My Supported Self Assessment User Guide
Contents
1. We want to know about your mood Examples are if you feel worried or depressed suffer from low mood or feelings of hopelessness are withdrawn or feel angry a lot of the time Memory Orientation Tell us if you have problems remembering things from day to day short term memory or things from long ago long term memory If you sometimes forget where you are or what you are doing muddle up times of day lose track of the day or date or don t recognise people who know well Tell us how this affects your day to day life Planning and decision making Tell us if you need help to make decisions This includes large decisions about planning for your future like where to live and managing your finances and smaller day to day decisions for SSAQ User guide version 2 July 2013 8 example deciding what to do each day what to buy for shopping who to spend your time with Tell us in the comments box what type of decisions or plans you need support with My behaviour that affects me and others Tell us if there any things that you do that causes you or other people problems or puts people at risk of harm For example wandering hoarding letting strangers into your home leaving the gas on being aggressive or violent threatening people disturbing neighbours not accepting help from people when you need it etc Tell us more about this in the comments box Question 7 My social activities and relationships Please tell us if you nee2. s Services team for advice Call 020 7527 7400 Question 10 The help I get from family friends neighbours and the voluntary sector These questions are about help you get from friends or family who are not paid to do this If you employ a family member via the direct payments scheme do not record the support they provide here If you do not receive any help from friends and or family please tick NO in the first section and go straight to the end of the form to add your signature Please tick the box that most closely matches your situation For example if a friend or family member helps you get dressed in the morning five days a week and you need help from paid carers two days a week tick have about 75 of the support I need in the Personal care in the morning section If the kind of support they provide changes every day then just make your answers about your average day Please tell us about the support your relative or friend is going to continue giving you as an ongoing arrangement For example if your friend is helping you at the moment but can t continue to do this in the near future don t tick that they provide all of the support that you need as this is not an ongoing arrangement SSAQ User guide version2 July 2013 10 If you are able to manage the task by yourself and or prefer not to have help with this task please tick am able or prefer to manage independently
3. ISLINGTON www islington gov uk My Supported Self Assessment User Guide This is a step by step guide to filling out the My Supported Self Assessment form Filling in the My Supported Self Assessment form is an important part of the Choice and Control process It s a way for you to tell Social Services what help you need This guide explains the reasons we ask these questions and gives you some ideas to help you with your answers Get this guide in a different format Please contact the Access Service to receive this information in another format including large print audio file Easy Read or other languages The Access Service Calshot Community Care Centre 57 Calshot Street London N1 9XH Telephone 020 7527 2299 Email access service islington gov uk Minicom 020 7527 1900 SSAQ User guide version 2 July 2013 1 Contents Introduction Page 3 Getting more information Page 3 What to tell us about when filling in this form Page 4 The My Supported Self Assessment form Step by Step My details and how to contact me Page 5 Consent to share information Page 5 My disabilities and health needs Page 5 Question 1 My personal care Page 6 Question 2 Eating and drinking Page 7 Question 3 Taking medication or using health aids Page 7 Question 4 Maintaining my home Page 7 Question 5 Staying Safe Page 8 Question 6 My emotional health and well being Page 9 Question 7 My social activities and relationships Page
4. If you have equipment or an adaptation to support you and you do not need someone to help you use the equipment then record this as not needing help from someone For example if you have a bath seat and this means you can heave a bath without help answer this as not needing help with washing and bathing You can tell us more about your personal care in the comments box provided SSAQ User guide version 2 July 2013 6 Question 2 Eating and drinking These questions are about things like making meals drinks or snacks getting help with eating and drinking and remembering to eat Tell us about anything that makes eating and drinking hard for you or stops you wanting to eat or drink Tell us if you have been losing weight or putting it on Is there special food you need to eat for health cultural or religious reasons Please write more details in the comments box Question 3 Taking medication or using health aids Tell us if you need help to take tablets medicines injections or use health aids Health aids are things like inhalers nebulisers oxygen hearing aids patches etc Please tell us how often you need this help in the next box Tell us in the comments box if you need to be prompted to take your medication or if you need physical help Question 4 Maintaining my home These questions are about help you may need with things like shopping laundry cleaning changing bed sheets blankets paying bills dealing
5. 10 Question 8 Work Education and training Page 10 Question 9 Looking after children other dependents and pets Page 10 Question 10 The help get from friends family neighbours or volunteers Page 11 Question 11 My caring role Page 12 The last page Declaration Page 12 What happens next Page 13 SSAQ User guide version 2 July 2013 2 Introduction The My Supported Self Assessment SSA is the form you use to tell Adult Social Services about your support needs It s for people who live in their own home in the community It s not for people who live in a residential or care home We will use your answers to work out what support you need and how much money is needed to pay for your support This is called a Personal Budget You can fill in the SSA on your own or with help from someone you trust like a family member a friend a social worker or an independent support broker For information on independent support available contact the Access service or look at the website http www islington gov uk services social care health managing paying transforming social _care supportbrokerage local_brokers Pages defau de aspx If you re not able to make decisions by yourself another person acting in your best interests can answer the questions with or for you As well as filling in the SSA you need to fill in a Financial Circumstances Form FCF so we can work out if you need to pay any of your own money towards your
6. July 2013 11 The last page This is a legal document so it is important that you are sure about the information you have put in the form If you have any questions talk to your social worker or call the Access Service on 0207 527 2299 You need to agree that the information in the form is true Putting your signature on the form means you agree with the answers on the form If you can t sign the form please ask someone you trust to sign it for you What happens next 1 When you have filled in the form please give it to your social worker or support advisor Or if you do not have an allocated worker send it to Access Service contact details are on page 2 2 Your social worker or support advisor will meet with you to let you know if you qualify for help from Social Services and to talk about what support you need This might include meeting with you and with another professional like an occupational therapist or nurse to talk about your needs 3 Islington s Council s eligibility criteria is based on the Department of Health s Guidance on Eligibility Criteria for Adult Social Care England 2010 You can get more information about this at http www islington gov uk services social care health older people assessing needs Pages eligibility aspx or from your social worker 4 We will return the form to you with a summary of your eligible needs and we will tell you what your estimated budget will be 5 Onc
7. Question 11 My caring role This part of the assessment is for your relative or friend who helps you the most unpaid to complete i e the person who is providing you with the support as outlined in the question above Please ask them to tick the box that is closest to their situation How does their caring role affect them Do they need a break from their caring role This is sometimes known as respite This may be on a regular weekly basis or they may need longer breaks during the year Respite should be a positive experience for both you and your carer so at your support planning stage you will need to discuss with your carer how they will spend time away from their caring duties either with you or separately If they do not need a break please tick No break is needed wanted They may be entitled to their own assessment called a Carer s Assessment This is a chance for them to tell us about their caring role and how it affects their daily life The assessment can be done privately they do not have to share anything they tell us with the person they care for They may be able to get a personal budget in their own right Please talk to your social worker and or contact the Access Service about a carer s assessment contact details are on the front page Carers can also get help and advice from Carer s UK Call 020 7378 4999 or look at the website at www islingtoncarershub org uk SSAQ User guide version2
8. personal budget If you have not received an FCF and or a copy of the booklet explaining how these are worked out please call the Income Assessment Team on 020 7527 3417 to request them They can assist you over the phone and or arrange a home visit to help you complete the FCF if needed Getting more information You can get more information about My Supported Self Assessment including help to fill out the form personal budgets and Choice and Control from e Your social worker if you have one e www islington gov uk choiceandcontrol or e The Access Service Calshot Community Care Centre 57 Calshot Street London N1 9XH Telephone 020 7527 2299 Email access service islington gov uk Minicom 020 7527 1900 SSAQ User guide version 2 July 2013 3 What to tell us about when filling in the form What help you would need if no one was there to help you It s important to tell us what help you would need if no one was available to help you even if you get help at the moment from carers family or friends You will be able to tell us about the help you get later on in the form If you need more or less help Tell us if you need more or less support than you are getting at the moment Needs that change from day to day If the kind of support you need changes every day then just make your answers about the support you need on an average day i e the average between your best and worst days Equipment that makes you indepe
9. d help to be able to get out to do things and visit friends and relatives or help staying in touch with relatives Do you need someone to help you use the phone for example Tell us if you need help to get to your place of worship or other places you like to visit like a gym day centre shopping centre on outings etc Tell us in the comments box if there things that stop you doing this such as problems with seeing hearing speaking your memory or difficulties moving about or using transport Please tick the box that best matches your current situation Tell us how often you need help to take part in social activities We measure this in half days week Question 8 Work education and training Do you need help to access employment or training If so how much support do you need Please tick the most relevant boxes If you need support accessing work or training tell us how many half days week you need Question 9 Looking after children other dependants Please let us know if have children under 18 that you look after or if you care for a disabled adult by ticking yes or no to this question SSAQ User guide version 2 July 2013 9 Please tell us more about your parenting and or caring roles and if you need support with this in the comments box Tell us if you have trouble finding good support for your child or the adult you look after If you re worried about a child you care for contact the Children
10. e you know what your estimated personal budget will be you can move onto thinking about how to arrange your support Your social worker or support advisor will tell you more about this at the time This is the end of the guide SSAQ User guide version 2 July 2013 12
11. g you first This is usually because you may be in danger and we need to protect you We will always tell you what information we have shared and who it was shared with as soon as possible My health conditions and impairments Please let us know about your health problems and or any physical or sensory impairments SSAQ User guide version 2 July 2013 Please answer the next set of questions by ticking the box on the form that most closely fits with your situation You can add more information in the comments boxes below each question If you need more space for comment there is space on the back page of the form Question 1 My personal care These questions are about things like being clean getting washed dressed or undressed using the toilet or incontinence pads brushing your teeth and looking neat and tidy Please tick the boxes that best describe your situation and how you manage or would manage if there is no one to help you If the amount of help you need changes regularly base your answer on your average day Dressing and Grooming Tell us about any help you need with dressing grooming e g shaving hair care skin care nail care glasses contact lenses etc Toileting and maintaining my continence Please tell us what help you need and how often you need help by ticking the relevant box Washing my whole body Please tell us what help you need and how often you need help by ticking the relevant box
12. ndent If you have a piece of equipment or an adaptation to support you like rails or a bath seat and you do not need someone to help you use the equipment then record this as not needing help from someone More information Each question has a comments box where you can give us more details and information to add to your answer This will help us get a good picture of what support you need SSAQ User guide version 2 July 2013 4 The My Supported Self Assessment form step by step My details and how to contact me Please fill this section as fully as possible with your full name address date of birth and contact details Consent to share information Social Services may need to share the information you have put in this form so that we can arrange support for you We may share it with other council staff or NHS staff or agencies that provide support We need your agreement to share this information To agree tick the YES box If there is some information you do not want us to share or if there are people or organisations you do not want us to share information with tick YES BUT WITH LIMITATIONS and write in the details If you tick NO we will not be able to process your assessment or provide you with any support Tick the UNABLE TO CONSENT box if you are filling out the form for someone who cannot agree for themselves and write in the details box why not Sometimes we have to share information without askin
13. with letters and maintaining your home and garden Tell us what things you find difficult and why Please tick the boxes that best match the amount of help you need Question 5 Staying safe These questions are about any dangers you may face in your daily life Examples include hurting yourself when cooking falling over at home and outside or on stairs going out at the wrong times or getting lost forgetting to take your medicine hurting or not caring for yourself SSAQ User guide version 2 July 2013 7 We also want to know if you are at risk from other people who might treat you badly or spend your money without your agreement Please tick the boxes that best match the amount of support you need Staying safe during the day Tell us how many times in the daytime approximately 7am 10pm that you need help to stay safe e g you may need someone with you when you are cooking 3 times a day or you may need someone to check on you twice a week Staying safe during the night If you need help during the night approximately after 10pm to 7am please tick the box that best matches how much help you need Please tell us why you need this help e g you are epileptic and have unpredictable fits and may need help in the night to deal with this Question 6 My emotional health and well being Please tell us if your emotional health makes life difficult for you and explain in the comments box what effect it has Emotional well being
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