Name:      	Main ID:      	Main assessor:      	
Carer’s Simple Review  - Question Set                                                                                                                                    Confidential	
Name:	     	Gender:		
Date of birth:	      	
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:      

	
Record of completion (this section to be completed by a social care authorised person)	
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 care and support plan when the following statements apply:
1.	Your physical or mental health is, or is at risk of, deteriorating; 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.	
Outcomes	Summary of your needs in each area	
Keeping a habitable home environment in the carer’s home (whether or not this is also the home of the adult needing care)	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or anyone else?	Yes  	No   	
	Details:      	
Managing and maintaining nutrition	The impact on how you feel		
	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	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Providing care to other people who the carer provides care for	The impact on how you feel		
	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	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:

      	
Using necessary facilities or services in the local community (including public transport, and recreational facilities or services)	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:

     	
Taking part in recreational activities	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
Taking part in work, training, education or volunteering	The impact on how you feel		
	Can you do this alone and without significant pain, distress, anxiety, or risk to yourself or others?	Yes  	No   	
	Details:      	
For information on carers' rights to flexible working: www.carers.org/help-directory/right-flexible-working	
Is your physical or mental health getting worse (or at risk of getting worse)?	Yes 	No  	
Are one or more Carer’s eligibility areas indicated as “No”?	Yes 	No  	
Support Plans and Reviews 	
Is the current support plan meeting the carers outcomes ?	Yes  	No  	
If the carer has one or more eligible needs and no support plan exists one should now be created. If "No" now review the carers support plan:	
Carers Views:

	
Review Officers Views:

	
Actions From Review	
There may be several outcomes of the review -- select as many as necessary	
No change / no actions required                                    	Carers Assessment                                                        	
Referral to reablement service                                         	Referral to Direct Payment Support Service                  	
Re-write support plan                                                       	Change to Direct Payment Arrangements e.g. end of DP or suitable person arrangement set up                          	
Professional Support                                                      	Information / Sign posting                                              	
Safeguarding Adults referral                                            	Close                                                                                  	
Other (please describe in the box below)                      		
If you have selected 'Other' as an answer in the previous question, please provide details here:

	
Next Carers Review Due by:	
Senior Practitioner:	
Date Signed off: