As day centres struggle to define their models and theoretical perspectives, and as they are required to present more information on their interventions and give evidence of their success or outcomes, the link between assessment and service delivery becomes ever more crucial. How can a day centre provide an appropriate service without a clear understanding of what the needs are of the client? Most of the day centres visited had some system of assessment although most would confess to approaching it from an “informal, low key” approach. The problems with this more informal approach is that some clients are likely to slip through the net, and there is a real danger that staff time can end up becoming consumed by those demanding clients not necessarily those in the most need.
Minimum Standards | What is assessment | Purposes of assessment | Maslow's Hierarchy of Need | The process of assessment and support planning | Allocation of day centre worker | Engagement (building a relationship) | Assessment of strengths, needs and aspirations | Networks | Formulation |
Assessment is the process by which information is collected, an opinion formed, such that a support plan can be produced. It is possibly the most important area for a day centre or indeed any service working with vulnerable people, to get right. Assessment and support planning practice in the homelessness sector is extremely variable in terms of what is done, how it is done, the quality of what is done and indeed whether or not anything is done at all. Whilst the definition of assessment given above may seem straightforward, assessment and support planning require a great deal of skill. That is not to say that it is difficult or over complicated, but it does require thought, careful consideration, support and training. Assessment is what services are based on. If you cannot assess a clients needs, you cannot adequately help them. If you cannot adequately help them, why are you providing a service?
Assessment and formulation of the issues is therefore the pre-requisite to engaging effectively with individuals to address their support needs and issues. Assessment is sometimes seen as something that requires masses of paperwork, interrogating clients, being intrusive, ticking boxes and being like other forms of authority that perhaps the day centre wants to avoid being like. This is simply not the case; assessment does not have to be like this at all. Paperwork should help staff and the clients. If it is too long and complicated and does not help, then it needs to be changed. Assessment is not just about asking questions in a formal interview setting. It is also about appraising situations and behaviour in informal settings. For example you can learn a lot about someone by the way they interact (or not) with others. On-going assessments can be contributed to by time spent talking to a client whilst they have coffee in the lounge or whilst they take part in an activity. You do need to remember to record this information though. If assessments only take place in a private room with a service, a day centre worker and a clipboard, then you will only get part of a person's story and you will miss vital information.
Assessment for support planning is therefore the process of:
Assessment can be used for different purposes. Some of the more common purposes include:
A useful concept in thinking about the needs of homeless people, and of us all, is Maslow's Hierarchy of Need. Abraham Maslow, (1908-1970) put forward the psychological theory that human needs can be represented as a pyramid, with the basis that the most primary needs are at the bottom and the more complex needs are met only once the lower 'rungs' of need are satisfied. As such, once an individual's physical and immediate needs have been met (food, water, shelter, safety), they may become interested in fulfilling more complex needs such as emotional support needs, the need for friends and relationships. It is very useful in understanding the motivations to change in those who use substances.
It is possible to see assessment and support planning as supporting the client as they take small steps up this hierarchy of need. This means that assessment and support planning is as much about personal growth and development, achieving ambitions and personal goals as about ‘care’. Assessment and support planning must be about learning, for the day centre worker as much as the client. This means that there must be space to try things out, make mistakes, reflect on what has happened and move forward.
It is possible to set out a process of assessment based on the Care Management Model. A good assessment will roughly follow the process shown, with additions and omissions, forward and backward loops, according to the situation being examined. It has nine stages:
The first stages of assessment, that is 1 - 3 are dealt with here, while the others are on the support planning and keywork page
In practice, the process will involve smaller loops within this overall process, building on initial assessment.
The nine stage process will take place over the time that the client engages with the day centre. The pace will be dependent on how often the client attends the day centre. It is conceivable that the whole process might take place within days in some cases, whereas in others, where clients engage for a longer period, the assessment of strengths, needs and aspirations might conclude after a couple of months. In this case the whole process will take place in much more depth.
Allocating one day centre worker to a client to be their main contact for assessment and support planning is not obligatory, but is useful. It helps to develop a trusting relationship between the client and staff member and can assist with continuity. Where possible, consideration should be given to allowing clients some choice as to who will be their day centre worker. Projects should be sensitive to issues around gender, sexuality, race, culture and so on when allocating staff. Of course, the allocated worker will not necessarily always be available, so within the team staff should share information as regularly as possible, such as in pre/post-shift meetings so that when the individual staff member is not there, the client can discuss issues and sort problems with other members of staff who are in the loop.
Prior to assessment and support planning the day centre worker should take some time to think about what he or she wants to achieve and how they might do this. For the initial session, the goal will be to develop trust in the relationship and explain the purpose of assessment and support planning, as well as practicalities such as confidentiality and so on.
In day centres, engaging with some clients can take time, patience and persistence. It is common for some clients to be socially isolated and difficult to engage. Staff should not give up, and may have to find creative ways to continue to try to engage with them. Some people will have had negative experiences in institutions and may be suspicious of assessment and support planning. Staff will have to be sensitive and assertive to develop the relationship. Particularly in day centres, staff are able to be flexible and innovative in their approaches to engagement - it does not have to happen immediately, or be the same for everyone. Try and ascertain what kind of communication, level of formality, etc works best for an individual.
For further ideas about developing effective relationships, see the chapter on The Relationship between staff and clients in the section on Creating a positive environment.
Assessment and support planning is about change. Through assessment the client and staff member create a shared picture of the client's past, their current situation and how they want their future to be. Through this they help them to identify their needs and wishes, the resources at their disposal, within themselves or support they can draw on from outside, in order to move towards their goals.
Assessment can tend towards being a list of all the things that are difficult and problematic in a persons life, especially within the care management model where drawing down funding depends on demonstrating how serious are the person’s needs. Assessment and support planning in a day centre setting should be different from community care assessment. It should be more ‘holistic’ and take into consideration the client’s strengths, interests and ambitions.
Of course, where the client has particular needs, a community care assessment may be necessary, but this should be one part of the support plan. Staff should be able to identify symptoms that indicate that the client needs an assessment under the Mental Health Act. Day centres’ procedures on assessment should set out guidelines for how and when an emergency assessment should be sought.
Providers should have assessment pro formas. These are useful in prompting questions and ensuring that all clients get a consistent service. Clients may feel more comfortable knowing that everyone is asked the same questions. (See below for a model of assessment and support planning which includes an assessment pack and training course.) In some cities ‘common needs assessment’ forms have been developed by homelessness partnerships. The intention of these is to prevent duplication of effort and ensure more effective multi-agency working.
The assessment stage should be a collaborative effort, with the day centre worker supporting the client in making their own assessment of their needs and strengths. Where there is disagreement in the assessment, this should lead to a genuine negotiation between the client and the day centre worker and both points of view should be recorded. Assessment should be a joint learning process. This part of assessment will often involve looking at the client’s past in order to understand their present, it may expose areas of great hurt. Staff should ensure that they can bring in other sources of help, from specialist staff if they feel they are getting out of their depth.
Information that will contribute to the this part of the assessment process may include:
An important function of assessment and support planning, and one where more development is needed in the homelessness sector, is in relation to the client’s ‘network’.
By ‘network’ we mean all the people who are important to an individual, including their partner, friends, family, friends from the gym, street, mosque or church, social workers and others that form his or her personal ‘community’. It includes their peers and role models. Our network includes those we turn to when things are difficult in our lives, or with whom we like to celebrate with when things go well.
Staff should help the client to look at their network. Through circumstances, many people who experience homelessness find that their network has unravelled and they have lost touch with people who were important to them in the past. Through living in institutional situations, they may also find that many of their relationships are now with paid staff. Furthermore, their network may have become dominated by negative or damaging relationships. The day centre worker may support their clients to develop or re-configure their network through, for example, re-establishing contact with family and friends or seeking positive relationships and peer group through involvement in activities, clubs, etc. The aim is to increase the number and depth of unpaid, genuine, positive and long-term relationships.
Thinking about and analysing the issues that a client presents with is the second stage in assessment. Once sufficient (and you can never have comprehensive or exhaustive information on someone) information has been obtained, the key to making this intervention the one that creates meaningful change in someone’s circumstances and situation is in formulation. This is about identifying which aspects of a clients presentation should be addressed first, next and later. The obvious selection criteria should be importance or gravity, but here you will want to look at the client’s motivation to change. They may have a very serious substance use problem that may preclude lasting success in other change areas but if they are not motivated to change in that area there is little point beginning the conversation about this. Rather, look for areas that will improve the client’s sense of self esteem, well being. These may be simple and easily addressed in the first instance – this is ideal, as successfully achieving something together as a first task will encourage trust and engagement for future, more difficult tasks. Above all, try and be guided by the client's own preference and sense of urgency, and begin work on the thing that is most important to them. One practitioner tells of a client he knew, who, before he became homeless, had worked as a printer. When identifying areas for action, the client, who had no accommodation and multiple issues around substance use, insisted that the first thing he wanted sorted was to make sure his membership of the National Union of Printers was renewed so that in future, he could return to work. Where possible, and practical, prioritise that which the client prioritises. Big gains in trust and confidence can be made this way.
A useful tool in formulation is the SMART (or SMARTER) models of task planning. Tasks should be Specific, Measurable, Achievable, Realistic and Timeframed.
SMART and SMARTER....
... and Re-evaluate!