The Skilled Conversation (Carers)

Under the Care Act it is important that the carer's needs are considered within the context of their family network of support and not in isolation.  This is what is meant by a whole family approach.

Taking a whole family approach enables the Local Authority to:

1. Understand the role that family members have in supporting the carer and the person with care and support needs; and
2. Identify and support other carers (both these things are duties under the Care Act).

Taking a whole family approach also builds the resilience of families and increases the likelihood that a non-service led self-sustainable method of supporting the carer will be identified.

When taking a whole family approach you should consider involving the following people in the assessment:

1. Adult's living in the same household as the carer;
2. Children living in the same household as the carer;
3. Adults living elsewhere but who form part of the carer's support network;
4. Children living elsewhere but who form part of the carer's support network.

Specifically you need to understand:

1. How other family members are supporting the carer and whether this is sustainable;
2. Whether other family members are providing care to the person with care and support needs (specifically whether the role that other adults or children in the family have constitutes a caring role under either the Care Act 2014 or the Children and Families Act 2014);
3. Where other family members are identified as having a caring role, whether they are being supported in this role and whether it is sustainable.

Where there is an appearance of need in any other family member you have identified as a carer you have a duty to offer an assessment.

Any conversations with adult family members must give regard to the duty to provide good information and advice about adult Care and Support. This could be in relation to the needs of the person that the carer is supporting, in relation to their own apparent needs or in relation to another adult that they support or are concerned about.

You must also consider whether any prevention service would be of benefit to any adult family member you speak to, either to support them as a carer or in their own right. Where they appear to have a need for a prevention service themselves you should support them to access this service.

Where you take action to support another adult in the carer's family via a whole family approach you should make sure that you make appropriate and proportionate recordings for the action you have taken or the information and advice you have provided.

The Duty to safeguard children

Children are protected under different legislation to adults. Whilst you are not expected to understand children's legislation in your role you are expected to know your statutory responsibilities in relation to protecting children so that you can respond appropriately.

Things that you must consider in relation to all children living in the household:

1. Whether the child is taking part in any caring activities that may be inappropriate for their age, gender or that cause them physical difficulty or emotional distress;
2. Whether the adult with Care and Support needs presents with behaviours that place the child at risk of harm or abuse;
3. Whether the child is at risk of neglect because the adult with care and support needs has caring responsibilities towards them that they cannot adequately meet as a result of their own needs;
4. Whether the child is at risk of neglect because the carer has caring responsibilities towards them that they cannot adequately meet as a result of caring for an adult;
5. Whether the home environment or any caring role is having a negative impact on the child's well-being, education or development.

If you are concerned about the safety of a child, or that they are at risk of abuse and neglect you must take action to protect them.

If you are concerned that a child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialing 999.

Responsibilities to young carers

The legal definition of a young carer under the Children and Families Act is:

"a person under 18 who provides or intends to provide care for another person (of any age, except where that care is provided for payment, pursuant to a contract or as voluntary work)".

There is a duty to meet the needs of young carers under the Children and Families Act in the same way as there is a duty to meet the needs of adult carers under the Care Act. This means that if you become aware that a child or young person under the age of 18 is providing care you must take steps to ensure they are appropriately supported.

The first thing you should do is liaise with children's services to establish whether the child or young person is already being supported as a young carer.

If support is in place you should provide children's services with any new information you may have about the impact of the adult's needs upon the child, but you will not need to provide any further support to the child.

If the young carer is not already being supported by children's services you should discuss and agree with your line manager and children's services who is best placed to assess them.

Option 1

If the young carer is not approaching the age of transition any assessment and subsequent support they receive will be provided under the Children Act 1989. The practitioner carrying out a young carer's assessment under the Children Act must be suitably skilled, knowledgeable and competent to do so.

Option 2

If the young carer is approaching the age of transition (or is at a time of their life when it would be of significant benefit for transition to begin) a young carer's assessment under the Children and Families Act or Care Act may be more appropriate. This will involve the development of a transition plan that will support the young carer through the transition to adult Care and Support (when they become 18).

There is a legal duty to ensure that transition planning and the whole transition experience is positive for the young carer. To this end an element of joint work will likely be required to ensure the young carer receives the support they need both now and into adulthood.

Wellbeing is the single most important concept of the Care Act. The duty to promote individual wellbeing applies at all times; in every single process, conversation or decision that is made and you must be able to demonstrate that you have done so.

It is vital that you understand your duties in relation to promoting individual Wellbeing. See: Promoting Individual Wellbeing.

In order to promote individual Wellbeing you must first understand what Wellbeing means to the carer. The Care Act sets out 9 domains of Wellbeing that you must consider. See: Wellbeing Domains.

As part of any process to establish needs you must understand:

1. Which areas of Wellbeing are most important to the carer at that moment in time;
2. Which areas of Wellbeing are least important at that time;
3. Whether there are other areas of the carer's life important to them but not listed as a domain (the domains under the Act are not definitive as Wellbeing is personal);
4. Which areas of Wellbeing are causing the carer concern or worry;
5. What impact any concern or worry is having (or could have) across the Wellbeing domains (is there a destabilising effect?); and
6. How the carer thinks any Support needs interact and impact on Wellbeing.

It is important to remember that under the Care Act the Wellbeing domains are all as important as each other. Any hierarchy can only be determined or described by the carer whose Wellbeing it is.

1. A sense of Wellbeing is extremely personal and will be different for every carer;
2. Never make assumptions about what is important and what is not important to a carer;
3. The carer is the expert in relation to their own Wellbeing;
4. If a carer tells you they have no worries in a particular area this does not mean the area is not important to them; and
5. Conversations about Wellbeing should be 'genuine' person centred conversations, not process led.

Often the key to an effective conversation about Wellbeing is preparation and you should take whatever steps are available to ensure that the carer is as prepared as possible for the conversation:

1. Provide information that will support the carer to understand the concept of Wellbeing and why it is important;
2. Offer advice about the things that a carer may want to think about before having a conversation about Wellbeing;
3. Make sure that anybody who will be supporting the carer understands Wellbeing and is confident and appropriate to support the carer to prepare for and have the conversation; and
4. Consider whether any tools may be helpful to support the carer to think about Wellbeing.

A conversation about Wellbeing can be a very difficult conversation for a carer to have. Not everyone will feel happy, confident or able to share with you how they are feeling about the different areas of their life. For many carers, this will be the first time they have been asked or given an opportunity to think about their own Wellbeing in this way, and they may also be doing so whilst adapting to significant change in their life or the life of the person they care for.

Any questions that are used to support a carer to think about Wellbeing must:

1. Be proportionate to the level of information required;
2. Be appropriate, taking into account the carer's specific needs around communication and their specific circumstances;
3. Be realistic in respect of the carers ability to be able to answer the question; and
4. Be asked in a manner that is accessible to the carer.

Powerful questions

A powerful question is a specific type of open question that:

1. Encourages a carer to reflect;
2. Is thought-provoking;
3. Supports an exploration of options; and
4. Helps the carer to gain a greater insight into their situation.

Powerful questions should be framed in a positive way to promote engagement of the carer and promote a strengths based approach.

Appreciative Enquiry

An appreciative enquiry is a conversation that is led by the carer and focuses on times of personal strength. It supports them to recognise that they do still have those strengths and abilities and to think about how they can apply them to their current situation.

The listener should invite the carer to:

1. Talk about a time or times when something has been working well in their life;
2. Explore what it was that worked well and supported them at that time;
3. Think about how that experience could support them now in making a plan for the future.

Some key questions to support an appreciative enquiry approach include:

1. Tell me about a time when things were going well for you?
2. What did you learn about your strengths at that time?
3. If you had a magic wand what would the future look like?
4. What is it that you value most in your life now?
5. What small changes would make the most difference?

The use of tools

A tool can be helpful to shape and focus a conversation about Wellbeing, making sure that you consider everything that needs to be considered from a statutory perspective. Tools are also useful because they:

1. Can be completed with the carer as part of any conversation you have with them; or
2. The carer can complete them in their own time as part of their preparation for the conversation.

See: Tools and Practice Guidance to Establish Needs.

Because Wellbeing is extremely personal different people are likely to have different perspectives about the same domains. The carer themselves is more likely to have a subjective view about their Wellbeing which may be dominated by worries or concerns they have about their presenting situation (or the situation of the person they care for), whereas someone who is emotionally removed from may see things more objectively.

It is important that you recognise when a carer's views about their Wellbeing may not be holistic and take steps to try and support them to gain insight or broaden their thinking. One way of doing this is to seek the views of family members and others involved in their life (with the carer's consent only). This supports a whole family approach to assessment but can also lead to a shared understanding and solution from within informal networks of support.

Even with the involvement and perspective of others certain factors effecting Wellbeing may still be difficult for carers to recognise, acknowledge or explore. If it is your view that these things are having an impact on Wellbeing then you must raise them for the purposes of:

1. Supporting the carer to gain insight into their situation;
2. Developing the carer's resilience through talking about difficult situations and exploring options to find a solution;
3. Providing information and advice;
4. Preventing, reducing or delaying the need for Support.

You may also find the tool Six Tips to Help You Have Difficult Conversations useful.

You should also make effective use of supervision to explore and develop skills that will support you to have difficult and sensitive conversations with carers in a positive way.

A carer's wellbeing is always affected by what is happening in their life at that time. It changes as their situation changes, and sometimes the changes in Wellbeing that take place can be quite dramatic. It is therefore important to understand a carer's Wellbeing in the context of their current situation, but to monitor and review Wellbeing as things change.

When you have understood a carer's individual Wellbeing you have a duty to promote it. To do this you must understand:

1. The things that they want to achieve;
2. The things they want to change; and
3. The things that they want to stay the same.

These things are known as the carer's outcomes. In order to promote Wellbeing you should explore with the carer during the assessment the steps that they can take to achieve their outcomes, as the two things are intrinsically linked.

NHS Choices have an online resource: 5 steps to mental wellbeing.

If, following assessment the Local Authority meets any eligible needs that the carer has you will need to explore not only what steps the carer can take to achieve their outcomes, but also how the support/services provided can help them do so too.

You have a duty to promote a carer's individual Wellbeing but this is not a duty at the detriment of others. The Wellbeing of others must be taken into account and may determine the action that you then do or do not take to promote a carer's Wellbeing.

For example, if promoting a carer's Wellbeing will put a vulnerable adult or a child at risk then you must not do so unless risks can be mitigated. The duty to protect people from abuse or neglect overrides the duty to promote individual Wellbeing.

The Local Authority has a duty to meet the eligible needs of carers under the Care Act from the time that the person they care for is 18, and it cannot fulfil this duty unless it establishes whether the needs that a carer appears to have are eligible.

A carer's needs also often directly impact on their Wellbeing, which you have a duty to promote. Therefore understanding needs will also support you to fulfil the duty to promote Wellbeing.

The Care Act sets out 8 areas of need that must be assessed whenever it appears that they exist:

• Carry out caring responsibilities for a child;
• Provide Care and Support to other adults;
• Maintain a habitable home environment in their own home;
• Manage and maintain nutrition;
• Develop/maintain family and other personal relationships;
• Engage in work, training, education or volunteering;
• Make use of community services;
• Engage in recreational activities.

Unlike a conversation about individual Wellbeing there is not a requirement to talk about all of the areas of need described in the Care Act, regardless of whether they appear to be present or not. Instead the conversation about needs must be proportionate and appropriate to each carer's situation and you should be mindful to make the best use of available information from existing assessments and plans.

Often the key to an effective conversation about need is preparation and you should take whatever steps are available to ensure that the carer is as prepared as possible for the conversation:

1. Provide information that will support the carer to understand the areas of need described in the Care Act and why establishing needs is important;
2. Offer advice about the things that a carer may want to think about before having a conversation about needs (there is a specific requirement under the Care Act to establish carers needs in relation to work, training, education and recreation);
3. Make sure that anybody who will be supporting the carer understands needs and is confident and appropriate to support the carer to prepare for and have the conversation; and
4. Consider whether any tools may be helpful to support the carer to think about needs.

A conversation about needs can be a very difficult conversation for a carer to have. Not everyone will feel happy, confident or able to talk about their needs. Some carers may lack insight into their needs, particularly if they are still going through a period of adjustment to their caring role or the changing needs of the person they care for.

Any questions that are used to support a carer to think about needs must:

1. Be proportionate to the level of information required;
2. Be appropriate, taking into account the carer's specific needs around communication and their specific circumstances;
3. Be realistic in respect of the carers ability to be able to answer the question; and
4. Be asked in a manner that is accessible to the carer.

Powerful questions

A powerful question is a specific type of open question that:

1. Encourages a carer to reflect;
2. Is thought-provoking;
3. Supports an exploration of options; and
4. Helps the carer to gain a greater insight into their situation.

Powerful questions should be framed in a positive way to promote engagement of the carer and promote a strengths based approach.

Appreciative Enquiry

An appreciative enquiry is a conversation that is led by the carer and focuses on times of personal strength. It supports them to recognise that they do still have those strengths and abilities and to think about how they can apply them to their current situation.

The listener should invite the carer to:

1. Talk about a time or times when something has been working well in their life;
2. Explore what it was that worked well and supported them at that time;
3. Think about how that experience could support them now in making a plan for the future.

Some key questions to support an appreciative enquiry approach include:

1. Tell me about a time when things were going well for you?
2. What did you learn about your strengths at that time?
3. If you had a magic wand what would the future look like?
4. What is it that you value most in your life now?
5. What small changes would make the most difference?

The use of tools

A tool can be helpful to shape and focus a conversation about need, making sure that you consider everything that needs to be considered from a statutory perspective. Tools are also useful because they:

1. Can be completed with the carer as part of any conversation you have with them; or
2. The carer can complete them in their own time as part of their preparation for the conversation.

See: Tools and Practice Guidance to Establish Needs.

To ensure an accurate assessment of need it is important that you identify whether the carer's needs for support fluctuate (change over time).

Fluctuating needs are needs that:

1. May not be apparent at the time of the assessment; but
2. Have been an issue in the past; and
3. Are likely to arise again in the future.

A simple question to ask a carer to establish whether their needs fluctuate is 'How do your needs change over time?'

Every carer with fluctuating needs will experience fluctuations differently. For example:

1. Some carer's needs fluctuate in line with the needs of the person they care for (becoming more intensive when the person's needs increase);
2. Some carers will have periods of stability that could last several weeks or months with no fluctuation (for example, fluctuations may occur when a person that supports a carer to sustain their role goes on holiday);
3. Some carer's fluctuations are related to their own physical or mental health condition (for example having arthritis that affects their ability to carry out the caring role when the weather is bad).

Because of the variance in fluctuation possible it is not appropriate to simply assess a carer as having 'fluctuating' needs. Neither should you make a judgement about need based solely on either a 'worse case' or a 'best case' scenario. Doing so would not provide a true representation of the carer's whole needs and it would be likely that any support the Local Authority did subsequently provide would be inappropriate or disproportionate (too much or not enough) to cover periods of fluctuation.

You need to be able to effectively demonstrate:

1. How often the carer experiences a fluctuation in needs;
2. The type of fluctuations that are experienced and the impact on other needs and Wellbeing;
3. What the potential causes or triggers are for fluctuations; and
4. What measures are effective in managing periods of fluctuation or reducing the risk that they will occur.

The kind of questions you could ask a carer to help understand their fluctuating needs includes:

1. How long has it been since you had a good/bad day?
2. What does a good/bad day look like?
3. What changes in support do you have on a bad day?
4. How often do your needs change on a bad day?
5. Which areas change the most on a bad day?

The length of extension to an assessment process to ensure that fluctuating needs are understood should be based on the individual needs and circumstances of the carer.

It may also be appropriate to pause an assessment to enable the carer to access support that may then prevent or reduce the number of fluctuations occurring (for example to allow a new medication to take effect or to allow time for the person they care for to access a health service).

Different people involved with the carer are likely to have different views about need. For example, the carer them self is likely to have a subjective view about their needs, which may be dominated by worries or concerns they have about their presenting situation (for example the potential impact of a serious health diagnosis or the changing needs of the person they care for), whereas someone who is emotionally removed from the situation may see things more objectively.

It is important that you recognise when a carer's views about their needs may not be holistic and take steps to try and support them to gain insight or broaden their thinking. One way of doing this is to seek the views of family members and others involved in their life (with the carers consent only). This supports a whole family approach to assessment but can also lead to a shared understanding and solution from within informal networks of support.

Even with the involvement and perspective of others certain needs may still be difficult for carers to recognise, acknowledge or explore. If it is your view that these needs exist and are having an impact on the carer then you must raise them for the purposes of:

1. Supporting the carer to gain insight into their needs and situation;
2. Developing the carer's resilience through talking about difficult situations and exploring options to find a solution;
3. Providing information and advice;
4. Preventing, reducing or delaying the need for Support.

You may also find the tool Six Tips to Help You Have Difficult Conversations useful.

You should also make effective use of supervision to explore and develop skills that will support you to have difficult and sensitive conversations with carers in a positive way.

Sometimes it is necessary to talk about needs that you know are likely to change at some point in the near future. For example:

1. When a carer or the person they provide care to is expected to make a full recovery from a health related condition;
2. When the person the carer provides care to has temporary needs only (e.g. needs that will be resolved through upcoming surgery or treatment); or
3. When a carer's needs are related to their circumstances and these circumstances are going to change (for example the person that they care for is going to move into residential care).

If those needs are eligible the duty to meet the needs applies, even if the need is only likely to be short term.

Where needs are likely to be changing over time it is important to make arrangements with the carer to monitor and review the needs over an appropriate timeframe that reflects the individual circumstances of the carer.

Sometimes it is necessary to establish needs during a period of crisis. For example:

1. When the carer is experiencing a breakdown in the caring role they provide;
2. When the informal support being provided to a carer breaks down or is suddenly no longer available; or
3. When the person being cared for has a sudden and drastic change in need and requires increased levels of care.

At times of crisis the presenting needs that a carer has may not be a true representation of their on-going needs support. As such it is important to make arrangements with the carer to monitor and review their needs and situation, re-assessing where there is evidence that long term needs are clear.

At this point in the assessment process you will not yet have made a formal determination about eligibility, although you may have gathered enough information to give a good indication. As the formal determination has not yet been made you should restrict conversations about ways that needs could be met to:

1. Ways that the carer could meet their needs (either independently or with the support of their informal support networks or community);
2. Information and advice about prevention services that could delay, reduce of prevent needs; and
3. Broad information about appropriate types of support that is available from the Local Authority (if the carer appears to have eligible needs).

A more specific conversation about how the Local Authority could meet needs will take place as part of the Support Planning process after:

1. The formal eligibility determination is made; and
2. The carer has confirmed that they wish for the Local Authority to meet their needs.

Risk is broadly defined as 'the probability that an event will occur with beneficial or harmful consequences'.

The aim of any conversation about risk is to maximise the benefits and reduce the likelihood of harm.

When you have a conversation about promoting Wellbeing, meeting needs or ways to achieve an outcome there will at some point be a need to talk about risk and doing so at an early stage can support the carer to:

1. Explore and understand the benefits of taking the risk;
2. Explore and understand the potential harmful consequences of taking the risk;
3. Think about the measures they can take to reduce the likelihood of a negative consequence; and
4. Make an informed decision about whether to take the risk.

The process of talking about risk can be very empowering for a carer and build resilience, confidence and independence.

Examples of risk you may need to talk about when establishing a carer's need for support can include:

1. Risk associated with the carers own impairment or disability (e.g. falls when carrying out caring related tasks);
2. Risk of accidental injury (e.g. from manual handling and supporting the cared for person to mobilise);
3. Risks to the carer from the person they care for (e.g. from verbal or physical abuse or from behaviour relating to the use of drugs or alcohol);
4. Risks to the carer's emotional health as a result of the caring role;
5. Risks to the carers work or family life as a result of their caring role; and
6. Risks to the carer's own network of support (e.g. is it sustainable and how likely is it to break down).

Depending on the level of risk a formal risk assessment may need to be carried out in addition to any other assessment process. See: Risk Assessment.

If, as part of any conversation you have with a carer or anyone else you become concerned that a vulnerable adult or a child is experiencing, or at risk of abuse or neglect you must respond appropriately.

See Safeguarding Adults, which also includes information about how to raise a concern about a person under the age of 18.

If you are concerned that an adult or child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialing 999.

Where the safeguarding concern relates to the carer whose needs are being established (for example if the cared for person is causing harm to the carer) a decision will need to be made about the need to pause the assessment process to allow a safeguarding enquiry to take place.

There are 3 possible options:

1. The carer's assessment process continues alongside any safeguarding process;
2. The carer's assessment is paused with no on-going intervention by the person carrying out the assessment whilst a safeguarding process takes place; or
3. The carer's assessment is paused but urgent interim support is arranged to ensure support needs are met whilst a safeguarding process takes place.

Any decision should involve the person carrying out the needs assessment, the person who will be carrying out any safeguarding process, and the carer.

You must consider any appropriate action required to authorise deprivations of liberty whenever:

1. The person being cared for lacks capacity to make decisions about the Care and Support provided to them; and
2. You feel the level of restriction being imposed on the person is depriving them of their liberty.

See: Recognising and Responding to Deprivations of Liberty.