2.2 Eligibility

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1. Introduction

This policy sets out how Lancashire County Council meets its duties in relation to section 13 of the Care Act 2014 in determining whether or not a person has eligible needs for care and support.

2. Policy Aim

This policy aims to support the determination of whether or not a person has eligible needs for care and support.

3. The Legal Framework

Local authorities must undertake an assessment for any adult with an appearance of need for care and support, regardless of whether or not the local authority thinks the individual has eligible needs or of their financial situation.

The national eligibility criteria sets a minimum threshold for adult care and support needs and carer support needs that the local authority must meet. All local authorities must comply with this national threshold. Local authorities can also decide to meet needs that are not deemed to be eligible, if they choose to do so.

Local authorities, however, continue to have discretion (power) to meet other needs that are below the national threshold. Therefore, Lancashire County Council can, if it chooses, meet needs it does not consider eligible.

The national eligibility criteria set a minimum threshold for adult care and support needs which local authorities must meet. All local authorities must comply with this national threshold. This threshold ensures that there is clarity and consistency around local authority determinations on eligibility.

The national eligibility threshold provides greater transparency on the threshold of need for eligibility. Improved clarity supports local authorities in deciding whether the provision of information and advice or preventative services could delay the adult from developing needs which meet the eligibility criteria, or whether longer-term care and support might be needed. It should also help the adult needing care or their carer to think more broadly about what support might be available in the local community or through their support network to meet their needs and support the outcomes they want to achieve.

Establishing whether or not an adult has eligible needs is one of the most important decisions under the Care Act 2014. Eligible needs are those which meet the eligibility criteria and which a local authority may be required to meet.

The threshold is based on identifying how a person’s needs affect their ability to achieve relevant desired outcomes, and whether as a consequence this has a significant impact on their wellbeing.

The Care Act 2014 has established that carers can be eligible for support in their own right. See the policy on Eligibility Criteria for Carers and Carer’s Breaks.

4. Principles

4.1 Eligibility decision

Following a proportionate assessment, an eligibility decision is then required. The first condition that Lancashire County Council must consider is whether an adult with care and support needs has eligible needs.

To do this, Lancashire County Council must consider whether:

1. Your needs arise from or are related to a physical or mental impairment or illness.
2. As a result of your needs, you are unable to achieve two or more of the specified outcomes (which are described in Section 5.2).
3. As a consequence of being unable to achieve these outcomes there is, or there is likely to be, a significant impact on your wellbeing (see Section 5.3).

5. Assessing Eligibility

Your needs are only eligible when they meet all three of the conditions in the eligibility criteria.

5.1 Condition one

The first step is to determine whether you have a condition as a result of either physical, mental, sensory, learning or cognitive disabilities or illnesses, substance misuse or brain injury. This judgement should be based on the assessment carried out with you, and a formal diagnosis of the condition should not be required.

Where your needs fluctuate, to determine whether they meet the eligibility criteria, Lancashire County Council will take into account your circumstances over a period of time it considers necessary. This is to ensure that Lancashire County Council has established an accurate indication of your ongoing level of need.

5.2 Condition two

The second condition that Lancashire County Council must consider is whether you are “unable” to achieve two or more of the outcomes set out in the regulations.

Being “unable” to achieve an outcome includes any of the following circumstances, where you are:

• unable to achieve the outcome without assistance. This would include where you would be unable to do so even when assistance is provided. It also includes where you may need prompting for example, some people may be physically able to wash but need reminding of the importance of personal hygiene.
• able to achieve the outcome without assistance but doing so causes you significant pain, distress or anxiety. For example, an older person with severe arthritis may be able to prepare a meal, but doing so will leave them in severe pain and unable to eat the meal.
• are able to achieve the outcome without assistance, but doing so endangers or is likely to endanger your health or safety or that of others – for example, if the health or safety of another member of the family, including any child, could be endangered when an adult attempts to complete a task or an activity without relevant support.
• are able to achieve the outcome without assistance but takes significantly longer than would normally be expected. For example, an adult with a physical disability is able to dress themselves in the morning, but it takes them a long time to do this, leaves them exhausted and prevents them from achieving other outcomes

The Eligibility Regulations set out a range of outcomes. Lancashire County Council must consider whether you are unable to achieve two or more of these outcomes when making the eligibility determination.

a) managing and maintaining nutrition – Lancashire County Council will consider whether you have access to food and drink to maintain nutrition, and that you are able to prepare and consume the food and drink.

b) maintaining personal hygiene – Lancashire County Council will, for example, consider your ability to wash yourself and wash your clothes.

c) managing toilet needs – Lancashire County Council will consider your ability to access and use a toilet and manage your toilet needs.

d) being appropriately clothed – Lancashire County Council will consider your ability to dress yourself and to be appropriately dressed, for instance in relation to the weather to maintain their health.

e) being able to make use of the home safely -Lancashire County Council will consider your ability to move around the home safely, which could for example include getting up steps, using kitchen facilities or accessing the bathroom. This should also include the immediate environment around the home such as access to the property, for example steps leading up to the home.

f) Maintaining a habitable home environment – Lancashire County Council will consider whether the condition of your home is sufficiently clean and maintained to be safe. A habitable home is safe and has essential amenities. You may require support to sustain their occupancy of the home and to maintain amenities, such as water, electricity and gas.

g) developing and maintaining family or other personal relationships – Lancashire County Council will consider whether you are lonely or isolated, either because your needs prevent you from maintaining personal relationships or because your needs prevent you from developing new relationships.

h) accessing and engaging in work, training, education or volunteering – Lancashire County Council will consider whether you have opportunities to access work, training, education or volunteering, if this is what you want to do. This includes the physical access to any facility and support with the participation in the relevant activity.

i) making use of necessary facilities or services in the local community including public transport and recreational facilities or services – Lancashire County Council will consider your ability to get around in the community safely, including using public transport, shops or recreational facilities when considering the impact this has on your wellbeing. Lancashire County Council does not have responsibility for the provision of NHS services such as patient transport, however it will consider needs for support i.e. if you would not understand information being given, when attending healthcare appointments, if no other support networks are available.

j) carrying out any caring responsibilities the adult has for a child – Lancashire County Council will consider any parenting or other caring responsibilities you have.

5.3 Condition three

The third condition that must be met is that Lancashire County Council must consider whether your needs and your inability to achieve the outcomes cause, or risk causing, a significant impact on your wellbeing. The meaning of “wellbeing” is set out in Section 1 of the Care Act 2014, with ‘wellbeing’ outcome areas being listed under Section 1.5 of the Care Act 2014:

(a) personal dignity (including treatment of the individual with respect).

(b) physical and mental health and emotional wellbeing.

(c) protection from abuse and neglect.

(d) control by the individual over day-to-day life (including over care and support, or support, provided to the individual and the way in which it is provided).

(e) participation in work, education, training or recreation.

(f) social and economic wellbeing.

(g) domestic, family and personal relationships.

(h) suitability of living accommodation.

(i) the individual’s contribution to society.

Lancashire County Council must determine how your inability to achieve any of the outcomes listed impacts on your wellbeing.  Where you are unable to achieve more than one of the outcomes, Lancashire County Council does not need to consider the impact of these individually but should consider whether the cumulative effect of being unable to achieve those outcomes causes a “significant impact on wellbeing”. In doing so, Lancashire County Council will also consider whether:

• your inability to achieve the outcomes above impacts on at least one of the areas of wellbeing in a significant way; or,
• the effect of the impact on a number of the areas of wellbeing mean that there is a significant impact on your overall wellbeing.

The term “significant” is not defined by the regulations and must therefore be understood to have its everyday meaning. Lancashire County Council will have to consider whether your needs and inability to achieve the relevant outcomes will have an important, consequential effect on your daily life, independence and wellbeing.

In making this judgment, Lancashire County Council will look to understand your needs in the context of what is important to you. Needs may affect different people in different ways, because what is important a person’s wellbeing may not be the same in all cases. Circumstances which create a significant impact on the wellbeing of one adult may not have the same effect on another adult.

Lancashire County Council will provide objective evidence to support their judgement when applying the criteria.

Prior to applying an eligibility decision, a proportionate assessment must be undertaken. See Assessment of Needs chapter.

6. Circumstances when an Eligibility Decision is Not Required

If providing for urgent needs prior to a more proportionate assessment, no eligibility decision will be required at that time but should be undertaken as soon as possible.

If referring for a preventative intervention, such as universal services, a period of reablement and providing equipment or minor household adaptations, no eligibility decision will be required until the outcome of this intervention is known.

In effect, Lancashire County Council is ‘pausing’ the assessment and eligibility process. Early or targeted interventions can delay your needs from progressing. The pause in the assessment process is to allow such interventions to take effect and for any benefit to you to be realised and determined, so that the final assessment of need (and determination of eligibility) is based on the remaining needs which have not been met through such interventions. For example, if Lancashire County Council believes that a person may benefit from a short-term reablement service which is available locally, it may put that in place and complete the assessment following the provision of that service.

7. After the Eligibility Determination has been Made

Once eligibility has been determined, Lancashire County Council must provide you with a copy of the decision.

Where you are found to have no eligible needs, Lancashire County Council must provide information and advice on what can be done to meet or reduce your needs, and what can be done to prevent or delay the development of needs in the future.  This should have the aim of delaying deterioration and preventing future needs and reflect what support is available locally.

If you have some eligible needs, Lancashire County Council must:

• agree with you which of your needs you would like Lancashire County Council to meet; and
• consider how Lancashire County Council may meet those needs. This does not replace or pre-empt the care and support planning process but is an early consideration of potential support options, in order to determine whether some of those may be services for which Lancashire County Council makes a charge. Where this is the case, Lancashire County Council must carry out a financial assessment.

8. Further Reading

7.1 Relevant chapters

Assessment of Needs

Preventing, Delaying or Reducing Needs

8.2 Relevant information

Chapter 6, Assessment and Eligibility, Care and Support Statutory Guidance (Department of Health and Social Care)

Assessment and Eligibility Case Studies, Resources