Social work with adults experiencing complex needs

The social worker must inform the person, in accordance with the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018, about the extent and content of information sharing across agencies and within multidisciplinary teams, and their rights in relation to this.

The social worker should be aware of NICE guidance about relevant conditions that could affect the person they work with and how they work with them. For example, the NICE guidelines on:

• autism spectrum disorder in adults

• challenging behaviour and learning disabilities

• cystic fibrosis

• depression in adults

• multiple sclerosis in adults

• psychosis and schizophrenia in adults.

Organisations (see box 2) should consider making time allowances for social workers in caseloads so they can build relationships with people with complex needs. Recognise that building relationships may take longer with people who may have had negative experiences with services, or people concerned about stigma from being in contact with services.

Organisations should provide continuous professional development for social workers that specifically covers equality and diversity, so they are competent and confident in:

• asking all people they support about their personal and social identity as well as circumstances or experiences that may lead to inequalities or discrimination (for example, related to characteristics listed in box 1) and

• understanding how their personal and social identity as well as circumstances or experiences may affect their lives, care needs and preferences.

Organisations should provide continuous professional development to ensure that social workers have up-to-date relevant legal literacy and sufficient knowledge of, for example, the:

• Mental Capacity Act 2005

• Mental Health Act 2007

• Human Rights Act 1998

• Equality Act 2010

• Care Act 2014

• Children Act 1989

• relevant case law

• inherent jurisdiction of the High Court.

Organisations, commissioners and social workers should:

• recognise that people with complex needs may experience the impact of intersectionality, resulting in increased inequalities in access to and outcomes of health and social care and

• take this into account when planning and delivering services so they are accessible and responsive to the whole range of people's needs (for example, if a person has multiple health and social care needs this could be addressed by multidisciplinary working between health and social care services – see the section on social workers and multidisciplinary teams: communication, support and collaboration).

Organisations should develop a framework, in line with the Social Work England professional standards, to support social workers in contributing to an open and creative learning culture in which they can:

• discuss and share best practice to promote the rights, strength and wellbeing of people, families and communities

• reflect on their own practice and that of their colleagues

• share experiences and learn from each other about how to balance the rights of the individual with the risks to self and others.

For other principles of improving people's experience in adult health and social care services, including the principles of care and communication, see the NICE guidelines on people's experience in adult social care services, patient experience in adult NHS services and service user experience in adult mental health. For guidance on how to make information accessible, see the NHS Accessible Information Standard.

The social worker should give the person information about their upcoming needs assessment in a format that is in line with their needs and preferences, and is accessible to them. Ensure they have enough notice and time to review documents, and prepare for the assessment.

In line with regulation 10 of the Care Act 2014, the social worker must inform carers of people with complex needs about their right to a carer's assessment (for more information, see the NICE guideline on supporting adult carers).

The social worker should inform the person being assessed about where and how they can access information about their rights under relevant legislation, such as the Care Act 2014, the Human Rights Act 1998 or the Mental Capacity Act 2005 (for example, providing written or oral information or signposting to relevant online resources or agencies – see also the section on principles of social work for adults with complex needs for relevant links related to meeting communication needs).

The social worker should be aware that a needs assessment can be stressful for the person being assessed, and their families and carers. Ensure that assessment practices are designed to minimise stress whenever possible, including:

• using a flexible approach to tailor the assessment to the person's needs (for example, by amending the order of assessment questions)

• helping the person to understand assessment documentation when appropriate (for example, explaining complex concepts in a simple, clear way).

Social workers should consider arranging a preparatory initial contact before the assessment itself if it will help the person with complex needs to participate fully in their assessment (in line with statutory guidance for a proportionate assessment in the Care Act 2014), taking into account:

• the urgency of the person's support need

• whether the person wants a preparatory initial contact, and if so whether they would prefer this as a home visit, virtual contact or a phone call

• whether the person would have substantial difficulty in being involved in the assessment and if so, whether an independent advocate should be provided for the assessment.

The social worker should ask the person about their preferences for the practical arrangements of the assessment, such as:

• the time and place of the assessment

• remote or in-person assessment

• whether they would like a supported self-assessment

• whether they would like anyone to be present to support them, for example a family member, carer or an independent advocate.

The social worker should take into account that when there is a concern about potential safeguarding issues, an in-person assessment is likely to be needed.

If the person chooses supported self-assessment, the social worker should discuss the advantages and disadvantages of this option with them, taking into account the complexities of their needs.

The social worker should offer people with complex needs individualised support to complete a self-assessment, such as:

• ensuring that they have complete information about what it involves, including the list of areas and questions which it covers

• involving advocacy services

• providing details of who to contact if they want to clarify or discuss any areas of the assessment

• giving reassurance that they can ask for an in-person assessment if their preference changes.

The social workers must ensure that the information provided by supported self-assessment is an accurate reflection of the person's circumstances (in accordance with section 6.44 of the Care and support statutory guidance, 2021). This can be done by cross referencing it with information from other sources (this should typically include involved family and carers or the multidisciplinary team).

The social worker must conduct the needs assessment for adults with complex needs in compliance with statutory guidance (see regulation 2(1) of the Care Act 2014), and taking account of the following:

• whether the person's needs arise from or are related to a physical or mental impairment or illness

• whether the person would have difficulties in achieving 2 or more of the 10 listed outcomes; see regulation 2(2) of the Care Act 2014

• whether there is a significant impact on wellbeing

• whether there are any unmet needs that may relate to a condition or difficulty that may need input from other specialist services, for example from speech and language services or mental health services.

The social worker should give the person a draft copy of their assessment and reviews, and the opportunity to identify any inaccuracies, omissions or differences of perspective, before the assessment is finalised.

The social worker should acknowledge and record in formal case notes and the care and support plan any differences of opinion about the needs assessment.

The social worker should give people with complex needs, their families and carers and other people important to them information about the complaints procedure, including how to access it and how to lodge a complaint if they wish to about the process or the outcome of the assessment.

If the person chooses a self-assessment, the organisation must provide them with relevant information that they hold about them and their carer's assessment if applicable, taking into account legal requirements related to consent (in line with sections 2[5] and 2[6] of the Care and Support [Assessment] Regulations 2014).

Social workers should assess risks as part of a holistic process of assessing the person's strengths, needs and wishes.

The social worker should discuss and record the person's views on involving family, carers, and other people important to them in the risk assessment in the formal case file. Let the person know that it has been recorded and share this information across relevant agencies and with other social workers when appropriate and necessary (in line with the UK GDPR and the Data Protection Act 2018).

The social worker should consider conducting the risk assessment over several contacts, so that:

• there is an opportunity for rapport to develop between the social worker and person being assessed

• the person's perspective on risks, their strengths, needs and wishes, and their health, environment and support networks are understood.

When planning a risk assessment, take into account the urgency of any situation that may need a risk assessment within a short timeframe (for example, in a single visit; see also the section on responding to an escalation of need, including urgent support).

The social worker should support the person to engage in advance care planning, including:

• planning to cover their wishes in the event of any future loss of capacity (see the section on advance care planning in the NICE guideline on decision making and mental capacity)

• developing a risk management plan.

Where a social worker has reasonable cause to suspect a person has experienced, is experiencing or is at risk of abuse or neglect, they must follow local safeguarding policies. If a need for action is established, the social worker must follow statutory safeguarding processes as set out in regulation 42 of the Care Act 2014.

For people with complex needs, social workers should tailor risk assessments to the person's strengths and needs and take into account beneficial and harmful outcomes, and their likelihood of occurring, including:

• risks to the person from their own behaviour (including accidents, self-neglect and suicide or self-harm)

• risks from others (including physical or sexual violence, psychological harm, neglect or exploitation)

• risks of harm to others

• risks of loss of independence or breakdown of caring arrangements.

When assessing mental capacity, social workers must take account of section 1(4) of the Mental Capacity Act 2005, and not assume that the person lacks capacity because they have made a decision that the practitioner perceives as risky or unwise. See also the section on assessment of mental capacity in the NICE guideline on decision making and mental capacity, including recommendation 1.4.19 on the difficulty in assessing capacity in people with executive dysfunction.

If a person lacks the mental capacity to make decisions related to risk, the social worker must seek and take into consideration their current wishes (and any relevant past wishes expressed at a time when they were believed to have capacity) about any decisions, in line with section 4(6) of the Mental Capacity Act 2005. For further details, see the NICE guideline on decision making and mental capacity.

If a person makes a decision that is likely to put them at significant risk, the social worker should consider assessing their capacity to understand, retain and weigh up the relevant information about safety, taking into account:

• previous decisions and choices and

• the perspectives of involved family members, carers and multidisciplinary team members.

Social workers should use plain language and terminology that is understandable and acceptable to the person. For example, talking about 'safety' or 'being careful', rather than 'risk' or 'self-neglect'.

In discussions between the person and the social worker about risk, consider the use of a structured risk checklist.

The risk assessment should:

• include discussion of what has caused previous problems and unplanned escalation of needs

• identify what interventions have worked previously to manage and reduce risks.

When assessing risk, in accordance with Social Work England's professional standards, social workers should:

• think about how any assumptions or personal biases may have influenced their assessment (for example, assuming that frail people would not want to participate in physical activities)

• be reflective about their own values, and challenge the impact they have on their practice (for example, how they personally feel about tidiness when working with a person who is hoarding).

Social workers should respect people's rights to make decisions that they (the social worker) perceive as risky or unwise when the person has capacity to do so. Do not use such decisions as a reason to refuse care.

If a person with capacity declines an intervention aimed at reducing risk (see recommendation 1.2.22 for the types of risk that may need to be reduced), social workers should continue to work with them to find ways to minimise risks.

If a person has been assessed as lacking capacity, then in accordance with the Mental Capacity Act 2005, social workers must:

• ascertain the person's best interests (using the best interests checklist in line with section 4 of the Mental Capacity Act 2005), including identifying whether there is a Lasting Power of Attorney or court-appointed deputy with appropriate decision-making powers to make best interests decisions

• ensure any restrictions or supervision in their care are proportionate to the risk of harm to the person

• take into account any less restrictive ways of meeting the person's needs and managing risks and use these where appropriate.

Social workers should avoid over-reliance on risk prediction (such as 'high' or 'low' risk) during assessments and when recording risks, and instead specify strategies on how to respond to factors contributing to increased risk and reduce potential harms.

When deciding whether to share information in circumstances where the person does not give consent, the social worker:

• must balance the rights of the person with complex needs under the Human Rights Act 1998, Article 8 (right to respect for private and family life) against the effect on children or individuals at risk if they do not share the information and

• should record all information-sharing decisions, and the reasons for those decisions, in line with the organisation's procedures and requirements.

In complex risk management situations involving potential risks of serious harm, the social worker should initiate and participate in a case conference involving all relevant agencies to:

• share information (in line with the UK GDPR and the Data Protection Act 2018) and

• develop a coordinated risk management plan.

The social worker should include the person (and the person's advocate, family and carers, if they wish them to be present) in case conferences for complex risk management situations involving potential risks of serious harm, unless doing so:

• would present a risk to (or cause an escalation of risk for) the person or

• would present a risk to any of the other parties involved (social workers, other care staff, or the person's advocate, family or carers).

The social worker should ensure that relevant information on significant concerns about risks is shared and discussed with all necessary agencies (taking into account the legal requirements under the UK GDPR and the Data Protection Act 2018).

The social worker should:

• give the person a draft copy of their risk assessment, and the opportunity to identify any inaccuracies, omissions or differences of perspectives, before the risk assessment is finalised

• acknowledge and record any differences of opinion about the assessment of risk in the risk assessment document and formal case notes.

Social workers should review risk assessments:

• at least annually and

• if needed, in response to an identified change in the person's circumstances or change in risks.

Organisations should:

• provide de-escalation training to staff to support their safety

• have systems for formally recording incidents of aggression, threats or abuse against staff.

Organisations should support staff when they experience any safety-related incidents, for example by:

• debriefing them

• providing peer support

• providing counselling following serious incidents.

Organisations should provide access to advice for social workers whenever they are working, including outside normal office hours, about immediate concerns related to the risk to the person with complex needs or others.

Organisations should ensure the following are in place:

• training, including multi-agency training, to support staff in assessing risks thoroughly

• supervision structures to support staff and encourage reflective and inclusive practice (for example, a multidisciplinary team discussion about individual situations).

Organisations should have a written strategy promoting a culture that supports staff in helping people with complex needs balance the benefits and harms relating to risk taking. This could include, for example, training and governance systems to support social workers with assessing complex and high-risk situations.

For further principles of decision making in situations where people may lack capacity, see the NICE guideline on decision making and mental capacity.