Carer’s name:      	Carer’s ID:      	Main assessor:      	
Carer’s Full Review – Question Set                                                                                                                   Confidential	
Family name:	     	Given name:	     	Title:		
Preferred 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:      	
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	
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:      	
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?	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:      

	
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     	
Do you 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     	
Details:      

	
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?		
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:      

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

	
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?		
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:      

	
For information on carers’ rights to flexible working: http://www.carers.org/help-directory/right-flexible-working 	
Your mental health and wellbeing	
How are you feeling?	I’m calm and unstressed 		I’m under regular stress		
	I’m under occasional stress		I’m regularly highly stressed		
What is the risk of your mental health getting worse because you are a carer?		
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		
Details:      

	
Your physical health	
How would you describe your current physical health/wellbeing?	I’m in generally good health		I’m in fairly poor health		
	I’m in reasonable health		I’m in very poor health/terminally ill		
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:      

	
Support from others with caring	
Do you share your caring role with another family member or friend?	Yes		No		
If ‘Yes’, are any of the other carer(s) under the age of 18?	Yes		No		
How much practical or emotional support do you receive from others?
(e.g. friends, family, volunteers)	None		A lot of support 		A little regular support		
	A substantial amount of support		Occasional support only		
Details:      

	
Does your GP know you are a carer?	Yes		No		
If ‘No’, would you like us to contact your surgery to let them know?	Yes		No		
Are there any arrangements in place for when you might be ill or unavailable and you are unable to do your caring role? (e.g. contingency plan)	Yes		No		
If ‘No’, you should consider drawing-up an emergency contingency plan.	
Details (including location of contingency plan):      

	
The care and support you are able and willing to provide on an ongoing 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:      

	
I will provide the following support as a carers on an on going basis:	
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.		
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 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.	
Is your physical or mental health getting worse (or at risk of getting worse)?	Yes		No		
Are one or more eligibility areas indicated as ‘No’?	Yes		No		
Impact of your needs on how you are feeling	
As a result – 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	
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:	     	
Review Information	
Route of access:		
Reason for Review:		
Details of reason for Review:		
Does your support plan meet your identified outcomes?	Yes      	No      	

Review Support plan if outcomes are not met.	
This section is only required when completing a review	
Do you have any issues in managing your direct payments?	Yes     	No      	
Details:		
Assessment Completion	
Share Data	Yes    	No     	
Details:	
End Date:	Priority:	
Outcome:		
End of Community Care Process	Yes     	No      	
Completed By:	
Complete? :	Yes     	No      	
Completed Date/Time: