Name:      	Main ID:      	Main assessor:      	
Overview Assessment – 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?		
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, carer, 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:      	
Your family, carer(s) or advocate’s views	
Details:      	
Do you have any concerns about how others treat you? (e.g. neglect, abuse, discrimination)	Yes  		No  		
Details:      	
Your home and living situation (based on typical week)	
Includes the eligibility outcome: Maintaining a habitable home environment	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Are you currently staying in a hospital or other NHS facility?	Yes  		No  		
Who do you live with?		
Do you rent or own your home?		
Maintaining your home in a sufficiently clean and safe condition	Are you able to do this yourself or do you need help? 	
Details of your needs and what you would like to achieve (maintaining your home in a sufficiently clean and safe condition):      	
Are you able to manage your own day-to-day paperwork?	Yes  		No  		
Are you able to manage your own finances? (if no, please include detail of any Lasting Power of Attorney, Deputy or Appointee below)	Yes  		No  		
Details of your needs and what you would like to achieve(managing paperwork, managing finances):      

	
If appropriate, you may wish to be referred for financial advice and/or maximising your benefits.	
Are you able to access/use the Internet?	Yes  		No  		
Are you using specialist technology to help you manage at home? (e.g. telecare)	Yes  		No  		
Details:      

	
Do you have any concerns about your current home and living situation?
(e.g. tenure, access/hazards, temperature, need for adaptations, smoke/carbon monoxide alarms)	Yes  		No  		
Details:      

	
Maintaining a habitable home environment	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Eating healthily and safely (based on typical week)	
Includes the eligibility outcome: Managing and maintaining nutrition	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Shopping for food/essentials	What help do you need? 	
Preparing meals/snacks/drinks	What help do you need? 	
	How often do you need help? 	
Eating and drinking	Your situation: 	
Details of your needs and what you would like to achieve (shopping, preparing meals/snacks/drinks, eating and drinking):      

	
If you need someone else to feed you, are you able to have food and drink by mouth?	Yes  		No  		
If you need someone else to feed you, how long does this usually take?		
Do you have any dietary or eating difficulties that put you at risk or require skilled support?	Yes  		No  		
Details:      

	
Managing and maintaining nutrition	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Your personal care (based on typical week)	
Includes the eligibility outcomes: Managing toilet needs; Maintaining personal hygiene; Being appropriately clothed	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Using the toilet/managing continence	What help do you need? 	
	How often do you need help? 	
	What help do you get? 	
Details of your needs and what you would like to achieve (using the toilet/managing continence):      

	
Managing toilet needs	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Maintaining personal hygiene
(e.g. wash hands/face, hair, nails, shave)	What help do you need? 	
Washing whole body 
(e.g. bath, shower, strip wash)	What help do you need? 	
	How often do you need help? 	
Details of your needs and what you would like to achieve (maintaining personal hygiene, washing whole body):      

	
Maintaining personal hygiene	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Dressing	What help do you need? 	
Undressing	What help do you need? 	
Details of your needs and what you would like to achieve (dressing and undressing):      

	
Being appropriately clothed	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Your mobility (based on typical week)	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Moving around the home	What help do you need? 	
Transfers	What help do you need? 	
To what extent does your weight impact on your mobility?
(e.g. if overweight or underweight/frail)		
Is there a risk of harm to others when assisting with your mobility/transfers?	Yes  		No  		
Details of your needs (moving around the home, transfers):      

	
Staying comfortable/repositioning	What help do you need? 	
Details of your needs (staying comfortable/repositioning):      

	
Do you require regular support for a skin condition or to prevent one developing?		
Do you have any pressure ulcers?		
If pressure ulcer(s) are present, is treatment currently working?	Yes		No  		N/A  		
Details of your needs (managing skin conditions):      	
Social relationships and activities (based on typical week)	
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	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
The relationships that are most important to you and anything you would like to improve or change
(e.g. relationships with carers, family, friends, neighbours, volunteers)	
Details of your needs and what you would like to achieve (maintaining relationships that are important to you):      	
Developing and maintaining family or other personal relationships	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Are you able to access the community?	Yes, independently		Yes, if accompanied  		No  		
What help do you need to stay safe out in the community?		
Details of your needs (staying safe in the community):      	
The activities that are most important to you and anything you would like to improve or change
(including social, leisure, cultural and spiritual activities; making a meaningful contribution within society)	
Details of your needs and what you would like to achieve (socialising, contributing to society):      	
What help do you need to maintain personal relationships and engage in social activities? (including leisure, cultural and spiritual activities)		
How often do you need support?		
Making use of necessary facilities or services in the local community (including public transport, and recreational facilities/services)	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Work, training, education and volunteering (based on typical week)	
Includes the eligibility outcome: Accessing and engaging in work, training, education or volunteering	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
What current paid employment or voluntary work do you do?		
What education/training are you currently doing?		
What would you like to improve or change about your involvement in work, training, education or volunteering?	
Details of your needs and what you would like to achieve (work, training, education or volunteering):      	
What help do you need to participate in work, training, education and volunteering?		
How often do you need help?		
Accessing and engaging in work, training, education or volunteering	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Caring for others (based on typical week)	
Includes the eligibility outcome: Carrying out any caring responsibilities for a child	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Do you have any children that are dependent on you?	Yes  		No  		
If ‘Yes’, do you need support with your parenting/caring responsibilities?	Yes		No  		N/A  		
Details of your needs and what you would like to achieve (caring for children):      	
Carrying out any caring responsibilities for a child	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Do you have any other caring responsibilities?	Yes  		No  		
Details of your needs (caring for other adults):      	
If you are providing care or support to other adults, you should be offered a carer’s assessment to discuss your caring role.	
Staying safe at home (based on typical week)	
Includes the eligibility outcome: Being able to make use of your home safely	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
What help do you need to stay safe at home during the day?(consider risk of falls and/or wandering, and responding to emergencies)		
What help do you need to stay safe at home during the night? (consider risk of falls and/or wandering, and responding to emergencies)		
Details of your needs and what you would like to achieve (making safe use of your home):      	
Being able to make use of your home safely	Can you do this alone within a reasonable time and without significant pain, distress, anxiety, or risk to yourself or others?	Yes    	No     	
Risks (based on typical week)	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
What are your current risks of falls?		
What are your current risks of self-neglect causing deterioration to your health/safety?		
What are the current risks of harm to yourself? (e.g. self-injury)		
What are the current risks of harm/injury to your carer? 		
What are the current risk of harm to others/property?		
Details of risks:      	
If there are concerns about your safety, a risk assessment may be needed (we will follow local Safeguarding Adults guidelines).	
Your mental health and wellbeing (including mental wellbeing issues arising from physical conditions)	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Do you or have you ever suffered from a serious mental health issue?	Yes  		No  		
Have you had contact with mental health services in the past year?	Yes  		No  		
Details:      	
How are you feeling?		
Details of your needs (emotional wellbeing):      	
Do you have any concerns with your memory or orientation?		
Do you need any help with planning and decision-making?		
Details of your needs (memory/orientation, planning and decision-making):      	
Do you have behaviours affecting self or others?(e.g. aggression, self-harm)		
Does your mood or behaviour impact on the support you get from others?		
Details of your needs (behaviour affecting self or others, impact of mood/wellbeing on acceptance of support):      	
Does the help you get reduce your mood/ behaviour towards others around you and reduce risks to you and them?		
Details:      	
If you have mental health issues, you may need a specialist assessment or referral for e.g. a mental capacity assessment.	

Health conditions and disabilities that impact your wellbeing	
Please list your disabilities, impairments & health conditions in order of most to least impact on your daily life and wellbeing:	
1		
2		
3		
4		
Details (including relevant medical history):      	
How often do your needs significantly change/vary due to your condition(s)?		
Details:      	
Details of any sensory impairment(s) (based on typical week)	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Does any sensory impairment affect your typical week?		
Details of your needs (sensory impairment):      	
If you have a significant sensory impairment, you may need to be referred for a specialist sensory assessment.	
Your medication and symptoms (based on typical week)	
Answer as if there is no support currently in place, but do consider the effect of existing equipment, adaptations or telecare.	
Are you currently taking any prescribed medication?	Yes  		No  		
If ‘Yes’, what help do you need with taking or applying medication?	Help needed: 	
	How often do you need help? 	
Details of your needs (medication):      	
Does your physical condition or any medication that you are taking cause you distress or pain?		
Are you getting adequate relief from pain or other distressing physical symptoms?	Yes  		No  		
Details of your needs (managing distress/pain from health conditions):      	
If you have needs in relation to medication, arrangements may need to be made for a review or an appropriate referral.	
Do you have any difficulties with breathing? 		
Do you need equipment to help you to breathe?		
Details of your needs (breathing):      	
Do you have any difficulties maintaining consciousness?
(e.g. due to epilepsy, seizures, blackouts)		
Details of your needs (maintaining consciousness):      	
Support you will receive on an ongoing basis from family/friends/volunteers (based on typical week)	
Details of support you currently receive from family, friends or volunteers (including what’s working well and not so well)	
     

Will you receive ongoing support from family, friends or volunteers?	Yes  		No  		
If you will receive no support from family/friends/volunteers, the rest of this section does not need to be completed.	
Who keeps your home clean and safe?		
Who manages your paperwork and finances?		
Who helps with shopping for your food/essential items?		
Who helps prepare your meals/snacks/drinks and helping you to eat and drink?	Mornings: 		
	Daytimes: 		
	Evenings: 		
Who manages your personal care tasks?                      (using toilet/managing continence, washing, dressing/undressing)	Mornings: 		
	Daytimes: 		
	Evenings: 		
Who helps you with your medication?	Mornings: 		
	Daytimes: 		
	Evenings: 		
Who supports you to access social, leisure, cultural and spiritual activities?		
Who supports you to access work, training, education or volunteering?		
Who makes sure you stay safe during the day?	Mornings: 		
	Daytimes: 		
	Evenings: 		
Do you need help during the night and who does it?		
Other ongoing support	Escorting you or providing transport 		Helping you communicate with others		
	Providing company and emotional support		Helping you care for children		
Details of all ongoing support to be provided by family, friends or volunteers (where this is safe and can be sustained) 	
     

Are there any people in particular who provide you with a high level of support?	Yes  		No  		
If ‘Yes’, your carer(s) should be offered a joint or separate carer’s assessment to discuss their caring role(s).	
Do you think that the care you receive impacts on the your main carer’s independence?		
Are arrangements in place to support you if your main carer(s) are ill or unavailable?	Yes		No		
Details of impact and arrangements:      

FACE Joint Carer’s Assessment Supplement                                                                                          	

Name:	
     	
Gender:	

Date of birth:	
     	
Age band at time of assessment:	

Impact of your needs on your wellbeing	

As a result – is there, or is there likely to be, a significant impact on your wellbeing?	
N/A  	
Yes  	
No   	

The impact on your wellbeing 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 your wellbeing (in the absence of any support 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:      	

Further details (to be completed by a social care authorised person, where relevant)	
Are full breaks (through the year) required to sustain the ongoing caring situation?	Yes		No  		N/A  		
Primary support reason		
Anticipated living situation		
Number sharing support in anticipated living situation		
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 and/or your representative(s) to prepare a care and support plan when all of the following statements apply:

1.	Your needs arise from or are related to a physical or mental impairment or illness.

2.	As a result of your needs you are unable to achieve two or more of the eligible outcomes below.

3.	As a result of being unable to achieve these outcomes there is, or is likely to be, a significant impact on your wellbeing.	
Are there two or more eligibility areas indicated as ‘No’?	Yes         	No               	
Impact of your needs on your wellbeing	
If ‘Yes’ above, is there, or is there likely to be, a significant impact on your wellbeing?	N/A      	Yes         	No               	
The impact on your wellbeing 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 your wellbeing (in the absence of any support 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: