Essential insights for effectively communicating your narrative in the adult social care self-assessment: resources

John is a 46-year-old man who lives alone. He was signposted to Central Hub in October 2021 by the Hartlepool and Stockton Health Social Prescribing Team.

The social prescriber shared that John had no real friends and was struggling with both his physical health and mental wellbeing. The initial good conversation with a community navigator revealed that John had no close friends and was estranged from his family. He had experienced a difficult childhood and believed that this affected his ability to cope as an adult with anything stressful. John said he was lonely and admitted feeling really low; he had been to counselling services in the past but didn’t feel that this had helped him much. John was having problems managing his finances and had difficulty making any decisions as his bouts of depression and anxiety overwhelmed him, and he felt he has lost all of his self-confidence. John said he needed help to sort out utility issues at home, as he just did not know what to do or where to get any help.

Since connecting with a community navigator in the hub, John has been helped in a number of ways. He has been introduced to and accompanied to appointments with partners who have been able to offer him support. He has received financial advice from the Citizens Advice Bureau, Advice at Hart, and the council’s welfare support team. He has joined The Bread and Butter Thing food membership scheme to buy food at substantially reduced cost. The digital navigators have connected him to online opportunities and with the support of a community navigator, John has worked with the Housing Company who have now carried out repairs to his property.

In February 2022, with the support of the hub and its partners, John made his PIP application and in March 2022 John called into the hub to share that he is ‘over the moon’ his PIP application had been awarded. He said he’s so grateful for the support from the Hub. He stated he’s feeling much better in himself and even suggested that he could get back to cycling as he used to enjoy this and knows it would be good for him.

In September 2022 John talked to the community navigator about how he was feeling more confident and wanted to have more purpose in his life. John is interested in finding out whether there are any training courses that he could access to kick start a change of direction.

John continues to pop into the Hub to have further chats and has built up a good rapport with the team. He is looking visibly much better, smiling more and gives eye contact when chatting, John’s general demeanour is lighter and much more relaxed. 

Laurence was referred for reablement support with a phased return home from 24 hour care. Laurence was residing in a residential care home and was keen to return home. He has a diagnosis of Lewy Body Dementia which has an effect on his mobility. Amanda supported Laurence to go home on several occasions, once with input from an OT, to see how he would manage with the steps outside his property and also the stairs. It was identified by the OT that it would not be safe for L to return home.

Amanda arranged for Laurence to access the rehab flat for a period of two weeks to better assess his functional skills. With daily input from the reablement team he moved into the rehab flat in August 2023 and it was really successful. Laurence was independent with most daily living tasks and was accessing communal areas and social groups. He has since committed to purchasing a part ownership extra care housing property within the Hartfields. He moved into his new home in September 2023 with continued support from the reablement team to help him settle in.

Reablement support has enabled Laurence to live independently in his own property and not remain in a 24 hour care setting. Laurence is accessing communal areas safely and independently within Hartfields and is considering further support to access the wider community safely. He has expressed his gratitude for the support as he feels that he would have had to remain in 24 hour care if this had not been provided.

Barbara was referred to the reablement team for support to return home after a stay in a care home following an admission to hospital with a broken knee. Barbara had been in hospital earlier in the year after breaking her other knee. On that occasion she was discharged to intermediate care and the day she returned home she fell and broke her other knee.

As a result of the two successive injuries, Barbara was extremely about transferring and mobilising without support despite having been assessed as being able to do so. Chloe supported Barbara home to assess how she would manage. Unfortunately Barbara couldn’t negotiate the front step into her property so returned to the care home. Chloe supported Barbara daily for 6 weeks to walk up and down the corridor and build on mobility, strength and confidence and a referred her for a physiotherapy assessment regarding negotiating steps. Barbara was able to negotiate one small step with walking aids but her home step could not be adapted to suit as it was a communal step as part of a block of flats. As a result it was not safe for Barbara to return to her own property.

Alternative housing options were discussed and considered including sheltered accommodation and extra care housing. Barbara also considered moving in with her daughter which would require installation of a stairlift. A MDT meeting was held involving the reablement team, Social Worker, Barbara and her family and it was agreed she would access the rehab flat to allow a full functional assessment to be completed and to maximise skills and independence to inform long term care planning. At the same time the feasibility of a stairlift being installed in her daughter’s property was completed. Unfortunately it wasn’t feasible to install a stairlift in the property.

A further MDT Meeting was held involving the reablement team, OT, carers who had supported Barbara in the rehab flat, Barbara and her family to discuss outcome of OT assessment. It was confirmed that Barbara would not be able to move in with her daughter due to being unable to install a stairlift and there being no suitable downstairs living space. While the OT assessment was ongoing Barbara was being supported by Chloe who visited daily to build her confidence and maximise independence with daily living skills. Barbara made good progress and was managing to prepare own hot drinks and snacks but continued to require support with preparing main meals. Barbara is very private and was tending to her personal hygiene independently. Due to her confidence increasing significantly while being supported within the rehab flat she then decided she would like to live independently but within the protective environment provided by extra care housing. After in the rehab flat Barbara was allocated a property within Hartfields. Her move was supported by the reablement team and she now lives in her own home with paid support and informal support from her family – an outcome she is very happy with.

‘C’ is a 60-year-old black woman who migrated from Congo. Her first language is French, and she is passionate about her culture. C’s assessment involved an interpreter and concluded that chronic pain had limited her independence and led to social isolation.

C’s local church community was identified as an asset, providing support with communication, shopping and meal preparation. As well as referrals for equipment and physiotherapy, C was supported to access a range of support organisations including North Herts African-Caribbean Community group, with arrangements underway to identify a personal assistant who speaks French, to be funded by a direct payment.

Auditor quote: “The worker has searched thoroughly and explored all possible avenues in order to source care that meets the individual’s wishes, cultural and language needs.”

The Festival of Practice, now in its 7th year, is an important learning opportunity, with high profile speakers at the forefront of social care thinking across a week-long programme of lectures and events. The festival is open all health and care professionals in Hertfordshire, making it an excellent recruitment advert for Hertfordshire and generating interest on social media.

Lyn Romeo, Chief Social Worker for England and Festival keynote speaker has said ‘the festival was an inspiring demonstration of Hertfordshire’s commitment to development of its practice and its team and partner organisations.’

The majority of staff in our evaluation surveys say the festival has a positive impact on their practice. Other local authorities, NHS Trusts and Social Work England have followed suit, running the same offer.

A is a friendly, outgoing young woman who likes spending time with friends and family.

A has a learning disability and requires supervision and support to be as independent as she can be with managing her home, health, personal care, nutrition and getting out and about in the community safely. A lives in a flat in a complex which has an element of oversight and support attached

A can complete a lot of tasks on her own but she does need support in maintaining a routine. She has support in planning and preparing her meals and going shopping and recently prompts have been put in place to ensure that A showers and changes her clothes regularly. A cannot manage money on her own. A’s bills are managed by Hartlepool Borough Council who are appointee for A. She visits the Civic Centre weekly to collect money and is supported to budget. Understanding her money and budgeting is a big challenge for A and can be the focus of frustration for her, leading to her arguing with her support staff when she wants more money than she has or wants to use it for something that has not been budgeted for.

A was referred to community nursing for support with communication and managing her emotions particularly relating to her approach with staff in her home. A has had 1:1 sessions with her community nurse who has supported A in developing visual aids and a daily planner for her to complete with her support staff on a day-to-day basis. This means that A knows what she is doing every day, which staff will be supporting her, and how much activities are costing.

The community nurse also provided support to A in relation to boundaries and guidance to her staff team on how they should appropriately respond to A. Non-negotiable statements have been completed with A and the staff team so that staff have a consistent approach to A.

Friends are important to A and she likes to compliment people telling them they are gorgeous and beautiful and blowing them kisses. There have been occasions where this has led to people misunderstanding A’s intentions. The Social Worker and community nurse are working with A to help her build good healthy relationships with others. A’s relationships with family members particularly her brothers and sisters are important to her and she needs support to maintain these relationships.

A has two volunteering placements – one in a charity shop and one in the Town Hall Theatre as an usher.

A – Evaluation summary

A is a young woman who strives to be as independent as possible. She comes from a large family and has 10 siblings. Some of A’s brothers and sisters are children in our care and the social worker recently identified that A’s contact with her brothers and sisters had reduced as A is not able to arrange this herself. The social worker has worked with children’s services and A’s support provider to ensure A is added to the family’s What’s App group so she can keep in touch. Because of this, A has now met up with family members for a coffee and the support provider will ensure that contact continues. A, with support from her social worker, attended the People, Power of Purpose (PPP) course in 2023. A really thrived and came to life, making new friends and contacts as the course progressed. She was clear that she wanted to work in a theatre and was supported as part of the course to start volunteering as an usher at the Town Hall Theatre.

A developed her CV, researched the role and practiced the role in the venue. She had an interview with Max at the Town Hall Theatre and then with support, went and bought her ‘uniform’ of black trousers, top and shoes This led to A hosting the final graduation ceremony, showing people to their seats and doing the housekeeping and making sure people turned their phones off! It should be noted that A has some difficulties with her speech so for her to master a public speaking role at the graduation with 100+ people present gave her and her fellow graduates a massive sense of achievement. A’s self-esteem grew and her pride when her dad and family turned up was immense. The focus on the importance of looking smart and tidy in her job as an usher along with the additional support the Social Worker put in place has helped A to take pride in her appearance and accept support to shower and put on clean clothes.

A is now spending more time in the community, volunteering and keeping in touch with her friends and family.

A is happy and proud of what she has achieved and wanted to share this photograph* of her with her colleagues at the Town Hall Theatre.  

J has always been an active woman with a busy job. She enjoyed travel, with a particular love of Greece where she has a second home. J has a diagnosis of vascular dementia and Alzheimer’s. The first contact with the council was from J’s sister who was worried when J got lost returning from Greece. J was well supported in the community by her sister, neighbours and friends and that support continued until May 2023 when her sister made contact again to advise that her health had declined and she was struggling to support J whose mental health was declining as well.

The Social Worker completed an assessment in May 2023 and home care support and telecare were put in place to promote her safety and independence at home. J managed reasonably well with two daily homecare calls and a weekly domestic call until January 2024, although the level of care provided did fluctuate over the period as J’s needs and willingness to have support from care staff changed. In January 2024 J began to show significant signs of confusion which increased risks to her wellbeing and a reassessment was completed on 25 January 2024. The assessment indicated a number of concerns around J’s ability to keep herself safe at home and in the community. J had been reported missing to the police and was found driving around the North East after saying that she wanted to get to Greece. There were also reports that she had not secured her property when going out. J was not able to identify when she was not feeling well and that had led to infections not always being noticed.

At the time of assessment, J believed that she was able to manage her daily needs and was reluctant to accept support from care staff which contributed to infections going unnoticed. J’s health had declined and she was diagnosed with suspected cellulitis and a urine infection. It was because of the decline in her physical health that J accepted an emergency placement in residential care.

Whilst preparing to move into the residential home, it became evident that J was struggling more than had been realised. Packing her bag took a lot of prompts and direction.

The move into a short-term placement was identified as being required to ensure J’s safety whilst recovering from infections and allowing for further assessments to take place to identify her long term needs. J has been assessed as lacking capacity in relation to her care and accommodation and has a Deprivation of Liberty Safeguard in place. J has an independent RPR who she has developed a good relationship with. J has also been assessed as lacking capacity in relation to her finances and her sister is applying for deputyship through the Court of Protection.

J – Evaluation summary

J had never married or had children. She has a really close relationship with her sister, nieces and cousins. She had a career as an environmental health worker and had worked in a number of places across the country. J liked to travel and she had previously lived in Greece for 5 years where she taught English for speakers of another language. J has stayed a fan of Greece and has a holiday home there.

J knows that she has a diagnosis of dementia and Alzheimer’s but does not have any insight into that diagnosis and the impact that this has on her ability to manage on her own. Even without insight into the impact of the diagnosis it does makes her fearful of her future and she worries about what will happen to her. J wants to be able to do the things that matter to her and the Social Worker supported J to remain in the community for as long as possible.

Whilst J was admitted into 24 hour care on a short-term placement, the Social Worker undertook a comprehensive assessment including involvement from the care home staff, Community Dementia Nurse and OT. The Social Worker, with involvement from J’s sister and the professionals that knew J well, completed a Balance Table of benefits and burdens to explore the options for J in regard to her care and accommodation needs in the short and long term. The balance table was presented by the Social Worker to the Adult Risk and Resource Panel. The options considered were: for J to return to her home; for J to move into an extra care scheme; or for J to remain within a 24 hour residential care setting.

The Balance Table demonstrates the consideration the Social Worker gave to each option all underpinned by J’s desire to remain independent. The process recognised the risks to J while focusing on ensuring least restrictive practice. The Social Worker acknowledges that it was a really difficult decision for her to advocate for J to move into 24 hour care as she recognised the restrictions this would place on J. However when she considered the option of J returning home with live-in 24 hour 1:1 support and oversight, she felt that would be more restrictive as J has never lived with someone in her home. J has more freedom in the care home and the Social Worker continues to promote J’s independence.

The staff in the care home work sensitively with J as she often believes she is a worker in the home and not a resident. The staff encourage this as they recognise it gives J a sense of purpose which in turn promotes her wellbeing.

The Social Worker has worked with J’s sister and the care home staff to bring some of J’s furniture to her room and she is choosing her own decoration. J’s room has been reorganised to create a relaxing seating area so she can still have her movie nights and take-outs with her nieces. Her cousin visits with her dogs who J loves and she has recently asked the Social Worker if she can go swimming again as she always enjoyed that. A Reablement Worker will be working with J and the care home to ensure that this happens.

The social worker has worked hard to try and mirror as much of J’s life at home in the care home as possible and involve her in decisions. This reflected in feedback from J who said that she feels listened to. J said “I can remember being involved with some decisions but I don’t always remember what they were.”

We will encourage staff to ‘step up to excellence’ as part of our improvement programme to deliver better services for residents by: 

• raise awareness of best practice for themes in the CQC Assurance framework 
• call on staff to make sure they can demonstrate best practice 
• invite staff to share examples of ‘best practice in action’ 
• support Heads of Service to understand our improvement journey and the requirements of the CQC, and provide assurance that staff are working safely, legally, and effectively.

• We are on an improvement journey with a renewed focus on our business processes, staff development and continual learning 
• You’re all already doing a great job, delivering good services already, but we need to evidence this
• We need to improve staff opportunities for regular development chats, learning or supervision 
• The LGA tells us 
  • we need to get more feedback from people and act on this 
  • we should work in partnership on key priorities like EEDI and co-production 
  • we can be better at collecting diversity data and delivering culturally competent car
  • we can do more to support unpaid carers 
    • pull together to be ready for CQC 
• the benefits of getting a good CQC rating include external recognition, easier recruitment, a workforce where everyone takes pride in what we do
• Step up to excellence

• Heads of service, adult care services 
• Team managers, adult care services
• Registered professionals in adult care services 
• HCC staff who work with adults in the 0-25 service in children’s services

All HCC staff who work in adult care services

In our Step up to excellence campaign, we will encourage staff to make sure that they can demonstrate that they are applying best practice and to double-check that all relevant policies, strategies and procedures in place and are up to date, taken from our CQC managers checklist. 

Each month we will focus on a different topic. We will produce easily accessible checklists, top tips and resources for staff to use that will help raise awareness of best practice in ten topic areas and communicate the actions that colleagues are expected to take for each topic to ‘step up to excellence’.

• Step Up to excellence ACS Assurance Checklist 
• communications calendar of monthly topics linked to the checklist. 
• for each topic, there will be: 
  • an ACS Leadership email from the PSW
  • weekly articles shared through various internal communications channels
  • five top tips
  • signposted links to related key resources.
• FAQs for CQC – when are they coming, why is it important, what role will I play, how are we preparing etc.

• ACS Leadership email from PSW – signpost to article 
• ACS Intranet article – monthly theme link to checklist and FAQs each time 
• weekly e-newsletter for ACS - ACS Weekly Update 
• monthly e-newsletter for ACS – ACS eBriefing 
• ACS Yammer 
• engagement events (e.g. AC.

Webinar series:

• Support for Carers and update on strategy
• Knowing your data 
• Assistive Technology 
• Legal workshop

Audience: All staff

Method: online

Staff development

• weekly stories
• five top tips
• links to resources e.g. iLearn, HR P&D pages

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, Sept 2023

Policy and procedures

• weekly stories
• five top tips
• links to resources e.g. policy pages on ACS intranet

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer Who and date: SR, FD and AW, Oct 2023

Strategies and plans

• weekly stories
• five top tips
• links to resources e.g. ACS Strategy docs

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update, ACS Yammer

Who and date: SR, FD and AW, Nov 2023

Complaints and compliments

• weekly stories
• five top tips
• links to resources e.g. eBriefing compliments page

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, Dec 2023

Practice

• weekly stories
• five top tips
• links to resources e.g. Connected Lives intranet pages

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, Jan 2024

Demographics and data

• weekly stories
• five top tips
• links to resources

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, Feb 2024

Feedback from people who access services

• weekly stories
• five top tips
• links to resources e.g. ACS Strategy docs

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, March 2024

Co-production

• weekly stories
• five top tips
• links to resources e.g. Co-production intranet/internet pages

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, April 2024

Partnership working

• weekly stories
• five top tips
• links to resources

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer

Who and date: SR, FD and AW, May 2024

Equality, equity, diversity and inclusion

• weekly stories
• five top tips
• links to resources e.g. EEDI intranet pages and tools

Audience: Staff in ACS and CS (0-25 Service)

Method: Promotion via ACS Leadership email from PSW, ACS intranet, eBriefing, ACS weekly email update and ACS Yammer