                                                                                    Confidential	
Family name:	     	Given name:	     	Title:		
Preferred name:	     	Gender:		
Date of birth:	     	Age band at time of assessment:	
Date of assessment:		
Supporting you in your assessment	
Preferred language:	     	Do you need an interpreter?	Yes       	No                	
Do you consider yourself to be any of the following:	Deaf   	Blind    	Deafblind   	
Do you have communication difficulties?	Yes      	No               	
Do you have any difficulties with understanding and/or retaining information?	Yes      	No              	
Do you have any difficulties making decisions and/or understanding their impact?	Yes      	No              	
If you have difficulties in communication, understanding or decision-making, you may need support for your involvement in your assessment, an advocate to represent you and help you explain your views, or a mental capacity assessment.	
Details of difficulties and what would help you communicate more easily during your assessment
(e.g. a family member or friend present, an independent advocate, specialist communication support)	
Details:      

	
Other people involved in your assessment (e.g. advocate, family, friend, other professionals)	
Details (including names, roles/relationships and contact details):      

	
About you	
Your personal and family background (including important recent events or changes in your life)	
Details:      

	
What areas of your life do you most enjoy or value? (including your main interests and where you can most contribute)	
Details:      

	
What changes would most improve your wellbeing or quality of life?	
Details:      

	
The care and support you provide	
Summary of the care and support you currently provide (including type of care/support, how often, time usually taken etc.?)	
Details:      

	
You may be entitled to Carer’s Allowance if you provide over 35 hours a week of support.	
What aspects of your caring role do you think are most important, valuable and positive?	
Details:      

	
Have you ever felt distressed or in danger due to the behaviour of the person you care for? (e.g. accusations, threats, actual harm)	Yes  	No 	
Support from other with caring	
Do you share your caring role with another family member or friend?	Yes  	No 	
Details:        

	
If ‘Yes’, are any of the other carer(s) under the age of 18?	Yes  	No 	
Details:      

	
Does your GP know you are a carer?	Yes  	No  	
If 'No' you should consider letting your GP know as there may be further advice available.	
Are arrangements in place for when you might be ill or unavailable? (e.g. contingency plan)	Yes  	No  	
If ‘No’, you should consider drawing-up an emergency contingency plan.	
Your home and living situation	
Includes the eligibility outcome: Maintaining a habitable home environment in the carer’s home (whether or not this is also the home of the adult needing care)	
Do you live with the person you care for?	Yes  	No  	
If ‘No’, do you have difficulties getting to the person? (e.g. long journey, transport issues)	Yes  	No  	
Details:      

	
Does being a carer make it difficult to keep your home sufficiently clean and safe?	Yes  	No  	
If ‘Yes’, how does/could this affect how you feel?		
Details:      

	
Are you having any money problems?	Yes  	No  	
Details:      

	
Have you or the person you care for had a benefits check?	Yes  	No  	
Maintaining a habitable home environment in the carer’s home (whether or not this is also the home of the adult needing care)	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No     	
Eating healthily and safely	
Includes the eligibility outcome: Managing and maintaining nutrition	
Does being a carer make it difficult to shop for and prepare adequate meals for yourself/your family?	Yes  	No  	
If ‘Yes’, how does/could this affect how you feel?		
Details:      

	
Managing and maintaining nutrition	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes   	No     	
Caring for others	
Includes the eligibility outcomes: Carrying out any caring responsibilities the carer has for a child; Providing care to other persons for whom the carer provides care	
Do you have any children that are you look after?	Yes   	No   	
If ‘Yes’, does being a carer impact on carrying out your parenting duties?	Yes   	No   	
If ‘Yes’, how does/could this affect how you feel?		
Details:      

	
Do look after any other adults?	Yes   	No   	
If ‘Yes’, does being a carer make it more difficult to meet your responsibilities?	Yes   	No   	
If ‘Yes’, how does/could this affect how you feel?		
Details:      

	
Providing care to other persons for whom the carer provides care	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes       	No   	
Social relationships and activities	
Includes the eligibility outcomes: Developing and maintaining family or other personal relationships; Making use of necessary facilities or services in the local community including public transport, and recreational facilities or services; Engaging in recreational activities	
Does being a carer make it difficult to keep in contact with people who are important to you?	Yes   	No    	
If ‘Yes’, how does/could this affect how you feel?		
Developing and maintaining family or other personal relationships	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes   	No     	
Does being a carer make it difficult for you to get out into the community?	Yes   	No  	
If ‘Yes’, how does/could this affect how you feel?	
Details:      

	
Making use of necessary facilities or services in the local community (including public transport, and recreational facilities or services)	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes   	No     	
Does being a carer make it difficult for you to do leisure, cultural or spiritual activities?	Yes   	No    	
If ‘Yes’, how does/could this affect how you feel?	
Details:      

	
Engaging in recreational activities	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes   	No     	
Work, training, education and volunteering	
Includes the eligibility outcome: Engaging in work, training, education or volunteering	
What current paid employment or voluntary work do you do?		
What education/training are you currently doing?		
Does being a carer impact on your involvement in work/training/education/ volunteering?	Yes   	No   	
If ‘Yes’, how does/could this affect how you feel?	
Details:      

	
Engaging in work, training, education or volunteering	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes   	No     	
For information on carers’ rights to flexible working: http://www.carers.org/help-directory/right-flexible-working 	
Your mental health and wellbeing	
Is (or is there a risk of) your mental health deteriorating due to your caring role?	Yes     	No         	
Level of risk of your mental health deteriorating due to your caring role	None                                                   	Low                                                    	
	Significant                                           	Serious                                             	
Details:      

	
Your physical health	
Is (or is there a risk of) your physical health deteriorating due to your caring role?	Yes      	No      	
Level of risk of your physical health deteriorating due to your caring role	None                                                         	Low                                         	
	Significant                                                 	Serious                                   	
What is the risk of your physical health getting worse because you are a carer?		
Do you have difficulty with helping the person you care for to move around?	Yes      	No         	
Details:      

	
The care and support you are able and willing to provide on an on going basis	
Are you able to continue as a carer?	Yes         	Yes with support              	No        	
Are you willing to continue as a carer?	Yes         	Yes with support              	No        	
Do you have concerns about the longer term future?
(e.g. finances, security of tenancy, maintaining your caring role as you or the person you care for get older)	Yes 	No         	
Details:      

	
Please choose a statement for each area that reflects the on going situation (e.g. over the next year)	
Helping with housework/laundry		
Helping with managing paperwork/finances		
Helping with shopping for food/essential items		
Helping with preparing meals/snacks/drinks and helping to eat and drink	Mornings: 		
	Daytimes: 		
	Evenings: 		
Helping to manage personal care tasks
(using toilet/managing continence, washing, dressing/undressing)	Mornings: 		
	Daytimes: 		
	Evenings: 		
Helping with medication	Mornings: 		
	Daytimes: 		
	Evenings: 		
Helping with Social, leisure, cultural and spiritual activities		
Helping with work, training, education or volunteering		
Ensuring safety during the day	Mornings: 		
	Daytimes: 		
	Evenings: 		
Helping during the night		
Other on going help that you will provide	Escorting person/providing transport   	Help communicating with others   	
	Providing company/emotional support 	Help caring for children                  	
Details of the person you care for	
Is the person you care for aware that you are having an assessment?	Yes 	No  	
Has the person you care for had their own needs assessed?	Yes   	No  	
Name:	     	Gender:		
Date of birth:	     	Social Care ID:	     	
Relationship to you:	Family member 	Neighbour 	Friend 	Other 	
What is the longest period you regularly leave the person you care for alone?	During the day: 		
	During the night: 		
Please choose a statement below to best describe the needs of the person you care for:	
0 = He/she is able to manage well in all areas as there are no significant physical or mental health issues.		
1 = He/she needs a small amount of weekly support as there are some minor physical/mental health issues or social difficulties, but he/she can manage alone for more than one day at a time.		
2 = He/she needs a small amount of daily support with one or two physical tasks and/or requires regular support to avoid low mood, loneliness or harm. He/she needs checking most days or daily to stay safe.		
3 = He/she needs support more than once a day with a number of physical tasks and/or requires significant support to avoid low mood, loneliness or risk of harm. He/she can be left alone for extended periods but needs support more than once a day to stay safe.		
4 = He/she needs support with most physical tasks and/or has mental health issues or social/learning difficulties which make it difficult to manage day-to-day life. He/she can only be left alone for up to 2-3 hours and/or needs checking at night but doesn’t need someone present all of the time.		
5 = He/she has difficulties in many/most areas and needs someone present all the time or nearly all the time to stay safe during the day or during the night but does not need 24 hour support.		
6 = He/she cannot be safely left alone during the day or at night, needing a high level of 24 hour support. He/she may need specialist care and support and/or may need the support of more than one carer.		
Date of assessment:	     	Assessment type:	Initial                     	Reassessment     	
Location of assessment:	     	Is this a supported self-assessment?	Yes                        	No                          	
If ‘No’, main assessor:	     	Assessor contact details:	     	
Summary of your assessment and eligibility (this section to be completed by a social care authorised person)	
The Local Authority has a duty to work with you to prepare a support plan when the following statements apply:
1.	Your physical or mental health is, or is at risk of, deteriorating; AND/OR
2.	As a result of your needs you are unable to achieve one or more of the eligible outcomes below and there is likely to be a significant impact on your wellbeing.	
Maintaining a habitable home environment in the carer’s home (whether or not this is also the home of the adult needing care)	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes         	No       	
	Details     

	

Managing and maintaining nutrition	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes           	No       	
	Details     

	
Carrying out any caring responsibilities the carer has for a child
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes           	No       	
	Details     

	
Providing care to other persons for whom the carer provides care
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes           	No       	
	Details     

	
Developing and maintaining family or other personal relationships
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes          	No       	
	Details     

	
Making use of necessary facilities or services in the local community (including public transport, and recreational facilities or services)	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes          	No       	
	Details     

	
Engaging in recreational activities	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes          	No       	
	Details     

	
Engaging in work, training, education or volunteering
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes           	No       	
	Details     

	
Are one or more eligibility areas indicated as ‘No’?	Yes      	No     	
Is your mental health getting worse (or at risk of getting worse)?	Yes      	No     	
Details     

	
Is your physical health getting worse (or at risk of getting worse)?	Yes  	No      	
Details     

	
Impact of your needs on how you are feeling	
As a result of:

•	You not being able to achieve one or more of the 8 outcomes above and/or
•	Your mental or physical health deteriorating (or being at risk of deteriorating) 
– is there, or is there likely to be, a significant impact on how you feel?	N/A  
	Yes  
	No  
	
The impact of how you are feeling should be looked at disregarding any support you may already have and should take into account the following areas, as well as your (or your representative’s) views:

● Personal dignity and being treated with respect              ● Physical and mental health and emotional wellbeing
● Protection from abuse and neglect                                  ● Suitability of living accommodation
● Participation in work, education, training or recreation    ● Social and economic wellbeing
● Domestic, family and personal relationships                     ● Your contribution to society
● Control over day-to-day life (including over care and support provided and the way it is provided)	
Details of the impact on how you are feeling (in the absence of any help you may already have in place):
     	
Information and advice(this section to be completed by a social care authorised person)	
Information and advice about your current needs	
Details:      	
Information and advice about preventing or delaying the development of needs in the future	
Details:      	
Agreement	
I / my supporter is satisfied that I and/or (s)he was involved in this assessment as much as possible and that I / my supporter was able to express what I / s(he) felt should be taken into account:	
Your signature (or signature of your supporter where relevant)	     	Date: