Making it work – putting the model into practice: seven "making it work" action cards

Making it work: Using strengths-based assessments

“I,” “we” and “together” statements:

I can explain what a good day looks like for me and what helps me feel confident and connected.

We listen and make sure assessments focus on what matters to people, not just tasks or forms.

Together we use assessments to understand strengths, not deficits, and plan support that makes sense to the person.

Key activities for adult social care staff: 

• A strengths-based assessment should cover:
• What a good day does (or could) look like
• Thinking about solutions not just problems
• Looking at the support that families, friends, and communities provide and how this can be strengthened.
• Setting goals and being realistic and creative about how they can be achieved

Needs should be described by the person, with support if needed – these do not need to match the language of the eligibility criteria, and any professional description of need should be strengths-based.

The impact on wellbeing of meeting the person’s needs should also be described by the person themselves, with support if required.

Only once individual needs and impact on wellbeing have been described should eligibility criteria be considered. Consider using checklists or other tools to determine eligibility to avoid having to use deficit phrasing when determining eligibility.

Ensure that IT systems that auto populate forms and AI tools are supporting strengths-based language within assessments .

Making it work: Using strengths-based support planning.

“I,” “we” and “together” statements:

I can tell you what matters to me and what I want to achieve with support.

We work with people to make their goals clear and achievable.

Together we co-create plans that balance priorities, risks, and opportunities for growth.

Key activities for adult social care staff:

• Talk to the person about what they want to achieve with their support.
• Co-produce the support options that work for the person.
• Consider things that help to increase independence, skills, and confidence.
• Consider structured reablement or enablement interventions (or both) as well as opportunities to develop networks and confidence.
• Offer technology options to further enhance opportunities.
• Work at the pace that is right for the person.
• Use personal budgets and offer self-directed support/direct payments/Individual service funds (ISFs) alongside other types of support.

Making it work: Using community and asset-based approaches.

“I,” “we” and “together” statements:

I want to use my connections and community to live a fulfilling life.

We explore and strengthen the natural networks, relationships, and assets around people.

Together we identify resources in the community, from local shops and clubs to voluntary groups, to support people in the ways that matter to them.

Key activities for adult social care staff:

• Work on the basis that a person just wants to live their life and may need some support to do this.
• Talk to the person about what “living their life” looks like. Really think about the language.
• Think about whole family approaches and the needs of family and friend carers and relatives (see making it work: to support family and friend relationships and unpaid carer roles).
• People will have existing connections and relationships that can be strengthened or supported with formal or informal care.
• Join up conversations and do not expect people to understand the difference between health and social care or different parts of the Council (for example housing and social care).
• Community assets are not just social care and voluntary sector organisations, they are hairdressers, local shops and cafés, churches, clubs, allotments, etc.

Making it work: Supporting mental capacity and best interest decisions.

“I,” “we” and “together” statements:

I want my choices and preferences to be understood and respected, even when risks exist.

We use guidance to support decision-making without taking control away from the person.

Together we work to balance safety, autonomy, and empowerment in a collaborative way.

Key activities for adult social care staff:

Capacity

• Recognise that in social care you are continuously assessing capacity – even if this is informally.
• Keep it simple. What is the decision? Does the person understand it? What information will they need to make the decision? Can they understand that information? Can they retain it long enough to use the information to make the decision?
• Embed advocacy and supported decision-making at every stage.
• Break down individual decisions if necessary.
• Do not expect the person to be able to describe care and support needs to demonstrate capacity.

Best interests 

• Be familiar with case law on best interest’s decisions.
• Be careful with balance sheets – use these to support not direct decisions.
• Recognise and resist defensive practice. Remember best interest decisions are for and about the person not what professionals would like to see happening.
• Remember the person is strong not vulnerable, see the strengths and build on these.

Making it work: Making safeguarding personal

“I,” “we” and “together” statements:

I want my choices and preferences to be understood and respected, even when risks exist.

We seek the views of the person to understand what outcomes the person wants to achieve from the safeguarding intervention.

Together we work to balance safety, autonomy, and empowerment in a collaborative way.

Key activities for adult social care staff:

• The person should be given the opportunity to say what they want (the outcomes) from the safeguarding process if they are willing and able to do this.
• Make time to understand what is going on from the person’s perspective. Particularly consider how a person’s identity and protected characteristics might have an impact on their experiences and their ability to protect themselves.
• Does the person need someone to help them talk about what they want? Or can a family or friend help them? If not, then advocacy must be considered.
• Just because a person may not understand about keeping themselves safe, what they want should mean as much as if they did understand.
• Supporting the person to be safe is important - but so is making sure they want to be safe. Remember the question posed by Juctice Munby:  What good is it making someone safer if it merely makes them miserable? .
• People who have experienced trauma may be uncomfortable or embarrassed talking about their safeguarding risks. Think carefully about how you phrase questions and consider sensitively how you interpret the responses.
• Are there ways of supporting people to avoid or reduce being at risk by doing things to support before a crisis?
• Remember protecting someone is just one of the six important things to make safeguarding personal.
• Use language that makes sense to the person and do not use labels.
• Use these relationships not just to increase engagement but to maximise the person’s control.
• Do not allow external factors or other people’s views to override the person’s perspective.
• Make sure that checking a person understands what is happening (capacity assessments) support decision making. Do not use capacity as a reason to restrict decisions - use it to help people make decisions (see making it work: supporting mental capacity and best interest decisions)
• If a person does understand (has capacity) do not assume that support is not needed.
• Do not walk away if someone says they do not want support but if there are concerns about factors that may be presenting risk. Work with the person to explore and understand how the risks they face can be better managed.
• Learning to take risks appropriately (e.g. for young people with care and support needs in transition to adulthood) should be personalised and enable people to live safe and happy lives.
• Take what is going on in a person’s life, and around them, into account when developing plans.
• Think about what you write about a person – would you be ok reading that about yourself or a family member or friend?
• Make sure that people are included and welcome to take part in meetings about them, with support if needed.

Making it work: Social care in hospital settings – acute, community and mental health (including private hospital care)

“I,” “we” and “together” statements:

I want to be treated as a person, not a system problem, when moving between hospital and home.

We communicate clearly with people and families about choices and plans.

Together we make transitions smooth, safe, and centred on what matters to the individual.

Key activities for adult social care staff: make it about the person not the system

• The person should be supported to get home quickly and safely without having to wait for an assessment.
• Talk to the person in everyday language about what the choices are and what will happen after they get home. Use visual and communication tools for those who need them.
• People should be supported in the context of the question “Why not home?  Why not today?”
• Family and friends can often be very worried about what happened before a person came into hospital and how things will work at home. Include family and friends appropriately while keeping the person’s voice central.  This may mean having some difficult conversations to make sure the person can go home rather than into a bed-based setting (see making it work: to support family and friend relationships and unpaid carer roles).  
• Remember that even though a person may not need to remain in a hospital setting they may not feel very well and find making decisions difficult.  Conversations and decision making should allow for this.  Help the person to think about what a good day would look like and what care and support they need when they are home.]
• Support everyone to have a chance to get better at home with the opportunity for recovery, reablement and rehabilitation. Home is the best place to conduct assessments for long term care.
• As social work (social care) professionals in the hospital environment
• We support someone to resume their usual life at home after a spell in hospital.  This means always being the person’s advocate, considering their capacity to make the right decision and providing appropriate support to manage risk.
• We understand that evidence demonstrates that staying in hospital leads to confusion, a reduction in physical strength and confidence (deconditioning) and loss of independence  .  This can lead to inappropriate placements in care homes from which people never return home.
• We practice advocacy, empathy, and enable people to have choice and control over their lives.  In the health setting it is important to help the person be heard and be part of the planning for their care as part of the multi-disciplinary team (or MDT).
• We ensure that advice and decision making support takes into account the persons mental capacity, their choices, their best interests and any safeguarding concerns (see the making work action cards to support each of these).
• We provide information, advice and guidance about community support options and other local services, including to people who may fund their own care and support.  We provide advice on social care charging arrangements and the financial assessment process.
• We are the link between community social care and the hospital setting.  We ensure a proactive, preventative approach to stop people being admitted to hospital when they don’t need to be and support safe and timely discharge.

Making it work: to support family and friend relationships and unpaid carer roles.

“I,” “we” and “together” statements:

I am treated as a partner when planning care and support for my family or friend.

We will listen and value the view of family, friends, and unpaid carers alongside the views of the person they support.

Together we will make sure that the support is right for the person recognising the role that family, friends and unpaid carers may play in this.

Key activities for adult social care staff

• Take time to listen to what family, friends and unpaid carers have to say as well as the person themselves.
• Treat family, friends, and unpaid carers as an equal partner in care when this is what the person wants – involve them in discussions and decision making alongside the person themselves.
• Use everyday language about what the options are – for themselves as carers (or as family and friends who are not in a caring role) and for the person who may draw on care and support.
• Be clear on when and how things may happen with timescales.
• Recognise that emotional responses impact on the perception of how risky something is . To change this perspective, you have to change the way the risk feels , allow time for discussion, reassurance and understanding.
• Use advocacy and other support as needed – particularly if there are differences in the views of the person from those of the family member or friend.