The Skilled Conversation

Under the Care Act it is important that the person's needs are considered within the context of their family network of support and not in isolation. This is what is meant by a whole family approach.

Taking a whole family approach enables the Local Authority to:

1. Understand the impact of the person's Care and Support needs on all family members, not just those that may be instantly recognisable as carers; and
2. Identify and support carers (both these things are duties under the Care Act).

Taking a whole family approach also builds the resilience of families and increases the likelihood that a non-service led self-sustainable method of meeting needs will be identified.

When taking a whole family approach you should consider involving the following people in the assessment:

1. Adult's living in the same household as the person;
2. Children living in the same household as the person;
3. Adults living elsewhere but who form part of the person's support network;
4. Children living elsewhere but who form part of the person's support network.

Specifically you need to understand:

1. The impact of the person's needs on family members (both adult and children);
2. Whether the role that other adults or children in the family have constitutes a caring role under either the Care Act 2014 or the Children and Families Act 2014;
3. Whether the support currently being provided to adults and children to manage the impact is appropriate (or whether a carer's/young carer's assessment should be offered); and
4. Whether the support being provided is sustainable.

Where there is an appearance of need in a carer you have a duty to offer an assessment. See the Carer's Procedures, which include procedures for carrying out a carer's assessment.

Any conversations with adult family members must give regard to the duty to provide good information and advice about adult Care and Support. This could be in relation to the needs of the person being assessed, in relation to their own apparent needs or in relation to another adult that they support or are concerned about.

You must also consider whether any prevention service would be of benefit to any adult family member you speak to, either to support them as a carer for the person or in their own right. Where they appear to have a need for a prevention service themselves you should support them to access this service.

Where you take action to support another adult in the person's family via a whole family approach you should make sure that you make appropriate and proportionate recordings for the action you have taken or the information and advice you have provided.

The Duty to safeguard children

Children are protected under different legislation to adults. Whilst you are not expected to understand children's legislation in your role you are expected to know your statutory responsibilities in relation to protecting children so that you can respond appropriately.

Things that you must consider in relation to all children living in the household:

1. Whether the child is taking part in any caring activities that may be inappropriate for their age, gender or that cause them physical difficulty or emotional distress;
2. Whether the adult with Care and Support needs presents with behaviours that place the child at risk of harm or abuse;
3. Whether the child is at risk of neglect because the adult with care and support needs has caring responsibilities towards them that they cannot adequately meet as a result of their own needs;
4. Whether the child is at risk of neglect because a carer has caring responsibilities towards them that they cannot adequately meet as a result of caring for an adult;
5. Whether the home environment or any caring role is having a negative impact on the child's well-being, education or development.

If you are concerned about the safety of a child, or that they are at risk of abuse and neglect you must take action to protect them.

If you are concerned that a child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialing 999.

Responsibilities to young carers

The legal definition of a young carer under the Children and Families Act is:

"a person under 18 who provides or intends to provide care for another person (of any age, except where that care is provided for payment, pursuant to a contract or as voluntary work)".

There is a duty to meet the needs of young carers under the Children and Families Act in the same way as there is a duty to meet the needs of adult carers under the Care Act. This means that if you become aware that a child or young person under the age of 18 is providing care you must take steps to ensure they are appropriately supported.

The first thing you should do is liaise with children's services to establish whether the child or young person is already being supported as a young carer.

If support is in place you should provide children's services with any new information you may have about the impact of the adult's needs upon the child, but you will not need to provide any further support to the child.

If the young carer is not already being supported by children's services you should discuss and agree with your line manager and children's services who is best placed to assess them.

Option 1

If the young carer is not approaching the age of transition any assessment and subsequent support they receive will be provided under the Children Act 1989. The practitioner carrying out a young carer's assessment under the Children Act must be suitably skilled, knowledgeable and competent to do so.

Option 2

If the young carer is approaching the age of transition (or is at a time of their life when it would be of significant benefit for transition to begin) a young carer's assessment under the Children and Families Act or Care Act may be more appropriate. This will involve the development of a transition plan that will support the young carer through the transition to adult Care and Support (when they become 18).

There is a legal duty to ensure that transition planning and the whole transition experience is positive for the young carer. To this end an element of joint work will likely be required to ensure the young carer receives the support they need both now and into adulthood.

For further information about young carer's transition assessments, see: Transition to Adult Care and Support.

Wellbeing is the single most important concept of the Care Act. The duty to promote individual wellbeing applies at all times; in every single process, conversation or decision that is made and you must be able to demonstrate that you have done so.

It is vital that you understand your duties in relation to promoting individual Wellbeing. See: Promoting Individual Wellbeing.

In order to promote individual Wellbeing you must first understand what Wellbeing means to the person. The Care Act sets out 9 domains of Wellbeing that you must consider. See: Wellbeing Domains.

As part of any process to establish needs you must understand:

1. Which areas of Wellbeing are most important to the person at that moment in time;
2. Which areas of Wellbeing are least important at that time;
3. Whether there are other areas of the person's life important to them but not listed as a domain (the domains under the Act are not definitive as Wellbeing is personal);
4. Which areas of Wellbeing are causing the person concern or worry;
5. What impact any concern or worry is having (or could have) across the Wellbeing domains (is there a destabilising effect?); and
6. How the person thinks any Care and Support needs interact and impact on Wellbeing.

It is important to remember that under the Care Act the Wellbeing domains are all as important as each other. Any hierarchy can only be determined or described by the person whose Wellbeing it is.

1. A sense of Wellbeing is extremely personal and will be different for every person;
2. Never make assumptions about what is important and what is not important to a person;
3. The person is the expert in relation to their own Wellbeing;
4. If a person tells you they have no worries in a particular area this does not mean the area is not important to them; and
5. Conversations about Wellbeing should be 'genuine' person centred conversations, not process led.

Often the key to an effective conversation about Wellbeing is preparation and you should take whatever steps are available to ensure that the person is as prepared as possible for the conversation:

1. Provide information that will support the person to understand the concept of Wellbeing and why it is important;
2. Offer advice about the things that a person may want to think about before having a conversation about Wellbeing;
3. Make sure that anybody who will be supporting the person understands Wellbeing and is confident and appropriate to support the person to prepare for and have the conversation; and
4. Consider whether any tools may be helpful to support the person to think about Wellbeing.

A conversation about Wellbeing can be a very difficult conversation for a person to have. Not everyone will feel happy, confident or able to share with you how they are feeling about the different areas of their life. For many people, this will be the first time they have been asked or given an opportunity to think about their own Wellbeing in this way, and they may also be doing so whilst adapting to significant change in their life.

Any questions that are used to support a person to think about Wellbeing must:

1. Be proportionate to the level of information required;
2. Be appropriate, taking into account the person's specific needs around communication and their specific circumstances;
3. Be realistic in respect of the persons mental capacity and ability to be able to answer the question; and
4. Be asked in a manner that is accessible to the person.

Powerful questions

A powerful question is a specific type of open question that:

1. Encourages a person to reflect;
2. Is thought-provoking;
3. Supports an exploration of options; and
4. Helps the person to gain a greater insight into their situation.

Powerful questions should be framed in a positive way to promote engagement of the person and promote a strengths based approach.

Appreciative Enquiry

An appreciative enquiry is a conversation that is led by the person and focuses on times of personal strength. It supports them to recognise that they do still have those strengths and abilities and to think about how they can apply them to their current situation.

The listener should invite the person to:

1. Talk about a time or times when something has been working well in their life;
2. Explore what it was that worked well and supported them at that time;
3. Think about how that experience could support them now in making a plan for the future.

Some key questions to support an appreciative enquiry approach include:

1. Tell me about a time when things were going well for you?
2. What did you learn about your strengths at that time?
3. If you had a magic wand what would the future look like?
4. What is it that you value most in your life now?
5. What small changes would make the most difference?

The use of tools

A tool can be helpful to shape and focus a conversation about Wellbeing, making sure that you consider everything that needs to be considered from a statutory perspective. Tools are also useful because they:

1. Can be completed with the person as part of any conversation you have with them; or
2. The person can complete them in their own time as part of their preparation for the conversation.

See: Tools and Practice Guidance to Establish Needs to access the range of tools that are available and practice guidance around the use of tools.

Some people will lack capacity to have a conversation or communicate how they feel about their own Wellbeing at a particular moment in time (verbally or through another means). For example, they may be too unwell to do so or have a significant learning disability. Where this is the case the duty to ensure their involvement still applies.

There are a range of ways that you can ensure the involvement of a person who lacks capacity, including but not limited to:

1. An appropriate other person or independent advocate to support the person to engage and ensure that they are represented;
2. Spending time with the person can show you what they enjoy about life and what may be most important to them (this could be a person, a place or something they do with their time);
3. Consulting with a range of people who know the person before reaching a judgement about Wellbeing. Speaking to a family member, a health professional, a paid carer, a college tutor and a day services manager will give a much better picture of what appears to matter most to the person than relying on the views of one person;
4. Use other available evidence to support you to understand Wellbeing (for example ABC charts and other records that show behaviour changes clearly linked to an event, person or place).

All information gathering and sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

Because Wellbeing is extremely personal different people are likely to have different perspectives about the same domains. The person themselves is more likely to have a subjective view about their Wellbeing which may be dominated by worries or concerns they have about their presenting situation (for example the potential impact of a serious health diagnosis), whereas someone who is emotionally removed from may see things more objectively.

It is important that you recognise when a person's views about their Wellbeing may not be holistic and take steps to try and support them to gain insight or broaden their thinking. One way of doing this is to seek the views of family members and others involved in their life (with the person's consent or in their best interests if they lack capacity). This supports a whole family approach to assessment but can also lead to a shared understanding and solution from within informal networks of support.

Even with the involvement and perspective of others certain factors effecting Wellbeing may still be difficult for people to recognise, acknowledge or explore. If it is your view that these things are having an impact on Wellbeing then you must raise them for the purposes of:

1. Supporting the person to gain insight into their situation;
2. Developing the person's resilience through talking about difficult situations and exploring options to find a solution;
3. Providing information and advice;
4. Preventing, reducing or delaying the need for Care and Support.

You may also find the tool Six Tips to Help You Have Difficult Conversations useful.

You should also make effective use of supervision to explore and develop skills that will support you to have difficult and sensitive conversations with people in a positive way.

A person's wellbeing is always affected by what is happening in their life at that time. It changes as their situation changes, and sometimes the changes in Wellbeing that take place can be quite dramatic. It is therefore important to understand a person's Wellbeing in the context of their current situation, but to monitor and review Wellbeing as things change.

When you have understood a person's individual Wellbeing you have a duty to promote it. To do this you must understand:

1. The things that they want to achieve;
2. The things they want to change; and
3. The things that they want to stay the same.

These things are known as the person's outcomes. In order to promote Wellbeing you should explore with the person during the assessment the steps that they can take to achieve their outcomes, as the two things are intrinsically linked.

NHS Choices have an online resource: 5 steps to mental wellbeing.

If, following assessment the Local Authority meets any eligible needs that the person has you will need to explore not only what steps the person can take to achieve their outcomes, but also how the support/services provided can help them do so too.

You have a duty to promote a person's individual Wellbeing but this is not a duty at the detriment of others. The Wellbeing of others must be taken into account and may determine the action that you then do or do not take to promote a person's Wellbeing.

For example, if promoting the person's Wellbeing will put another vulnerable adult or a child at risk then you must not do so unless risks can be mitigated. The duty to protect people from abuse or neglect overrides the duty to promote individual Wellbeing.

The Local Authority has a duty to meet eligible needs, and it cannot fulfil this duty unless it establishes whether the needs that a person appears to have are eligible.

A person's needs also often directly impact on their Wellbeing, which you have a duty to promote. Therefore understanding needs will also support you to fulfil the duty to promote Wellbeing.

The Care Act sets out 10 areas of need that must be assessed whenever it appears that they exist:

• Manage and maintain nutrition;
• Maintain personal hygiene;
• Manage toilet need;
• Being appropriately clothed;
• Be able to make use of their home safely;
• Maintain a habitable home environment;
• Develop/maintain family and other personal relationships;
• Access/engage in work, training, education or volunteering;
• Make use of community services;
• Carry out caring responsibilities for a child.

Unlike a conversation about individual Wellbeing there is not a requirement to talk about all of the areas of need described in the Care Act, regardless of whether they appear to be present or not. Instead the conversation about needs must be proportionate and appropriate to each person's situation.

Often the key to an effective conversation about need is preparation and you should take whatever steps are available to ensure that the person is as prepared as possible for the conversation:

1. Provide information that will support the person to understand the areas of need described in the Care Act and why establishing needs is important;
2. Offer advice about the things that a person may want to think about before having a conversation about needs;
3. Make sure that anybody who will be supporting the person understands needs and is confident and appropriate to support the person to prepare for and have the conversation; and
4. Consider whether any tools may be helpful to support the person to think about needs.

A conversation about needs can be a very difficult conversation for a person to have. Not everyone will feel happy, confident or able to talk about their needs. Some people may lack insight into their needs, particularly if they are still going through a period of adjustment to the need.

Any questions that are used to support a person to think about needs must:

1. Be proportionate to the level of information required;
2. Be appropriate, taking into account the person's specific needs around communication and their specific circumstances;
3. Be realistic in respect of the persons mental capacity and ability to be able to answer the question; and
4. Be asked in a manner that is accessible to the person.

Powerful questions

A powerful question is a specific type of open question that:

1. Encourages a person to reflect;
2. Is thought-provoking;
3. Supports an exploration of options; and
4. Helps the person to gain a greater insight into their situation.

Powerful questions should be framed in a positive way to promote engagement of the person and promote a strengths based approach.

Appreciative Enquiry

An appreciative enquiry is a conversation that is led by the person and focuses on times of personal strength. It supports them to recognise that they do still have those strengths and abilities and to think about how they can apply them to their current situation.

The listener should invite the person to:

1. Talk about a time or times when something has been working well in their life;
2. Explore what it was that worked well and supported them at that time;
3. Think about how that experience could support them now in making a plan for the future.

Some key questions to support an appreciative enquiry approach include:

1. Tell me about a time when things were going well for you?
2. What did you learn about your strengths at that time?
3. If you had a magic wand what would the future look like?
4. What is it that you value most in your life now?
5. What small changes would make the most difference?

The use of tools

A tool can be helpful to shape and focus a conversation about need, making sure that you consider everything that needs to be considered from a statutory perspective. Tools are also useful because they:

1. Can be completed with the person as part of any conversation you have with them; or
2. The person can complete them in their own time as part of their preparation for the conversation.

See: Tools and Practice Guidance to Establish Needs to access the range of tools that are available and practice guidance around the use of tools.

To ensure an accurate assessment of need it is important that you identify whether a person has needs that fluctuate (change over time).

Fluctuating needs are needs that:

1. May not be apparent at the time of the assessment; but
2. Have been an issue in the past; and
3. Are likely to arise again in the future.

A simple question to ask a person to establish whether their needs fluctuate is 'How do your needs change over time?'

Every person with fluctuating needs will experience fluctuations differently. For example:

1. Some people's needs fluctuate throughout each and every day;
2. Some people's needs fluctuate on some days each week;
3. Some people will have periods of stability that could last several weeks or months with no fluctuation;
4. Some people's fluctuations are related to a physical or mental health condition (for example Parkinson's Disease or Bi-Polar Disorder); and
5. Some fluctuations are a response to a change in circumstance or environment (for example the weather affecting arthritis).

Because of the variance in fluctuation possible it is not appropriate to simply assess a person as having 'fluctuating' needs. Neither should you make a judgement about need based solely on either a 'worse case' or a 'best case' scenario. Doing so would not provide a true representation of the person's whole needs and it would be likely that any support the Local Authority did subsequently provide would be inappropriate or disproportionate (too much or not enough) to cover periods of fluctuation.

You need to be able to effectively demonstrate:

1. How often the person experiences a fluctuation in needs;
2. The type of fluctuations that are experienced and the impact on other needs and Wellbeing;
3. What the potential causes or triggers are for fluctuations; and
4. What measures are effective in managing periods of fluctuation or reducing the risk that they will occur.

The kind of questions you could ask a person to help understand their fluctuating needs includes:

1. How long has it been since you had a good/bad day?
2. What does a good/bad day look like?
3. What changes in support do you have on a bad day?
4. How often do your needs change on a bad day?
5. Which areas change the most on a bad day?

The length of extension to an assessment process to ensure that fluctuating needs are understood should be based on the individual needs and circumstances of the person and could be a day, a week or several months in duration.

It may also be appropriate to pause an assessment to enable the person to access support that may then prevent or reduce the number of fluctuations occurring (for example to allow a new medication to take effect or to access to a health service to support anxiety).

Some people will lack capacity to have a conversation or communicate information about their needs (verbally or through another means). For example, they may be too unwell to do so or have a significant learning disability. Where this is the case the duty to ensure their involvement still applies.

There are a range of ways that you can ensure the involvement of a person who lacks capacity, including but not limited to:

1. An appropriate other person or independent advocate to support the person to engage and ensure that they are represented;
2. Spending time with the person can show you what needs they have and how they are currently being supported;
3. Consulting with a range of people who know the person before reaching a judgement about need. Speaking to a family member, a health professional, a paid carer, a college tutor and a day services manager will give a much better picture of the person's needs than relying on the views of one person;
4. Use other available evidence to support you to understand need (for example ABC charts, carer's notes and other records).

All information gathering and sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

Different people involved with the person are likely to have different views about need. For example, the person them self is likely to have a subjective view about their needs, which may be dominated by worries or concerns they have about their presenting situation (for example the potential impact of a serious health diagnosis), whereas someone who is emotionally removed from the situation may see things more objectively.

It is important that you recognise when a person's views about their needs may not be holistic and take steps to try and support them to gain insight or broaden their thinking. One way of doing this is to seek the views of family members and others involved in their life (with the person's consent or in their best interests if they lack capacity). This supports a whole family approach to assessment but can also lead to a shared understanding and solution from within informal networks of support.

Even with the involvement and perspective of others certain needs may still be difficult for people to recognise, acknowledge or explore. If it is your view that these needs exist and are having an impact on the person then you must raise them for the purposes of:

1. Supporting the person to gain insight into their needs and situation;
2. Developing the person's resilience through talking about difficult situations and exploring options to find a solution;
3. Providing information and advice;
4. Preventing, reducing or delaying the need for Care and Support.

You may also find the tool Six Tips to Help You Have Difficult Conversations useful.

You should also make effective use of supervision to explore and develop skills that will support you to have difficult and sensitive conversations with people in a positive way.

Sometimes it is necessary to talk about needs that you know are likely to change at some point in the near future. For example:

1. When a person is expected to make a full recovery from a health related condition;
2. When a person's needs are likely to be temporary (e.g. needs relating to upcoming surgery to resolve a physical need); or
3. When a person's needs are related to their circumstances and these circumstances are going to change (e.g. needs relating to caring for a child when the child is going to be staying long term with another family member).

If those needs are eligible the duty to meet the needs applies, even if the need is only likely to be short term.

Where needs are likely to be changing over time it is important to make arrangements with the person to monitor and review the needs over an appropriate timeframe that reflects the individual circumstances of the person.

Sometimes it is necessary to establish needs during a period of crisis. For example:

1. When an informal caring relationship has completely broken down with immediate effect; or
2. When the person's physical or mental health condition deteriorates rapidly and current services being provided are no longer working.

At times of crisis the presenting needs that a person has may not be a true representation of their on-going needs for care and support. As such it is important to make arrangements with the person (or their representative) to monitor and review their needs and situation, re-assessing where there is evidence that long term needs are clear.

At this point in the assessment process you will not yet have made a formal determination about eligibility, although you may have gathered enough information to give a good indication. As the formal determination has not yet been made you should restrict conversations about ways that needs could be met to:

1. Ways that the person could meet their needs (either independently or with the support of their informal support networks or community);
2. Information and advice about prevention services that could delay, reduce of prevent needs; and
3. Broad information about the type of services available in the marketplace that may be appropriate to meet needs (if the person appears to have eligible needs).

A more specific conversation about how the Local Authority could meet needs will take place as part of the Care and Support Planning process after:

1. The formal eligibility determination is made; and
2. The person has confirmed that they wish for the Local Authority to meet their needs.

Risk is broadly defined as 'the probability that an event will occur with beneficial or harmful consequences'.

The aim of any conversation about risk is to maximise the benefits and reduce the likelihood of harm.

When you have a conversation about promoting Wellbeing, meeting needs or ways to achieve an outcome there will at some point be a need to talk about risk and doing so at an early stage can support the person to:

1. Explore and understand the benefits of taking the risk;
2. Explore and understand the potential harmful consequences of taking the risk;
3. Think about the measures they can take to reduce the likelihood of a negative consequence; and
4. Make an informed decision about whether to take the risk.

The process of talking about risk can be very empowering for a person and build resilience, confidence and independence.

Examples of risk you may need to talk about when establishing need can include:

1. Risk associated with an impairment or disability (e.g. falls);
2. Risk of accidental injury (e.g. from traffic when in the community or using a household appliance at home);
3. Risks around a person's ability to manage medication;
4. Risks around the use of drugs or alcohol; and
5. Risk of abuse or neglect (e.g. exploitation by others);

Depending on the level of risk a formal risk assessment may need to be carried out in addition to any other assessment process.

See: Risk Assessment.

If, as part of any conversation you have with a person or their family you become concerned that a vulnerable adult or a child is experiencing, or at risk of abuse or neglect you must respond appropriately.

See Safeguarding Adults, which also includes information about how to raise a concern about a person under the age of 18.

If you are concerned that an adult or child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialing 999.

Where the safeguarding is in respect of the person whose needs are being established a decision will need to be made about the need to pause the assessment process to allow a safeguarding enquiry to take place.

There are 3 possible options:

1. The needs assessment process continues alongside any safeguarding process;
2. The needs assessment is paused with no on-going intervention by the person carrying out the assessment whilst a safeguarding process takes place; or
3. The needs assessment is paused but urgent interim support is arranged to ensure needs are met whilst a safeguarding process takes place.

Any decision should involve the person carrying out the needs assessment, the person who will be carrying out any safeguarding process, the person with care and support needs (or their representative) and any carer.

You must consider any appropriate action required to authorise deprivations of liberty whenever:

1. The person lacks capacity to make decisions about the Care and Support provided to them; and
2. You feel the level of restriction being imposed on the person is depriving them of their liberty; or
3. You feel the level of restriction required to meet their care and support needs following assessment is likely to deprive them of their liberty.

See: Recognising and Responding to Deprivations of Liberty.