Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Principles of social work for adults with complex needs

For social workers

1.1.1 Treat people with respect and dignity, recognising and supporting their decisions and choices. In particular:

  • show understanding of people's and their family's circumstances, and be non-judgemental

  • respect the validity of the person's lived experience

  • value their first-hand knowledge of their own needs to inform care planning

  • use professional curiosity and professional judgement

  • understand the power imbalance between the person and social workers.

1.1.2 When first contacting someone, and throughout provision of support, the social worker should establish with the person or with their family, carers or people important to them whether there are any advocacy, sensory or communication needs or impairments, in line with recommendation 1.1.5 in the NICE guideline on people's experience in adult social care services (see also the NICE guideline on advocacy services for adults with health and social care needs).

1.1.3 For any social work activity or process, the social worker should ensure that the person understands:

  • the reasons for the activity or process (for example, an assessment, or care management and support)

  • the aims of the activity or process, and how this relates to them

  • the key processes that will be followed, ensuring the person knows these at the planning stage for the process or activity

  • what will happen at each new stage in the process (for example, by giving the person information about any upcoming review meetings).

1.1.4 Social workers should provide people with the support they need to be fully and actively involved in discussion and decision making, taking into account:

  • whether the person has any familiarity or previous experience with statutory processes and support agencies

  • whether the person might be reluctant to ask for help or raise issues because of personal, societal or other factors, such as stigma or mistrust of services

  • the person's expectations and emotional state

  • the person's wishes and needs for both family support, and for culturally specific support services.

1.1.5 Social workers should ensure that they discuss and actively listen to the person's:

  • history and life story

  • family and community networks

  • experience of disadvantage, discrimination or abuse

  • wishes and aspirations

  • past experiences of services.

1.1.6 Social workers should discuss with the person how their experiences may impact on their care needs and preferences, and how any difficulties may be mitigated. In these discussions:

  • avoid making assumptions about the individual's circumstances

  • recognise that some people's prior positive or negative views and experiences of social work may impact on the relationship with the social worker and services.

1.1.7 Social workers should explore with the person:

  • their experiences of society and accessing services and

  • the potential impact of intersectionality.

    Take these into account when planning care (for example, by liaising with appropriate support organisations).

1.1.8 When planning support, social workers:

  • must consider whether reasonable adjustments can be made to protect against, or help the person deal with, discrimination arising from a person's protected characteristics as defined by the Equality Act 2010, or from other life circumstances and experiences (see box 1) and

  • record the rationale for the decision made.

Box 1 Characteristics, life circumstances or life experiences relating to inequalities

Protected characteristics of the Equality Act 2010

  • age

  • disability

  • gender reassignment

  • marriage and civil partnership

  • pregnancy and maternity

  • race

  • religion or belief

  • sex

  • sexual orientation.

Life circumstances and experiences that could lead to discrimination or inequalities, including:

  • modern slavery

  • coercive control

  • domestic abuse

  • trafficking

  • refugee status

  • asylum seeking

  • being a migrant

  • being from a traveller community

  • being a prisoner

  • being an offender

  • homelessness

  • poor literacy

  • learning difficulties

  • learning disabilities

  • cognitive impairment

  • acquired brain injury

  • autism

  • communication impairment

  • leaving care

  • transitioning from children's to adults' care services

  • sensory impairment

  • substance misuse

  • living in rural and isolated areas

  • long-term conditions

  • English not being a first language

  • socio-economic status

  • addictions.

1.1.9 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.

1.1.10 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:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on principles of social work for adults with complex needs (for social workers).

Full details of the evidence and the committee's discussion are in:

For organisations

Box 2 Organisations that employ social workers

What is an 'organisation'?

In the context of this guideline, organisations are bodies that employ social workers in a professional capacity. This can include local authority social care departments, health services, the criminal justice system, higher and further education and voluntary and community services.

1.1.11 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.

1.1.12 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.

1.1.13 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:

1.1.14 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).

1.1.15 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.

1.1.16 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on principles of social work for adults with complex needs (for organisations).

Full details of the evidence and the committee's discussion are in:

1.2 Assessment

Needs assessment

Providing information

1.2.1 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.

1.2.2 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).

1.2.3 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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment – needs assessment (providing information).

Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.

Planning the assessment

1.2.4 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).

1.2.5 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.

1.2.6 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.

1.2.7 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.

1.2.8 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.

1.2.9 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment – needs assessment (planning the assessment).

Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.

Conducting the assessment

1.2.10 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).

1.2.11 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment – needs assessment (conducting the assessment).

Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.

Recording and reviewing the assessment

1.2.12 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.

1.2.13 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.

1.2.14 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.

1.2.15 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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on needs assessment (recording and reviewing the assessment).

Full details of the evidence and the committee's discussion are in:

Risk assessment

Planning the risk assessment

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

1.2.17 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).

1.2.18 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.

1.2.19 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).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (planning the risk assessment).

Full details of the evidence and the committee's discussion are in evidence review B: risk assessment.

Conducting the risk assessment

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

1.2.21 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.

1.2.22 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.

1.2.23 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.

1.2.24 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.

1.2.25 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.

1.2.26 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'.

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

1.2.28 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.

1.2.29 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).

1.2.30 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.

1.2.31 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.

1.2.32 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.

1.2.33 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.

1.2.34 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (conducting the risk assessment).

Full details of the evidence and the committee's discussion are in:

Recording and reviewing the risk assessment

1.2.35 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:

1.2.36 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).

1.2.37 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).

1.2.38 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.

1.2.39 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.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (recording and reviewing the risk assessment).

Full details of the evidence and the committee's discussion are in:

Organisational support

1.2.40 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.

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

  • debriefing them

  • providing peer support

  • providing counselling following serious incidents.

1.2.42 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.

1.2.43 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).

1.2.44 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.

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

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (organisational support).

Full details of the evidence and the committee's discussion are in evidence review B: risk assessment.

1.3 Individual or family casework

1.3.1 Social workers should take account of the principles of social work for adults with complex needs when conducting individual or family casework.

1.3.2 Social workers should help people with complex needs to identify personal goals and desired outcomes (for example, through task-focused approaches).

1.3.3 Social workers must understand the options available through legal frameworks so they can effectively support the rights of the person and the rights (and limits of the rights) of family members, including in situations of conflict and challenge. For example:

1.3.4 Organisations should consider training and support for social workers to promote the rights, strength and wellbeing of people and families (in line with Social Work England's professional standards) to gain specialised and advanced skills in family interventions (for example, behavioural family interventions, family group conferences and restorative approaches).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on individual or family casework.

Full details of the evidence and the committee's discussion are in evidence review F: individual or family casework.

1.4 Helping people to connect with local communities and reduce isolation

1.4.1 To help people with complex needs develop social connections, social workers should talk to them about their social networks, strengths (using strengths and asset-based approaches), and preferences for activities and social contact.

1.4.2 Social workers should help people to access a range of groups, social activities and social networks to meet their needs and preferences, looking across the community in addition to what is provided by health and social care services. This could be done by:

  • identifying local community groups and networks, and resources (for example, social clubs, community gardens, faith and cultural groups, user-led social groups)

  • finding out about these resources and whether they may meet the person's needs and preferences

  • helping the person make contact with these groups and activities (for example, by arranging IT and digital training, using familiar and accessible places).

1.4.3 Social workers should think creatively about the types of community resources and networks that they can put in place or support people to develop (for example, by active involvement in commissioning discussions and flexible use of personal budgets, including direct payments).

1.4.4 The social worker should check with the person whether any new community connection is meaningful, beneficial to wellbeing and enjoyable, and if not support the person to find a more suitable alternative.

1.4.5 Organisations and social workers should keep up to date with information on currently available community assets, and pass this information on to adults with complex needs and their families. For example by:

  • creating lists of resources and updating them regularly

  • allocating workers to identify resources

  • liaising with community groups

  • commissioning voluntary organisations to keep up-to-date resource lists.

1.4.6 Organisations should make information available about their services, and other community resources to people with complex needs (for example, disabled people's user-led organisations and other community groups). This information should cover:

  • catchment area, and people's right to access services outside of their catchment area

  • eligibility criteria

  • referral processes.

1.4.7 For information on community engagement approaches that seek to improve health and wellbeing and reduce health inequalities, see the NICE guideline on community engagement: improving health and wellbeing and reducing health inequalities. For information aimed at engaging people over 65 years in activities to improve mental wellbeing, see the NICE guideline on mental wellbeing in over 65s: occupational therapy and physical activity interventions.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on helping people to connect with local communities and reduce isolation.

Full details of the evidence and the committee's discussion are in:

1.5 Supporting people to plan for the future, including considering changing needs, wishes and capabilities

1.5.1 The social worker should provide information to support the health and wellbeing of carers in their caring role, and on how the carer can help support the person with complex needs. See also the recommendations on providing information and support to carers in the NICE guideline on supporting adult carers.

1.5.2 Social workers should ensure that care planning meetings take place in the person's preferred location whenever possible and practical.

1.5.3 Social workers should implement a rights-based approach to case management and care planning. This should reflect the following principles:

  • promoting people's dignity and wellbeing

  • respecting people's right to self-determination

  • promoting and supporting participation

  • taking a holistic approach

  • focusing on people's strengths and not solely on their needs.

1.5.4 Social workers should, when appropriate and wanted, include input from key support networks in the person's care plan. This should:

  • be in collaboration with the person, and with their consent

  • include paid and unpaid support networks (for example, family, carers and other people important to them).

1.5.5 Social workers should respond to the person and their changing circumstances by:

1.5.6 Social workers should ensure that, at time of writing or review, care plans:

  • take account of the person's wishes and preferences

  • state how the person's eligible and non-eligible needs would be best met

  • identify how arrangements will be made to meet eligible needs

  • record any eligible needs which are unlikely to be met or only partially met, the reasons they cannot be met or only partially met and any potential actions that would allow them to be met in future.

1.5.7 The social worker should ensure that the person has their work contact details so they can get in touch if their needs or circumstances change. Document this information in the person's care plan.

1.5.8 The social worker should plan the review date of the care plan with the person (a review should happen at least once a year), or conduct an unplanned review as soon as possible if, for example:

  • the person's needs escalate or reduce, and circumstances change (for example, after transfer from hospital)

  • the person, or their carer, a family member, advocate or another person important to them requests it.

1.5.9 Each social worker must (in line with Social Work England's professional standards):

  • use supervision and feedback to critically reflect on their own practice, including how research and evidence has informed practice

  • keep their practice up to date, and record how research, theories and frameworks inform practice and professional judgement

  • contribute to an open, creative, learning culture in the workplace to discuss, reflect on and share best practice.

1.5.10 Where possible, organisations should provide people who receive social work support with a named social worker.

1.5.11 Organisations should provide social workers with regular practice-based supervision and support, ensuring organisational resources are sufficient to allow:

  • continuity of named social workers or a clear handover if the social worker has to change

  • adequate time to monitor and review cases

  • responsiveness to unexpected change

  • the ability to be flexible, when appropriate, to the needs of the person.

1.5.12 To support people to plan for the future when they transition between services, settings or between levels of care, see the following NICE guidelines:

1.5.13 To support people growing older with learning disabilities to plan for the future, see recommendations 1.4.5 to 1.4.7 in the NICE guideline on care and support for people growing older with learning disabilities.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting people to plan for the future including considering changing needs, wishes and capabilities.

Full details of the evidence and the committee's discussion are in

1.6 Responding to an escalation of need, including urgent support

1.6.1 When responding to an unplanned escalation of need, social workers should take into account the person's wishes, preferences, social circumstances and cultural background (for example, if someone expresses a strong desire to stay at home, even if necessary care may more easily be provided in a residential or inpatient setting).

1.6.2 In the event of an unplanned escalation of need, social workers (with consent from the person) should:

  • assess the escalated need jointly with colleagues who have the most knowledge about the person's care, wherever practical (for example, requesting a community Care and Treatment Review or a case conference)

  • consult on the response to the escalated need with:

    • other involved practitioners and community organisations

    • relevant family and social networks.

1.6.3 When an unplanned escalation of need occurs, social workers must:

  • explore the least restrictive alternatives to address the need (in accordance with section 1(6) of the Mental Capacity Act 2005)

  • seek provision of interventions that will have the least detrimental impact on the person's rights and living situation.

1.6.4 Social workers should establish whether a person with complex needs has any advance statement of their wishes or crisis planning, and must take these into account when planning care during a crisis. Document in the person's records how this has informed decision making and review the plan after an escalation of need.

1.6.5 When responding to an escalation of need, as well as considering an advance statement if available, the social worker should take into account and document:

  • the person's wishes and preferences

  • the views of others (for example, family, carers, and other people important to them) concerned for the person's welfare.

1.6.6 Organisations should ensure that social workers have access to prompt support and opportunities to be debriefed during and after their work with someone experiencing a crisis. This should include the opportunity for social workers to reflect on practice and the potential risk to themselves and the person.

1.6.7 Local authorities should have arrangements in place to provide services that:

  • are available 24 hours, so decisions on applications for detention under the Mental Health Act (in line with section 14.35 of the Mental Health Act 1983: Code of Practice) can be made at any time

  • can respond promptly to a person's escalating need

  • communicate any out-of-hours responses to escalating need quickly and clearly to daytime services.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on responding to an escalation of need, including urgent support.

Full details of the evidence and the committee's discussion are in evidence review D: support during an escalation of need.

1.7 Social workers and multidisciplinary teams: communication, support and collaboration

1.7.1 Organisations should ensure that multidisciplinary teams develop a shared statement of values, core purposes and activities, and have clear objectives and aims to jointly work towards.

1.7.2 Organisations should consider the routine sharing of information (in line with the UK GDPR and the Data Protection Act 2018), and of professional expertise and perspectives, within the multidisciplinary team (for example, with joint working, forums or team meetings, themed discussions, or by championing a particular multidisciplinary approach).

1.7.3 Organisations should ensure there is clear communication within the multidisciplinary team by:

  • holding multidisciplinary team meetings, including case discussions

  • having mutual access to diaries when possible

  • providing virtual means to stay in touch even when team members are working from different locations

  • making use of informal opportunities to communicate (for example, staff networking events).

1.7.4 Organisations and commissioners should provide interdisciplinary training to promote shared understanding of each role in the team, and the legal frameworks within which they work, as well as an understanding of the range of lived experiences of people with complex needs. This should:

  • be provided across health and social care including other relevant settings as needed

  • be co-produced with people with lived experience

  • be ongoing

  • be followed up with clear plans for implementing any best practice and lessons learnt from the training sessions.

1.7.5 Organisations should support social workers in defining their role within multidisciplinary teams by:

  • providing professional social work supervision, in particular when the team manager is not a social worker

  • providing opportunities for peer supervision

  • making joint training available that provides clarity about the role of the social worker within a multidisciplinary team

  • providing bespoke, continuing professional development for social workers

  • recognising and addressing differences in organisational culture between professionals involved in the team.

1.7.6 To improve the efficiency of referral within multidisciplinary teams, health and social care organisations should simplify referral processes and referral pathways, for example by having clear and simple eligibility criteria.

1.7.7 Organisations should think about co-location to support more efficient responses and opportunities for discussion within multidisciplinary teams where feasible.

1.7.8 Organisations should develop shared formal agreements (including budgets and information sharing) early in the process of establishing integrated working to underpin accountability and decision making.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on social workers and multidisciplinary teams: communication, support and collaboration.

Full details of the evidence and the committee's discussion are in evidence review E: integrated working.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Debriefing

Debriefing after a distressing or safety-related incident involves the social worker having an opportunity to speak to a manager or senior colleague as soon as possible after the incident. This can be used, for example, to acknowledge the difficult situation and look into any support the social worker needs, including psychological support or counselling. This could start a reflective process to identify any lessons or ways to improve practice in future.

Intersectionality

The term describes the interconnected nature of social categorisations such as age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation and other characteristics or experiences listed in box 1, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.

Professional curiosity

Professional curiosity is to explore and understand what is happening with an individual or family; enquiring deeper and using skilled, proactive questioning and investigation. It is about comparing what the person is saying with what is observed and any other available information, questioning any incongruity, rather than making assumptions or taking things at face value, to provide appropriate and tailored support.

Rights-based approach

A rights-based approach ensures that both the standards and the principles of human rights are integrated into policy making, as well as the day-to-day running of organisations and social work practice.

Strength and asset-based approaches

Strengths and asset-based approaches in social care focus on what individuals and communities have, and how they can work together, rather than on what individuals or communities cannot do or do not have. The terms 'strengths' and 'assets' are often used interchangeably to apply to either individuals or communities. Personal strengths and assets can include relationships, experience, skills and aspirations. Community strengths and assets can include knowledge, people, spaces, networks and services.

Task-focused approach

This approach seeks actionable solutions to specific problems. It usually involves 4 steps:

  • defining a target area to work on together

  • agreeing specific goals and actions for both the social worker and the person they are supporting to help achieve these goals

  • discussion and support about progress with, and impact of, agreed actions

  • reviewing and deciding whether a further process of task-centred goal setting is needed or the process has been successfully completed.

Task-focused work is typically relatively brief but can be applied flexibly across a range of social work contexts as stand-alone support or within a broader package of care.

Wellbeing

In the context of the guideline, wellbeing is defined in accordance to regulation 1(2) of Care Act 2014, which states:

'Wellbeing', in relation to an individual, means that individual's wellbeing so far as relating to any of the following:

  • personal dignity (including treatment of the individual with respect)

  • physical and mental health and emotional wellbeing

  • protection from abuse and neglect

  • 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)

  • participation in work, education, training or recreation

  • social and economic wellbeing

  • domestic, family and personal relationships

  • suitability of living accommodation

  • the individual's contribution to society.

  • National Institute for Health and Care Excellence (NICE)