2.4 Establishing Eligibility for Adult Social Care

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1. Principles

The Care Act introduced a national eligibility framework to establish a minimum threshold at which a person’s needs must be met by the local authority. The eligibility threshold is not based just on needs but considers whether the person can achieve specified outcomes and how this affects their wellbeing.

Eligibility can only be established following an assessment of the person’s needs. During the assessment, a preventative service or intervention such as reablement may be offered. This service may help reduce a person’s needs to the point at which they no longer require ongoing support. In this situation, the decision about eligibility should be delayed until the preventative intervention has taken place.

2. The Eligibility Criteria

Any person can approach Hull City Council for support. Some people will be provided with advice and information, but others will need the provision of services or money to buy services. The eligibility criteria are used by local authorities to decide which of a person’s needs it must meet.

For a need to be eligible it must:

1. Arise from a physical or mental impairment or illness;
2. Mean the person is unable to meet one or more of the outcomes specified in the Care Act;
3. Have a significant impact on the person’s wellbeing.

A person’s needs are only eligible if they meet all three of these conditions. It must be remembered that  the inability to perform a function will  impact people differently. For example one person may, as a result of a physical impairment, take an hour to dress in the morning and the effort involved leaves them exhausted and unable to go to work. That need would be eligible. Another person with the same impairment may take the same time to dress but then be able to go about their day in the usual way. That need would not be eligible.

2.1 Specified outcomes

The specified outcomes are:

1. Carrying out one or more basic care activities;
2. Staying safe at home;
3. Maintaining family or other significant personal relationships;
4. Accessing and engaging in work, training, education or volunteering;
5. Accessing necessary facilities or services in the local community;
6. Carrying out any caring responsibilities the person has for a child.

The person is regarded as being unable if:

1. They can’t do it without help;
2. They can do it but it causes significant pain, distress or anxiety;
3. They can do it but only at significant risk to their health and safety or that of others;
4. They can do it but it takes significantly longer than would normally be expected.

2.2 Carers

Carers can be eligible for services in their own right, regardless of whether the person they care for has eligible needs. There are two ways in which carers become eligible:

1. If they need support to enable them to carry on in their caring role;
2. If caring is having a significant impact on their wellbeing.

When assessing whether a carer is eligible for support to maintain their caring role, local authorities must consider:

1. Whether the carer is unable to carry out one or more necessary caring tasks without help;
2. The carer can carry out the tasks but doing so causes them or the person they care for significant pain, distress or anxiety, or it endangers their health and safety or that of the cared for person
3. Whether the carer is able to achieve the outcome without assistance but doing so is likely to endanger the health or safety of the carer or any adults or children for whom the carer provides care.

AND this means that:

1. The carer’s physical or mental health is deteriorating;
2. The carer cannot carry out some or all of their basic household activities;
3. The carer cannot carry out their caring responsibilities for a child;
4. The carer cannot provide care to other people for whom they provide care;
5. The carer cannot maintain family or other significant personal relationships;
6. The carer cannot maintain their home environment;
7. The carer cannot manage and maintain nutrition for them and their family;
8. The carer cannot engage in work, training, education or volunteering;
9. The carer cannot make use of necessary facilities or services in the community;
10. The carer cannot engage in recreational activities.

See also Carer’s Assessment and Self Assessment.

3. Assessing Eligibility and Sharing the Decision

Following assessment (which can be a self assessment, a supported self assessment or an assessment carried out by a worker), the information gathered  must be measured against the eligibility criteria  and a decision made about whether a particular need meets the eligibility threshold. This must be recorded and a copy of the record of decisions given to the person.

4. Appealing a Decision about Eligibility

If the person disagrees with the eligibility decision, they can appeal against it. The appeal will be considered by a manager who may appoint an worker who is independent of the original assessment and decision making process to examine all relevant information and reconsider the eligibility decision. If new information about the adult’s needs and the impact of those needs on their wellbeing becomes available, it must be taken fully into account. In some cases, the new information may be added to the original assessment and in others, it may mean a  reassessment is required.

5. Financial Assessment

Following a decision that a person  has eligible needs for care and support, a financial assessment must be carried out to ascertain whether the local authority will pay for some or all of that support.

The financial assessment may establish that the person must fund their own services but the local authority must provide or arrange them if the person asks it to.   See Charging and Financial Assessment.

6. Procedure steps