RNIB – supporting people with sight lossFactsheet

Implementing the Care Act for blind and partially sighted people: Regulations and guidance summary for Local Authorities

September 2015

There are 1.86 million people in the UK living with sight loss. By 2020 this number is predicted to increase by 22 per cent and will double to almost four million people by the year 2050.

The loss of sight can have a profound impact. Everyday activities such as making a cup of tea, reading, cooking, shopping and using the internet become a challenge. New skills and strategies have to be learnt to be able get around the home safely, to go outside, cross roads and avoid hazards. For many people there is the additional fear of how they will be able to continue with work. The Care Act and accompanying statutory regulations and guidance will significantly improve social care provision for blind and partially sighted people. For the first time, rehabilitation services for blind and partially sighted people are acknowledged in statutory guidance.

Overview: This document sets out five key areas of the regulations and guidance which have a direct impact upon blind and partially sighted people.

Preventing, reducing or delaying needs (including rehabilitation)

Local authorities must provide minor aids and adaptations up to the value of £1,000 free of charge (per item), for the purpose of assisting with nursing at home or aiding daily living.

RNIB charity numbers 226227, SC039 316 and 1109

Rehabilitation for blind and partially sighted people should be provided based on assessed needs, and therefore not be limited to 6 weeks.

Rehabilitation support should not be subject to eligibility criteria. When designing services, local authorities need to develop an approach to understand and plan for local needs.

Assessment and eligibility Self assessment forms must be provided in a format which is

accessible to the individual. Assessments must be carried out by a person who has the

necessary skill, knowledge and competency. The assessment process starts from the moment a person

has contact with the local authority, and everyone is entitled to an assessment.

Information and advice Local authorities must have due regard for the needs of

people with a visual impairment in the provision of information and advice services.

Charging It is recommended that rehabilitation support for people with

a visual impairment is not charged for beyond six weeks due to the clear benefits it has on preventing care needs and delaying hospital admissions.

Registers Local authorities must maintain registers for blind and

partially sighted people.Local authorities should make contact with an individual within two weeks of a CVI (Certificate of Visual Impairment) being issued.

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Details of Care Act

1. Preventing, reducing or delaying needsBoth regulations and guidance contain a section on prevention. The regulations set the framework for “intermediate care and reablement support services” and “community equipment (aids and minor adaptations)” and the charging for such provisions.

Aids and adaptations The Care and Support (Eligibility Criteria) Regulations 2014 state that there should be no charge for aids and minor adaptations provided at a cost of £1,000 or less;

Interpretation2. “Community equipment (aids and minor adaptations)” means an aid, or a minor adaptation to property, for the purpose of assisting with nursing at home or aiding daily living and, for the purposes of these Regulations an adaptation is minor if the cost of making the adaptation is £1,000 or less;

Services to be provided free of charge4. A local authority must not make a charge under regulation 3(1) where the provision made under section 2(1) of the Act is –(a) a service which consists of the provision of community equipment (aids and minor adaptations);(b) intermediate care and reablement support services for the first 6 weeks of the specified period or, if the specified period is less than 6 weeks, for that period.

Aids and adaptations should include any equipment which is recommended through a rehabilitation intervention, or through an assessment. This may include, white canes, kitchen equipment, magnification and screen readers (this is not an exhaustive list).

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Rehabilitation servicesRehabilitation services for blind and partially sighted people are formally recognised within statutory guidance. Guidance defines rehabilitation to include ‘living skills and mobility training for people with visual impairment’ (2.13). Rehabilitation support for visually impaired people is recognised as a form of intermediate care and reablement. The guidance states that rehabilitation should not be limited to 6 weeks.

Delay: tertiary prevention2.9. These are interventions aimed at minimising the effect of disability or deterioration for people with established or complex health conditions, (including progressive conditions, such as dementia), supporting people to regain skills and manage or reduce need where possible.

Tertiary prevention could include, for example the rehabilitation of people who are severely sight impaired (see also chapter 22 sight registers). Local authorities must provide or arrange services, resources or facilities that maximise independence for those already with such needs, for example, interventions such as rehabilitation/reablement services, e.g. community equipment services and adaptations and the use of joint case-management for people with complex needs.

Intermediate care and reablement 2.13. The term “rehabilitation” is sometimes used to describe a particular type of service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness or disease. Rehabilitation services can include provisions that help people attain independence and remain or return to their home and participate in their community, for example independent living skills and mobility training for people with visual impairment.

Paragraph 2.13 clearly defines rehabilitation support as a form of preventative tertiary intermediate and reablement support. The guidance is then explicit that a local authority is responsible for

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providing preventative support to all adults, irrespective of whether the person has eligible needs. Eligibility criteria must not be applied to accessing rehabilitation services.

2.3. The local authority’s responsibilities for prevention apply to all adults, including:adults with needs for care and support, whether their needs are eligible and/or met by the local authority or not (see chapter 6).

Guidance sets out that local authorities must consider the impact and consequences of ending preventative services, and that poor exit strategies can have a significant impact on preventing, reducing and delaying needs (paragraph 2.62).

2.62. Local authorities should consider the potential impact and consequences of ending the provision of preventative services. Poorly considered exit strategies can negate the positive outcomes of preventative services, facilities or resources, and ongoing low-level care and support can have significant impact on preventing, reducing and delaying need.

Training Local authorities are advised to consider securing specialist rehabilitation and assessment provision, in order to identify the specific needs of blind and partially sighted people and to maximise independence.

22.21. Local authorities should consider securing specialist qualified rehabilitation and assessment provision (whether in-house, or contracted through a third party), to ensure that the needs of people with sight loss are correctly identified and their independence maximised.

Certain aspects of independence training with severely sight impaired and sight impaired people require careful risk management and should only be undertaken by professionals with relevant experience and training. This type of rehabilitation should

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be provided to the person for a period appropriate to meet their needs. This will help the person to gain new skills, for example, when training to use a white cane. As aspects of rehabilitation for people with sight loss are distinct from others refer to the Association of Directors of Adults Social Services’ (ADASS) position statement of December 2013.164

Charging Rehabilitation is defined as an intermediate or reablement programme, and therefore must be free of charge for six weeks. However, because of the clear benefits of rehabilitation, and since the intervention will in many circumstance need to be provided for longer than six weeks, the government strongly urge local authorities not to charge for any it any stage.

Charging for preventative support2.59. The regulations require that intermediate care and reablement provided up to six weeks, and minor aids and adaptations up to the value of £1,000 must always be provided free of charge (see also 8.14).

2.60. Where local authorities provide intermediate care or reablement to those who require it, this must be provided free of charge for a period of up to six weeks. This is for all adults, irrespective of whether they have eligible needs for ongoing care and support. Although such types of support will usually be provided as a preventative measure under section 2 of the Act, they may also be provided as part of a package of care and support to meet eligible needs. In these cases, regulations also provide that intermediate care or reablement cannot be charged for in the first six weeks, to ensure consistency.

2.61. Whilst they are both time-limited interventions, neither intermediate care nor reablement should have a strict time limit, since the period of time for which the support is provided should depend on the needs and outcomes of the individual. In some cases, for instance a period of rehabilitation for a visually impaired

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person (a specific form of reablement) may be expected to last longer than six weeks. Whilst the local authority does have the power to charge for this where it is provided beyond six weeks, local authorities should consider continuing to provide it free of charge beyond six weeks in view of the clear preventative benefits to the individual and, in many cases, the reduced risk of hospital admissions.

Understanding local needLocal authorities should develop a local approach and understand and plan for local needs. They should also ‘consider the different opportunities for coming into contact with those people who may benefit from preventative support, including where the first contact may be with another professional outside the local authority (paragraph 2.38).

RNIB have produced a sight loss data tool which provides statistics on sight loss broken down to a local authority level for the UK. It is a free tool and provides information at www.rnib.org.uk/datatool

2. Assessment and eligibility There are separate regulations for assessment and eligibility and joint guidance for both.

Eligibility regulations; The government has set the minimum eligibility criteria, at ‘significant’. This is roughly equivalent to ‘substantial under FACs.

The criteria for assessing whether a person has significant care needs, is divided into a three tier "test." 2.—(1) An adult’s needs meet the eligibility criteria if— (a) the adult’s needs arise from or are related to a physical or mental impairment or illness; (b) as a result of the adult’s needs the adult is unable to achieve two or more of the outcomes specified in paragraph (2); and (c) as a consequence there is, or is likely to be, a significant impact on the adult’s well-being.

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a) Physical impairment

Firstly the person must be an adult and have needs that have arisen from a physical or mental impairment or illness. Guidance defines physical impairment to include a person with a sensory impairment.

b) Unable to achieve outcomes

A full list of the defined outcomes is set out below. It is clear that many blind and partially sighted people will experience difficulties in meeting these outcomes, and should qualify for support.

(a) managing and maintaining nutrition; (b) maintaining personal hygiene; (c) managing toilet needs;(d) being appropriately clothed; (e) being able to make use of the adult’s home safely; (f) maintaining a habitable home environment; (g) developing and maintaining family or other personal relationships; (h) accessing and engaging in work, training, education or volunteering; (i) making use of necessary facilities or services in the local community including public transport, and recreational facilities or services; and (k) carrying out any caring responsibilities the adult has for a child.

The regulations define what it could mean to be unable to do any of these above activities. Two of the four areas that are of particular relevance: if they need assistance, or if they can do the activity without assistance but it takes significantly longer. Therefore a person with a visual impairment could qualify for support under this criterion.

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Guidance sets out further explanations of what may be involved with meeting an outcome. Many of the criteria reflect the everyday challenges blind and partially sighted people face. Of particular welcome is the inclusion of laundering of clothes (b); maintaining of amenities(f) as blind and partially sighted people are unable to read meters and correspondence, and therefore are unable to maintain their amenities; and the inclusion of getting around the community safely (i).

(b) maintaining personal hygiene. Local authorities should, for example, consider the adult’s ability to wash themselves and launder their clothes.

(f) maintaining a habitable home environment. Local authorities should consider whether the condition of the adult’s home is sufficiently clean and maintained to be safe. A habitable home is safe and has essential amenities. An adult may require support to sustain their occupancy of the home and to maintain amenities, such as water, electricity and gas.

(i) making use of necessary facilities or services in the local community including public transport and recreational facilities or services. Local authorities should consider the adult’s ability to get around in the community safely and consider their ability to use such facilities as public transport, shops or recreational facilities when considering the impact on their wellbeing. Local authorities do not have responsibility for the provision of NHS services such as patient transport, however they should consider needs for support when the adult is attending healthcare appointments.

c) Significant impact

The third tier of the "test" is whether the impact on the individual is "significant". Significant impact is not defined in the regulations, but the guidance states that;6.110. The term “significant” is not defined by the regulations, and must therefore be understood to have its everyday meaning. Local

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authorities will have to consider whether the adult’s needs and their consequent inability to achieve the relevant outcomes will have an important, consequential effect on their daily lives, their independence and their wellbeing.

6.111. In making this judgment, local authorities should look to understand the adult’s needs in the context of what is important to him or her. Needs may affect different people differently, because what is important to the individual’s wellbeing may not be the same in all cases.

Circumstances which create a significant impact on the wellbeing of one individual may not have the same effect on another.

Local authorities must take into consideration that eligibility for support does not rely on all outcomes to have a significant impact on wellbeing, but rather the cumulative impact must be considered.

6.109 sets out the cumulative impact – i.e. if a person meets 2 or more, it is not that these all must have a significant impact on wellbeing – but that the impact that they have combined.

If a person is found to have eligible needs, but their carer, partner is able to and willing to provide the support then the local authority does not have to meet that eligible need.

The carer is however, entitled to an assessment and will be assessed for their eligibility.

Assessments

Self assessments Key to the assessment regulations is the strengthening and promotion of the role of self assessment which is “an assessment carried out jointly by the local authority and the individual to whom it relates”. It is welcome that within the regulations it is very clear that these should be provided in an accessible format.

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Self assessment must be provided in an accessible format.

(7) The information must be provided in a format which is accessible to the individual to whom it is given.

Knowledgeable and competent staff assessments should be appropriate and proportionate and the person being assessed should be able to participate in the process as effectively as possible.

Assessments must be carried out by a person who has the necessary skill, knowledge and competency. However, a person carrying out an assessment for deafblind individuals must have specialist expertise.

Training, expertise and consultation5.—(1) A local authority must ensure that any person (other than in the case of a supported self assessment, the individual to whom it relates) carrying out an assessment—(a) has the skills, knowledge and competence to carry out the assessment in question; and(b) is appropriately trained.

(2) A local authority carrying out an assessment must consult a person who has expertise in relation to the condition or other circumstances of the individual whose needs are being assessed in any case where it considers that the needs of the individual concerned require it to do so.

(3) Such consultation may take place before, or during, the carrying out of the assessment.

Specialist expertise, assessment for deafblind individuals must be carried out by a person with the specialist expertise.

Requirement for specialist expertise – deafblind individuals

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6.—(1) An assessment which relates to an individual who is deafblind must be carried out by a person who has specific training and expertise relating to individuals who are deafblind.

(2) A local authority must facilitate the carrying out of the assessment by providing any person carrying out such an assessment with any relevant information which it may have—(a) about the individual whose needs are being assessed; and(b) in the case of—(i) a carer’s assessment, about the adult needing care;(ii) a child’s carer’s assessment, about the child needing care;(iii) a young carer’s assessment, about the adult needing care.

(3) In this regulation, an individual is “deafblind” if the individual has combined sight and hearing impairment which causes difficulties with communication, access to information and mobility

Appropriate assessments guidance sets out a number of areas which help to ensure that blind and partially sighted people receive an appropriate assessment.

There is a clear expectation that the assessment process should start from when the local authority begins to collect that information about that person (6.2).

Assessments ‘must follow the core statutory obligations’ but the process can be flexible. (6.4)

The assessment aim is to identify needs and outcomes to help people improve their wellbeing (6.5). Outlined below

6.5. The aim of the assessment is to identify what needs the person may have and what outcomes they are looking to achieve to maintain or improve their wellbeing. The outcome of the assessment is to provide a full picture of the individual’s needs so that a local authority can provide an appropriate response at the right time to meet the level of the person’s needs. This might range from offering guidance and information to arranging for services to meet those needs. The assessment may be the only contact the

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local authority has with the individual at that point in time, so it is critical that the most is made of this opportunity.

Assessments and eligibility; significantly section 6.12, sets out that eligibility can only be made on the basis of an assessment. Therefore a decision cannot be made as to whether someone is not eligible for care based upon their condition. An assessment must be carried out. 6.12. Eligibility determinations must be made on the basis of an assessment, and cannot be made without having first carried out an assessment. Once an eligibility determination has been made, and the local authority has determined whether it will meet the person’s needs (whether eligible or not),

Assessments and prevention; guidance sets out that a local authority can pause an assessment, if they think that the person would benefit from preventative services.

Prevention and assessments 6.62. Where the local authority judges that the person may benefit from such types of support, it should take steps to support the person to access those services. The local authority may ‘pause’ the assessment process to allow time for the benefits of such activities to be realised, 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 the local authority 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.

Providing an interpreter; section 6.87 of Guidance states blindness as a condition affecting communication which might require the local authority to provide an interpreter to enable the individual to complete a joint assessment.

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6.87. When assessing particularly complex or multiple needs, an assessor may require the support of an expert to carry out the assessment, to ensure that the person’s needs are fully captured. Local authorities should consider whether additional relevant expertise is required on a case-by-case basis, taking into account the nature of the needs of the individual, and the skills of those carrying out the assessment. The local authority must ensure that the person is able to be involved as far as possible, for example by providing an interpreter where a person has a particular condition affecting communication – such as autism, blindness, or deafness.

3. Information and adviceSection 4 of the Care Act sets out the duty on the local authority to provide information and advice. Information services must have due regard for the needs of people with a visual impairment.

3.2 Local authorities must “establish and maintain a service for providing people in its area with information and advice relating to care and support for adults and support for carers”.

It is clear that the local authority is to consider accessibility of information for blind and partially sight when providing this service itself or in partnership with other providers. Local authorities should also consider the ‘accessibility of information’. This can mean both how accessible information is in terms of a person trying to get hold of it, and whether they are able to read/understand it. 3.3. The local authority has an active and critical role in the provision of information and advice and must take an active role. To fulfil its duty under section 4 of the Act, a local authority is likely to need to go further than providing information and advice directly (though direct provision will be important) by working to ensure the coherence, sufficiency, availability and accessibility of information and advice relating to care and support across the local authority area. Importantly, this duty to establish and maintain an information and advice service relates to the whole population of

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the local authority area, not just those with care and support needs or in some other way already known to the system.

Equality Act; regulations and guidance do not replace local authority’s responsibilities under the Equality Act.

3.28. As required under the Equality Act 2010, reasonable adjustments should be made to ensure that disabled people have equal access to information and advice services.Reasonable adjustments could include the provision of information in accessible formats or with communication support.

3.29. Advice and information content should, where possible, be provided in the manner preferred by the person and will therefore often need to be available in a number of different formats. The duty in the Care Act will not be met through the use of digital channels alone, and information and advice channels are likely to include all of the following:face-to-face contact;

use of peer-to-peer contacts;community settings;advice and advocacy services;telephone;GP surgeries;use of ‘free’ media such as newspaper, local radio stations, social media;local authority’s own and other appropriate internet websites, including support for the self-assessment of needs;third party internet content and applications;email.

An additional paragraph again highlights the importance of recognising the access needs of people with a visual impairment.

3.30. Some groups in need of information and advice about care and support may have particular requirements. Local authorities

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must ensure that their information and advice service has due regard to the needs of these people. These include, but are not limited to: people with sensory impairments, such as visual impairment, deafblind and hearing impaired;

Information, advice and prevention; local authorities should be aware that they cannot rely on their information and advice services to fulfil their duty to prevent, delay and reduce needs. The requirement to provide information and advice is separate to any other duty in the Act.

3.4 It is important to be clear that the duty to establish and maintain an information and advice service is distinct from the duty to meet eligible needs (see chapter 6): this is true for both people with care and support needs and their carers. While a person’s eligible needs may be met by the provision of information and advice this will be an individual response following a needs or carer assessment. Local authorities cannot fulfil their universal information and advice duty simply by meeting eligible needs, and nor would information and advice always be a appropriate of way of meeting eligible needs.

4. Charging There are both regulations and guidance in relation to charging.

The charging guidance reiterates that certain types of care and support must be free, including reablement. Rehabilitation services should be provided free of charge for six weeks. Also it is made clear that local authorities should consider not charging if the need continues beyond this period

8.14. The local authority must not charge for certain types of care and support which must be arranged free. These are:Intermediate care, including reablement, which must be provided free of charge for up to six weeks. However, local authorities must have regard to the guidance on preventative support set out in Chapter 2. This sets out that neither should have a strict time limit

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but should reflect the needs of the person. Local authorities therefore may wish to apply their discretion to offer this free of charge for longer than six weeks where there are clear preventative benefits, such as when a person has recently become visually impaired.

Community equipment (aids and minor adaptations). Aids must be provided free of charge whether provided to meet or prevent/delay needs. A minor adaptation is one costing £1,000 or less.

Treatment of incomeAnnex C ‘treatment of income’, local authorities are provided with “detailed guidance on how to apply the Care and Support (Charging and Assessment of Resources) Regulations 2014, and how to treat different types of income when calculating what a person can afford to contribute to the cost of their eligible care needs.”

The guidance only applies when a person is to be charged for a service and the local authority undertakes a financial assessment. In doing this the income and capital of the person must be assessed.

When assessing income and finances of a disabled person there are a number of expenditures related to the disability which must be discarded, this now includes internet connection.

Disability – related expenditure45. In assessing disability - related expenditure, local authorities should include the following:

xiv. internet access for example for blind and partially sighted people

5. RegistersThe Care Act, sets out that local authorities must maintain registers for blind and partially sighted people.

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The guidance sets out very clearly the processes of certification and registration. Alongside this, it is welcome that the guidance makes clear that people who have not met the criteria for certification still need to be considered in service planning. 22.14. Local authorities should note that there will also be people who have a reduced/low vision but do not meet the criteria for certification who may need to be considered in service planning.

The guidance refers to the need for timely assessment. 22.3. Local authorities should help health and social care organisations to work together to meet the needs of people who have sight loss, for example, ensuring that care and support services know what help somebody needs in their home when they leave hospital. Timely assessment and care and support that is integrated with health care and person-centred offer the potential to make improvements in experience and outcomes of people who are sight impaired, as well as improving system efficiency.

Further, local authorities should make contact with an individual within two weeks of the CVI being issued.

Making contact22.16. Upon receipt of the CVI, the local authority should make contact with the person issued with the CVI (regardless of whether the person has decided to register or not) within two weeks to arrange their inclusion on the local authority’s register (with the person’s informed consent) and offer individuals a registration card as identified on the CVI registration form. Where there is an appearance of need for care and support, local authorities must arrange an assessment of their needs in a timely manner.

The guidance will also help to strengthen what is set out in the preventing, reducing and delaying needs guidance. It is also

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welcome that the guidance refers to the ADASS rehabilitation statement.

22.22. This makes it clear that rehabilitation for sight impaired people is a specific form of reablement. However, there are some intrinsic characteristics which define rehabilitation as being distinct from other forms of reablement. It is therefore not appropriate to take a one size-fits-all approach, and local authorities need to ensure that individual needs are met appropriately.

Further information

Tara Chattaway, Policy and campaigns officer, social care.

Tara.chattaway@rnib.org.uk 01179 341 707

Campaigns@rnib.org.uk 020 7391 2123

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