Adult Social Care Record (MODS): Adult Social Care Record (MODS) Implementation Guidance

Scenario:

Mr. Bodat (Subject of care) is a 73-year-old man (Date of birth), a widower (Marital status).

He was quite healthy until recently but is getting more and more health complaints (Problems, Needs) and social care needs (Needs). He lives in a complex home situation (Accommodation status, Environment, Circumstances).

For a week, he cannot not really move due to recent foot problems - he lives on the third floor of an old apartment building with only steep stairs (Problems, Needs). His days seem to become lonelier and lonelier, and neighbours from downstairs now rarely see him (Social circumstances, Needs). One neighbour (Personal contact) talked to a social care youth worker (Care worker) he met accidentally and mentioned the situation. The youth worker (Care worker) offered to refer (Referral) Mr. Bodat (Subject of care) to Adult Social Care for an assessment of his needs (Care needs assessment).

Goal:

To assess Mr. Bodat’s eligible care and support needs, and to commission a package of care which will meet those needs and allow him to continue living independently in his own home.

Assumptions:

The system needs to reconcile Mr. Bodat's eligible outcomes, as assessed under the Care Act, with his desired outcomes in terms of his ability to live a fulfilling life. The assessment may identify non-eligible needs which Mr. Bodat nevertheless would like to have met. The care provider and Mr. Bodat may agree on a slightly different set of priorities and outcomes for the care to be provided versus the care funded by the local authority. However, since Mr. Bodat cannot contribute any first-party top-ups to the cost of his care, the costs need to remain within the authority's funding envelope.

Process breakdown

Youth care worker acknowledges he is not responsible for care, but makes referral to Social Care for assessment (Referral) Emma, a Social Worker (Care worker), visits Mr. Bodat (Subject of care) and carries out a Care Act needs assessment (Care needs assessment) Emma assesses Mr. Bodat's wellbeing, health, selfcare abilities and social situation, and determines that he is eligible for care to be provided by the local authority (Care needs assessment) Caroline, a finance officer, visits Mr. Bodat to carry out a financial assessment to determine what if anything he will need to pay towards the cost of his care. His income and savings are below the relevant thresholds and the local authority will fund the full cost of meeting his eligible care needs (Out of scope) Caroline also makes an appointment for Mr. Bodat to speak to the Benefits Advice team at the council, as she believes he is eligible for more disability benefits than he is currently receiving due to his declining health (Out of scope) In parallel, Emma (Care worker) completes a care plan (Care and support plan) covering Mr. Bodat's (Subject of care) eligible needs (Needs). This includes a base unit (Device) providing medication reminders and a Lifeline alarm (Device), and two home visits a day (Task) to meet his personal care needs. Emma also puts Mr. Bodat in contact with a community group who offer a befriending service (Service), can help him get online (Task), and can do a weekly shop for him (Task). Once the care plan (Care and support plan) has been agreed (Agreed with person or legitimate representative) with Mr Bodat (Subject of care), Emma (Care worker) passes it to the Brokerage team to procure the home care elements (Out of scope) The package is picked up by a local provider (Social Care Provider), who sends Sue (Care worker) to visit Mr. Bodat (Subject of care) to get to know him and see what his situation is really like. Sue confirms the information received from the local authority, captures further details of his day-to-day needs (Needs) and completes the "About Me" record (About me). Sue is able to gauge for herself, as she talks to Mr. Bodat (Subject of care), that the information on the record is accurate in terms of his health, mobility, mental capacity and cognition (Needs)(Review) Mr. Bodat (Subject of care) tells Sue (Care worker) about his regular medications (Medication) - although he can administer them himself, he worries about forgetting to take his medication and about getting his repeat prescriptions (Risk) Sue (Care worker) returns to the office and updates the records. She discusses Mr. Bodat's (Subject of care) care needs (Needs) with her manager and they agree a more detailed care plan (Care and support plan) showing how his needs will be met within the time funded by the local authority. The manager assigns another worker, Andi , to be Mr. Bodat's care worker (Care worker)