Home » Effective assessments and outcome-based support planning KSS 6

Effective assessments and outcome-based support planning KSS 6

Last updated: 15 February 2021

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This page sets out the knowledge and skills listed under point 6 (effective assessments and outcome-based support planning) in the Department for Health and Social Care’s knowledge and skills statement. Against this, we have mapped Community Care Inform Adults’ guides, research, learning tools and other resources to help social workers meet and evidence this part of the statement. The links to the resources are in blue; click to follow them to the page you’re interested in.

What the statement says	Resources to help you
• In undertaking assessments, social workers must be able to recognise the expertise of the diverse people with whom they work and their carers and apply this to develop personalised assessment and care plans that enable the individual to determine and achieve the outcomes they want for themselves. The social worker must ensure the individual’s views, wishes and feelings (including those who may lack mental capacity) are included as part of their full participation in decision making, balancing this with the wellbeing of their carers. • Social workers should demonstrate a good understanding of personalisation, the social model of disability and of human development throughout life and demonstrate a holistic approach to the identification of needs, circumstances, rights, strengths and risks. • In particular, social workers need to understand the impact of trauma, loss and abuse, physical disability, physical ill health, learning disability, mental ill health, mental capacity, substance misuse, domestic abuse, ageing and end-of-life issues on physical, cognitive, emotional and social development both for the individual and for the functioning of the family. • They should recognise the roles and needs of informal or family carers and use holistic, systemic approaches to supporting individuals and carers. They should develop and maintain knowledge and good partnerships with local community resources in order to work effectively with individuals in connecting them with appropriate resources and support.	Guide to conducting effective assessments examines how to use a strengths-based, person-centred approach during assessments to ensure they are focused on outcomes. Guide to care and support planning covers how to meet your legal duties and gives advice on overcoming challenges in support planning. Guide to self-directed support and personal budgets explains the core skills needed to work with someone using self-directed support, and the challenges that practitioners face in doing so. Assessment: using narratives to improve outcomes covers what is meant by narrative in the context of practice with older people, how to use narratives in assessment, safeguarding work, when working with adults with dementia and to support older people through transition, loss and change. Dementia: guidance on assessment, care planning and review provides information on how to build the holistic model of dementia into assessments and reviews to ensure a strengths-based approach, using dementia-friendly communication, and the challenges facing carers of adults with dementia and how to support them. Using attachment theory to work with adults explains how using an adult attachment interview can help improve assessments and outcomes. Using trauma-informed approaches to work with adults explains the different types of trauma and the physical, emotional, cognitive and behavioural effects they can have, plus the key principles behind a trauma-informed approach and how to put them into practice. The trauma knowledge and practice hub contains all our content on trauma including guides, webinars and podcasts. Working with adults with an acquired brain injury (ABI) looks at what should be taken into consideration when assessing someone with a suspected or diagnosed acquired brain injury. Supporting carers in end-of-life care contains advice on how to: communicate sensitively and effectively with carers who are caring for someone approaching the end of their life; apply the law on assessment, support planning and review to support carers at this difficult time; and support carers as the condition of the person they care for deteriorates. Guide to end-of-life care covers the social work role in the physical, emotional and spiritual care of people who are dying, the effects of bereavement on families and how you can support them, and the implications for end-of-life care of the Mental Capacity Act and Deprivation of Liberty Safeguards. Older carers: lessons from research looks at the impact caring has on older people’s physical and mental health and financial situation, and how social workers can best support them, as well as carers’ experiences of assessments under the Care Act.

What the statement says

Resources to help you

• In undertaking assessments, social workers must be able to recognise the expertise of the diverse people with whom they work and their carers and apply this to develop personalised assessment and care plans that enable the individual to determine and achieve the outcomes they want for themselves. The social worker must ensure the individual’s views, wishes and feelings (including those who may lack mental capacity) are included as part of their full participation in decision making, balancing this with the wellbeing of their carers.

• Social workers should demonstrate a good understanding of personalisation, the social model of disability and of human development throughout life and demonstrate a holistic approach to the identification of needs, circumstances, rights, strengths and risks.

• In particular, social workers need to understand the impact of trauma, loss and abuse, physical disability, physical ill health, learning disability, mental ill health, mental capacity, substance misuse, domestic abuse, ageing and end-of-life issues on physical, cognitive, emotional and social development both for the individual and for the functioning of the family.

• They should recognise the roles and needs of informal or family carers and use holistic, systemic approaches to supporting individuals and carers. They should develop and maintain knowledge and good partnerships with local community resources in order to work effectively with individuals in connecting them with appropriate resources and support.

Guide to conducting effective assessments examines how to use a strengths-based, person-centred approach during assessments to ensure they are focused on outcomes.

Guide to care and support planning covers how to meet your legal duties and gives advice on overcoming challenges in support planning.

Guide to self-directed support and personal budgets explains the core skills needed to work with someone using self-directed support, and the challenges that practitioners face in doing so.

Assessment: using narratives to improve outcomes covers what is meant by narrative in the context of practice with older people, how to use narratives in assessment, safeguarding work, when working with adults with dementia and to support older people through transition, loss and change.

Dementia: guidance on assessment, care planning and review provides information on how to build the holistic model of dementia into assessments and reviews to ensure a strengths-based approach, using dementia-friendly communication, and the challenges facing carers of adults with dementia and how to support them.

Using attachment theory to work with adults explains how using an adult attachment interview can help improve assessments and outcomes.

Using trauma-informed approaches to work with adults explains the different types of trauma and the physical, emotional, cognitive and behavioural effects they can have, plus the key principles behind a trauma-informed approach and how to put them into practice.

The trauma knowledge and practice hub contains all our content on trauma including guides, webinars and podcasts.

Working with adults with an acquired brain injury (ABI) looks at what should be taken into consideration when assessing someone with a suspected or diagnosed acquired brain injury.

Supporting carers in end-of-life care contains advice on how to: communicate sensitively and effectively with carers who are caring for someone approaching the end of their life; apply the law on assessment, support planning and review to support carers at this difficult time; and support carers as the condition of the person they care for deteriorates.

Guide to end-of-life care covers the social work role in the physical, emotional and spiritual care of people who are dying, the effects of bereavement on families and how you can support them, and the implications for end-of-life care of the Mental Capacity Act and Deprivation of Liberty Safeguards.

Older carers: lessons from research looks at the impact caring has on older people’s physical and mental health and financial situation, and how social workers can best support them, as well as carers’ experiences of assessments under the Care Act.

Effective assessments and outcome-based support planning KSS 6

Links to resource maps for other parts of the KSS: