Our assessment services and our social care model - 'make the difference'

Our assessment services and our model “Make the difference”

In 2019 we introduced our 'Make the Difference' assessment framework (Figure 2), based on the 'three conversations' model across all of our locality and specialist teams (Figure 3). This focuses on ‘what a good life looks like’ for people and ways to promote and enable this, including through community connections and promoting citizenship and community participation.  Our Mental Health Social Workers utilise the Integrated Narrative Assessment (INA).

Figure 2 - Make the Difference Model

Tier 3 - more help for fewer people

• Vision: living your good life with the support that works for you
• How? Unlock social capital and personal strengths before exploring if longer term support might have a role
• Opportunities to be an active citizen
• Longer term support from local and community opportunities
• Services that organise around natural supports
• A life, not just a service

Tier 2 - a bit more while it's needed

• Vision: some help just while people need it
• How? Helping people access short term help locally to get back on their feet or learn life skills
• A bit of help in the short term that builds strengths for the long term
• Building access to short term community based solutions
• Can see people through a crisis without engaging long term support

Tier 1 - something for everyone

• Vision: everyone has access to local people, places and things that help them live their good life
• How? Helping people meet their own needs whenever they can by supporting communities, building connections and improving availability of self-serve options
• Digital and person-to-person solutions
• Helping people to help themselves
• Thriving community-based local solutions

Occupational Therapy (OT) is commissioned and delivered from Gloucestershire Health & Care NHS Foundation Trust as part of our integrated community teams (ICTs).  ICTs bring together OTs with other healthcare professionals and reablement workers alongside GPs to provide care and support at a local level to help prevent emergency hospital admissions and support people to live at home. 

Further information about our model of social care assessment and some of our assessment teams can be found in Appendix 7.

ASC operational teams

• Tewkesbury
• Cheltenham
• Forest of Dean
• Stroud
• Gloucester
• Cotswolds

Delegated functions

GHC: mental health social work, OT, reablement and telecare

Adult Social Care operational teams

• Tewkesbury integrated care team
• Forest of Dean integrated care team
• Cheltenham integrated care team
• Gloucester integrated care team
• Stroud and Berkeley Vale integrated care team
• Cirencester and North Cotswolds integrated care team
• Learning disabilities operations team
• PBS, SW, CHC team, sensory team
• Transitions and enablement

Adult Social Care support teams

• Gloucestershire Equipment Loan Service
• FAB and deferred payments, care services finance, direct payments 
• Contact centre, receptions, blue badge, Your Circle
• Learning disabilities respite units, inhouse day care, GWC and Shared Lives