South West Peninsula

SAP Policy &

Implementation
Guidelines

SAP Policy and Implementation Guidelines

v3 March 07

Document Control
Amendment History
Version
V1

Date
January 07

V2

February 07

V3

March 07

Amendment History
Released by SAP Programme Manager,
Heather Eardley
Released by SAP Programme Manager,
Heather Eardley
Released by SAP Programme Manager,
Heather Eardley

Updating & Approvals

This document requires the following approvals.
Name

Title

Date of Issue

Version

SAP Programme
managers

Jude Anthonisz, Jennie

Stephens

3/1/07

V1

SAP Learning &

Development
work stream

Learning development
leads from each org.

10/1/07

V1

SAP Information
Governance
work stream

Info governance lead

reps from each
participating
organisation

07/02/07

V1

SAP Learning
disability Work
stream

Learning disability
leads from each org

8/2/07

V1

Various
representative
practitioner
groups

ESAP champions,
Devon ASC, Cornwall
ASC, Plymouth ASC,
Jenny Kingman District
Nurse, Devon PCT,
Sandra Clark- Fully
funded nursing care
lead Devon PCT D, V

Jan/Feb 07

V1- resulting
in version 2

Document Location & Owner

This document is only valid on the day it was printed. Please contact the Document
Controller for location details or printing problems., i.e. Bruce OConnor on 01392
687141 or [email protected].
This is a controlled document.
On receipt of a new version, please destroy all previous versions (unless a specified
earlier version is in use throughout the project).

SAP Policy and Implementation Guidelines

v3 March 07

SAP Policy and Implementation Guidelines

What is this document?
The Single Assessment Process (SAP) policy and implementation guidelines provide
key information for health and social care staff across the south west peninsula who
will use the Single Assessment Process to enable them to assess the health and
social care needs of adults (excluding Mental Health).
The guidelines can be read as a whole document or as separate pages on key topics
for preparation for SAP and eSAP (electronic SAP) implementation. There are
separate word documents available for each section at www.devon.gov.uk/sap-pro .
Who is it for?
The document is aimed at frontline health and social care staff and their managers to
provide a policy and implementation framework and answer frequently asked
questions. The staff groups covered will include:

GPs, Nurses, occupational therapists, physiotherapists and other allied health

professionals who work in community and acute hospital settings.

Social care community care workers, referral co-ordinators, contact centre call
handlers, social workers and occupational therapists

Modern Matrons, Social Care Practice managers, Locality managers, Team

managers etc.

The voluntary and independent sector staff, who may want to know more about
the Single Assessment Process, although they may not be directly using it.

How will it be updated?

The guidance notes will be updated as and when required by the SAP programme
team and updated versions will be displayed on a version control sheet at the front of
this document and displayed on the SAP website.
How can I get more information?
The SAP website: www.devon.gov.uk/sap and staff pages : www.devon.gov.uk/sappro. This contains all key documents including all the SAP tools and regular
newsletters, which can be downloaded. Responses to questions on policy and
practice matters and on the use of electronic assessments will be made available on
the SAP website and each organisations internal intranet site and the existing means
used in organisations to communicate changes/updates in the use of IT systems.

SAP Policy and Implementation Guidelines

v3 March 07

SAP Policy and Implementation Guidelines

Contents

Section 1 - SAP Policy

Section 2 - Legal & Policy Framework
Section 3 - Joint Working & Assessment Standards
Section 4 - Sharing and Protecting Personal Information
Section 5 - SAP Tools
Section 6 - Education, Training and Development
Section 7 - Person Held Records
Section 8 - Comments, Queries or Complaints about SAP

SAP Policy and Implementation Guidelines

v3 March 07

The Single Assessment Process ( SAP ) Policy

Purpose
This policy is aimed at all staff in NHS and social care organisations (or wider) who
undertake the assessment and care planning of health or social care needs. It
requires staff to use the Single Assessment Process (SAP) in place of existing
processes. This is initially as a paper or word template version, but from April 07, an
electronic version (eSAP) will be gradually introduced to make this process easier.
The implementation of SAP and eSAP is the responsibility of each participating
organisation, alongside their own policies, protocols and procedures. The SAP policy
is an overarching policy, which all organisations will use as a basis for their own more
detailed ones.
Background
The Single Assessment Process (SAP) originated from the Older Peoples National
Service Framework (NSF) which was launched by the Department of Health in March
2001 with the aim of promoting independence, ensuring that age discrimination is
eradicated and that older people and their carers receive consistently high quality
services, wherever they live and whatever their circumstances. Standard 2
empathises the need for a person centred approach and one single assessment
process for NHS and social care staff to assess the health and social care needs of
people without unnecessary duplication and ensuring the amount of assessment is
proportionate to the persons needs.
In the South west peninsula (as in many other parts of the country) it was decided to
apply the Single assessment Process across adults (except Mental health where the
Care Programme Approach (CPA) will still be used though this can be seen as a
specialist assessment within SAP.
What is the Single Assessment Process (SAP)?
The Single Assessment Process is a new way of assessing health and / or social
care needs for adults. It involves health and social care organisations working
closely together with the person themselves and their carer (if they have one) to
enable services or treatment to be received at the right time, through a multi-agency
assessment, care plan and review process.
With the persons permission, assessment information will be shared with staff
across health and social care agencies that are involved in providing care or services
for the person. This means different professionals contributing to one assessment
rather than repeating the process in separate assessments. This is a big culture
change for staff in health and social care organisations, but it will be made easier
with the introduction of an electronic SAP to enable information to be passed easily
between the two.

SAP Policy and Implementation Guidelines

Section 1- SAP Policy

v3 March 07

Are there different types or levels of assessment within SAP?

Although SAP is a single assessment process in order to ensure assessment is only
proportionate to a persons needs there are 4 different types of assessment:
Contact at the initial point of contact basic personal information and
presenting problem is gathered including some risk assessment screening. A
multi agency referral tool which can be completed by a range of different staff.
Overview a holistic assessment that gives an overall picture of the persons
needs from a health and social care perspective. Includes risk triggers and
information about other services or treatment and whether any further
specialist assessment is required.
Specialist one or more specialist assessment may be carried out when
specific difficulties have been identified at contact or overview for unstable,
unpredictable or complex needs and a specialist professional opinion is
required.
Comprehensive in the southwest peninsula this is process not another tool.
It is for complex, unpredictable and unstable cases where a large care
package is likely and a number of professionals or agencies are involved. A
person is required to co-ordinate the various professional contributions and
monitor progress.
(For list of tools to cover these types of assessment see section 5 SAP Tools and
SAP at a glance available on www.devon.gov.uk/sap-pro )

What can service users and carers expect from SAP?

The person will receive an information leaflet about the Single Assessment
Process, explaining what SAP is, information sharing and consent, how
information is stored, how decisions are made and how to make a complaint.

The person being assessed will be central to the assessment process. Their
views and wishes will be listened to and acted upon when ever possible. If this is
not possible, then a full written explanation of the reason will be provided.

The person will be offered a copy of their assessment or a summary and be

provided with a copy of their care plan, explaining what services and treatment
will be put in place.

With the persons consent, one assessment will be carried out and shared across
different health and social care agencies. This should limit duplication of effort
and the assessed person repeatedly providing the same information.

SAP Policy and Implementation Guidelines

Section 1- SAP Policy

v3 March 07

When should SAP be used and what should it replace?

Whenever there is a request for an assessment to identify needs for services and
treatment in the NHS or social care then the Single Assessment Process should be
used. This should replace any existing assessment processes and enable joint
agency assessment and care planning.
Which organisations will be using SAP and who has agreed this?
The Single Assessment Process Programme Board (with representatives from each
participating organisation) has agreed a common set of documentation across all
NHS and social care organisations in the southwest peninsula (excluding Mental
Health). Each organisation should ensure that SAP replaces existing assessment
documentation whenever possible to eliminate any duplication.
The participating organisations are:

Cornwall Adult Social Care

Cornwall & Isles of Scilly PCT
Devon Adult Social Care
Devon Doctors on Call
Devon PCT
North Devon Healthcare Trust
Plymouth PCT
Plymouth Community Care
Services

Royal Devon & Exeter Foundation

Trust
South Western Ambulance Trust
South Devon HealthCare Trust
Torbay Care Trust

Royal Cornwall Hospitals Trust*

Plymouth Healthcare Trust*

* These organisations are not participating in eSAP at present. However, they will be
participating in the principles of SAP and have licences for using the FACE tools.

SAP Policy and Implementation Guidelines

Section 1- SAP Policy

v3 March 07

Continuing Health Care

In the South west peninsula the SAP Health Needs Assessment (HNA) is the
tool to use for assessing Continuing Health Care needs and for funding panels to
make decisions about residential, nursing or complex care packages funding. It
should usually be completed after an Overview Assessment, but in some
circumstances a Contact and fully completed Health Needs Assessment may
contain sufficient detail to enable funding panels to make decisions without
duplication of assessment information.

The Continuing Care (National Health Service responsibilities) Modification

Directions 2006 should be referred to (see Dept of Health website:
www.dh.gov.uk ). It is extremely important that professional decisions are well
evidenced and documented and there is separate guidance and training for staff
to ensure this takes place. Please seek guidance from your line manager if you
have any doubts about this area of work.

What does this policy exclude?

SAP and this document exclude the policies and the standards that accompany
commissioning and service delivery. These aspects will be covered by the specific
standards and policies within each organisation.

SAP Policy and Implementation Guidelines

Section 1- SAP Policy

v3 March 07

SAP Legal & Policy Framework

The Department of Health National Service Framework for Older People 2001
requires NHS and social care organisations to undertake one single assessment
process to avoid duplication and ensure a person centred approach. There are a
number of other legal responsibilities for NHS or social care organisations which
impact upon the Single Assessment Process (SAP). Staff should familiarise
themselves with these.
Table 1 - Legislation for Local Authorities and NHS Organisations
Local Authority

NHS

NHS and Community Care Act 1999

NHS and Community Care Act 1999

Chronically Sick and Disabled Persons Act

1976

National Health Service Act 1977

Health Act 1999

Health and Social Care (Community Health

and Standards) Act 2003

Health and Social Care Act 2001

NHS Reform and health care professions Act
2002

Disability Discrimination Act 1995

Disability Discrimination Act 1995

Mental Health Act 1983

Mental Health Act 1983

Mental Capacity Act 2005

Mental Capacity Act 2005

Children Act 2004

Children Act 2004

Carers Act 1996

Carers (Equal Opportunities) Act 2004

Carers Act 1996

Carers (Equal Opportunities) Act 2004

Care Standards Act 2000

Care Standards Act 2000

Community Care (Delayed Discharges) Act

2003

Community Care (Delayed Discharges) Act

2003

National Assistance Act 1948

National Health Service (Consequential

Provisions) Act 2006

Race Relations (amendment) Act 2000

Race Relations (amendment) Act 2000

Employment Equality (Sexual Orientation)

and (Religious Belief ) Regulations 2003

Employment Equality (Sexual Orientation)

and (Religious Belief ) Regulations 2003

Equality Act 2006

Equality Act 2006

Employment Equality (Age) Regulations

2006

Employment Equality (Age) Regulations

2006
NHS Code of Practice Records Management
2006

SAP Policy and Implementation Guidelines

Section 2 - The Legal and Policy Framework

March 07

Information Sharing and Holding of Data

Police and Criminal Evidence Act 1984
Common Law Duty of Confidentiality
Data Protection Act 1998
Computer Misuse Act 1990
Human Rights Act 1998
Freedom of Information Act 2000
Local Government Act 1972
Crime and Disorder Act 1998

Most legislation since 1977 has been summarised within three acts of parliament.
These received royal assent on 8th Nov 2006 and will come into effect on 1st March
2007 (subject to a few exceptions). These are: The National Health Service Act
2006, The National Health Service Act (Wales) 2006 and the National Health Service
(Consequential Provisions) Act 2006.
Information sharing
The information sharing aspect of Single Assessment is primarily covered by the
legislation listed in the table above, together with other specialist legislation on health
and social care. Essentially, all personal information collected on the individual must
comply with confidentiality rules and be protected as specified in the Acts above.
The individual must be properly informed on the use of their information, and their
consent obtained before sharing with other agencies involved in their care. For more
detailed information on information sharing, see SAP Implementation Guidelines:
Section 4 - Sharing and Protecting your Information, and the Southwest NHS and
Social Care Information sharing protocol at www.devon.gov.uk/sap-pro
Other Relevant Polices or Strategies

Fair Access to Care Services 2003 - guidance on eligibility criteria for social care
The Continuing Care (National Health Service Responsibilities) Modification
Directions 2006
National Service Framework for Long Term Conditions - Good Practice Guide and
Examples 2005
Urgent Care - Department of Health Direction of Travel for urgent care (2006)
White paper - "Our Health, Our Care, Our Say" and Making it happen (2006)
No Secrets guidance developing multi-agency policies and procedures to protect
vulnerable adults from abuse 2000

SAP Policy and Implementation Guidelines

Section 2 - The Legal and Policy Framework

March 07

The Caldicott Report 1997 - (confidentiality principles)

The Coughlan judgement 1999 (continuing health care)
The Grogan judgment 2006 (continuing health care)
National Care Standards Commission Regulation & Standards
Dignity in Care Campaign - Dept of Health
NHS Code of Practice on confidentiality
The Community Care Assessments Directions 2004

For more details of the above and other relevant policy and guidance, see the
Department of Health website www.dh.gov.uk.
Another useful website with information about various conditions and host of the
national SAP website is www.cpa.org.uk (Centre for Policy on Ageing).

SAP Policy and Implementation Guidelines

Section 2 - The Legal and Policy Framework

March 07

Joint Working & Assessment Standards

Why joint working?
In the White Paper, "Our health, our care our say " an emphasis is placed on health
and social care organisations to work more closely together using a common
assessment framework. The Single Assessment Process is a sound basis for the
common assessment framework ( CAF) and requires joint working arrangements in
place to ensure more effective co-ordinated services are provided across health and
social care.
What are the standards that are required to ensure a quality assessment?
In order to ensure consistency of outcomes to assessment and care planning across
organisations, all staff must apply these standards when carrying out the Single
Assessment Process.
Standard 1 - The person being assessed should be fully involved in the process (and
also the carer, if the person agrees).
Standard 2 - Information should be gathered in a way that is respectful and sensitive
as well as efficient, proportionate, timely and adequate with due regard to peoples
equality and diversity needs.
Standard 3 - The process should help to recognise and build on the strengths of
people who use services, and their carers, enabling and supporting people to resolve
their needs themselves wherever possible.
Standard 4 - Assessment should fulfil all legal requirements as described in SAP
implementation guidelines 2- Legal & Policy framework)
Standard 5 - The Single Assessment Process should avoid the need for people to
repeat information to different staff involved in assessing and providing for their
health and social care needs.
Standard 6 - Assessments and care plans must be clearly and succinctly recorded
providing evidence for decisions made.
Standard 7 - Records and plans must be communicated and made accessible to the
person assessed and their carers where consent is given.
Standard 8 - Information must only be shared after consent has been given and only
for the purposes stated on the consent form.
Standard 9 - Single assessment and care planning must involve effective
communication and collaboration within a culture across health and social care

SAP Policy and Implementation Guidelines

Section 3 - Joint Working and Assessment Standards

March 07

agencies with a mutual respect and understanding of each others professional roles
and responsibilities.
Standard 10 - Assessment must include assessment of risk by taking account of the
need to protect individuals from harm but also enabling them to make decisions
about their own lives including aspects of independence, choice and dignity.
Standard 11- Assessments and care plans should be completed within the
timescales required by each organisation.
Do we have to trust each other's assessment?
The principles of the Single Assessment Process mean that assessments and care
planning information is shared across agencies and professionals and will therefore
rely on a degree of trust. This is quite a new concept and will take time to develop
but is very much part of a person centred approach where service users and carers
do not like having to repeat information and have an expectation that there will be
good joint working arrangements in place.
Will someone be needed to co-ordinate the assessment and care plan?
If there are several people involved in one assessment it will be necessary to identify
the key worker or care coordinator and discussion needs to take place with the
service user and carer about who is the most appropriate person to do this. The
personal held record, which is kept in the persons home and contains assessment
and care planning information, can help with communication between professionals
in these situations (see implementation guidelines 6- personal held record).
What difference will eSAP make?
With the introduction of electronic SAP (eSAP), the amount of sharing of information
and joint work on an assessment will be possible to an extent which has never really
been possible before.
Whereas in the past each professional would undertake their own assessment and
often ask the service user very similar questions, the electronic version of SAP will
enable much easier sharing of information and should therefore help improve joint
working arrangements. eSAP enables different professionals to be able to work on
an assessment together and complete different domains by sending the assessment
electronically to each other and being able to access it in one place electronically.
This will take time to get used to and will require better communication and more
efficient processes between professionals and scrutiny about whether further
assessment or care planning adds value or has already been carried out by someone
else.

SAP Policy and Implementation Guidelines

Section 3 - Joint Working and Assessment Standards

March 07

How will professional skills and identity be maintained?

SAP will involve a set of skills for joint working to enable standards to be met whilst
recognising the value of different professional skills. See standards and joint working
arrangements.
Who should do what?
The SAP at a glance outlines which type of staff should complete which tools (see
www.devon.gov.uk/sap-pro).

SAP Policy and Implementation Guidelines

Section 3 - Joint Working and Assessment Standards

March 07

Sharing and Protecting Personal Information

1. The purpose of this section
The purpose of this document is to provide guidance to ensure that the SAP
Information Sharing Protocol is effectively put into practice and adhered to.
The SAP information sharing protocol is a framework for the secure and confidential
obtaining, holding, sharing and storing of information for the Single Assessment
Process and can be obtained from the SAP website www/devon.gov.uk/sap-pro.
The agreement on information sharing has two focuses:

The communication between the professional disciplines within joint teams or

other service providers contributing to the delivery of the Single Assessment
Process.

The sharing of information gained from the Single Assessment Process with
those agencies who are not SAP Participating Organisations, such as
housing, education, police and independent providers who represent the
wider context of delivering co-ordinated and holistic services.

2. What does the SAP information-sharing protocol contain?

The SAP protocol replaces the separate protocols for Devon & Cornwall entitled
Information sharing for SAP. It contains sections on:
Reasons for sharing SAP information
The type of information that can be shared
The legal basis for sharing confidential and personal-identifiable information
Disclosures outside the scope of the agreement
Responsibilities and standards for participating organisations
Complaints
Monitoring and review
3. What information can be shared?
The components of the Single Assessment Process cover basic personal
information, needs and health, and an integrated care plan. This information will be
recorded in the current versions of the FACE SAP assessment tools and will be
SAP Policy and Implementation Guidelines
Section 5 - SAP Tools

March 07

shared between the parties to this protocol for the purpose of assessment and care
planning.
The type of service user information to share will cover:

Statistical information
Depersonalized /Anonymous Information
Personal Identifiable Information

4. Legal responsibilities
The legal framework for the information sharing aspects of Single Assessment are
primarily covered by:

Common Law Duty of Confidentiality

Data Protection Act
Caldicott principles
Human Rights Act

The specific legislation for NHS and Local Authority organisations to share
information is set out in the SAP Implementation Guidelines: Section 2 The Legal
and Policy Framework, together with other specialist legislation on health and social
care as listed. This is supplemented by a range of Governmental guidance on
information sharing, all of which have been used to establish best practice in
information sharing.
You should be familiar with the specific guidelines, policies and their application
regarding the legislation mentioned above for your organisation.
5. When and how should the Consent to share and protect your information
form be completed?
As soon as is practically possible, you should ensure that the person being assessed
is asked to consent to information sharing across agencies or staff members by
signing the "Consent to Share and Protect Your Personal Information" form.
Service users and carers should be advised about what will happen to their
information and how it will be shared with all those relevant to the provision of their
care. The SAP user/carer leaflet gives details about information sharing as well as
the whole process.
The service user should complete the Consent to Share and Protect Your Personal
Information form at the time of first contact or assessment. This is then refreshed
each time a new assessment is completed by asking if the consent still stands as the
assessment tools are completed (each of the FACE tools (as listed in SAP
implementation guidelines 5- Tools) has some questions about consent to share
information. If the Consent to Share and Protect Your Information form has already

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

been completed by one agency then the simple check questions on the SAP
assessment tools are all that is required. The more detailed consent to share and
protect your information form must initially be completed once and held on file
or recorded on eSAP.
Once electronic SAP (eSAP) is in place, records will be shared with relevant staff
through a robust and secure method. However, until that time interim arrangements
have to be put in place to ensure that best practice is followed with the sharing of
information under the Single Assessment.
.
6. Why do we have to have secure methods for transferring information?
The reasons for having secure methods for transferring information are two fold:

To safeguard the service users legal right to confidentiality and privacy in the
exchange of their personal information.

To safeguard professional staff by providing measures that allow only appropriate

and controlled access to service users' personal information to:

Ensure they have enough information to form professional judgements and

to inform care planning under the Single Assessment Process.

Ensure they are informed about known and potential risks.

Ensure that a commonly understood framework is available to manage

access to information and to protect professional staff.

7. Who can access information and be shared with?

Once a service user has given their informed consent for information to be shared
with SAP partner organisations, (as listed in SAP implementation guidelines 1) it is
acceptable to share that information based on the "need to know" principle. If a
service user is known and has already completed a consent form, there is still a
requirement to check that the person still agrees to this consent and fully
understands what information they have consented to share. For example, someone
may consent to share a contact assessment, then go on to have an overview but
may not be in agreement for that detail to be shared so this will need checking.
8. What if the person is unable to give consent?
If a person is unconscious or unable, due to a mental or physical condition, to give
consent or to communicate a decision, the professionals concerned must take
decisions about the use of information. This needs to take into account the persons
best interests and any previously expressed wishes, informed by the views of
relatives or carers as to the likely wishes of the patient. If a patient has made his or
her preferences about information disclosures known in advance, this should be
respected. There is a SAP FACE Mental Capacity Assessment tool, which can be
used to assess someones mental capacity if required.

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

9. How should information be transferred between agencies?

Until an electronic version is available, you should follow your own organisations
safe-haven procedures for transfer of SAP forms, by fax or email. Where email is
being used, care must be taken to ensure that the information is encrypted and sent
securely.
A care plan, which includes a summary of needs, should be offered to the service
user and carer, together with any part of the assessment form which the service user,
carer and professional consider useful. The option of a person held record file is
available to be kept in the persons home (see SAP Implementation Guidelines:
Section 6 - Person Held Record). Assessment co-ordinators should keep a copy of
all documents along with a record of what has been sent, to whom and when.
10. What about vulnerable adult situations?
In cases of vulnerable adults where adult protection is an issue, care must be taken
about information that may be seen by a variety of people in the persons home. For
further advice, see your organisation's adult protection policy.
11. Complaints
Any complaint received from or on behalf of a service user or carer, containing
allegations of inappropriate disclosure of information, will be dealt with through the
internal complaints procedure of the organisation receiving the original complaint.
12. Are there separate guidelines for the transfer of information electronically?
Separate guidelines will be given as part of the training on the electronic SAP system
by your organisation.

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

Single Assessment Process Tools

The Single Assessment Process (SAP) requires a common set of tools to be used
across organisations with a set of domains issued from the Department of Health.
There are a number of Department of Health accredited SAP tools. The southwest
peninsula has adopted the FACE toolset for use across all the organisations that
have signed up to SAP (for list of organisations see www.devon.gov.uk/sap). FACE
does not replace SAP they are simply the tools we have chosen to use for SAP
A southwest peninsula version of the FACE toolset has been purchased on licence to
enable us to use this in paper and electronic versions. FACE stands for: Functional
Assessment of Care Environments and the tools are based on a sound evidence and
research base. The southwest peninsula SAP partnership requested some
additional amendments. These include falls check, housing questions and carer's
assessments, enabling referral to the falls register and home improvement agencies,
and covering the Department of Health carers information requirements.
FACE has a number of "first line" and "second line" tools. The tools in use across the
southwest peninsula and which will be available electronically on eSAP are as
follows:
First line tools

FACE SWP v1 - Background and Contact Assessment to be completed by

health or social care staff to gather basic personal information and an outline of
reasons for referral. It also includes brief information about health, social
circumstances, housing, carers and falls. Information and advice, services or
treatment may be set up with this level of assessment if you consider you have
sufficient information to make this decision.

FACE SWP v2- Overview assessment - This is a more detailed holistic

assessment, which can be completed by health or social care staff to identify risks
and needs and the need for any further specialist assessment. The Personal
View of your Needs form ( v2 June 05) can be given to the service user to
prepare for this assessment.

FACE Rapid Assessment - This is a cut down version of the Overview, which
therefore has its limitations. (e.g.. section on carers is missing and some other
domains from overview merged) It may be used in emergency situations on
paper versions but each organisation will have its own policy about its usage. It
will not be part of eSAP as assessment information will be much more quickly
recorded on the overview assessment and non-appropriate sections can be easily
deleted.

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

SWP Health Needs Assessment (HNA v2 Jan 07) - This can be completed by
a range of health care staff, such as nurses, physiotherapists or occupational
therapists. It can also be used to identify continuing health care needs and for
funding panels to make decisions about residential, nursing or complex care
packages funding. It should usually be completed after an Overview Assessment,
but in some circumstances a Contact and fully completed Health Needs
Assessment may contain sufficient detail to enable funding panels to make
decisions without duplication of assessment information (see SAP Implementation
Guidelines: Section 1- SAP Policy- continuing health care). This will be available
on eSAP

Core assessment (LD)- this enables a more a detailed assessment to be carried

out when a person has learning disabilities or complex needs. This will be
available on eSAP.

Admission Summary - This is suitable for use in hospitals for gathering

admission information quickly. It will not be available on the eSAP system.

Care Plan - This is a multi-agency care plan that summarises the services or
treatment to be provided to the service user. It also contains information about
contingency plans in the event of an emergency and a diary sheet, so that all care
provided over a week can be easily viewed by all involved with that person,
including their carer. The care plan does not need to be signed by the service
user, but a copy should be given or sent to the service user. Performance
information is collected about this to ensure it is happening. The service user or
carer may or may not also wish to have a copy of their assessment tool(s). Each
agency may require a more detailed care plan to be completed, but it is each
organisation's responsibility to specify what is required in this aspect. This will be
available on eSAP

Review - All care plans should be regularly reviewed to ensure that the services
or treatments in place meet the person's or their carer's needs. A review date
should be set when services or treatment are first set up. There must be
agreement with the service user and carer about frequency of reviews, but the
minimum is annually. The service user or carer should be informed that they may
request a review at any time and know who to contact to do this.

Consent to Share and Protect your Personal Information - This should be

completed at the beginning of any new contact and signed by the service user to
agree to share information. Once this is on file (or on eSAP, when in place) it will
not need to be repeated, unless the information changes or is added to, at which
time new consent for new purposes will be sought. For each new assessment,
there is a short section on the Background Information and Contact and Overview
tools for you to check with the service user whether the original consent still
applies.

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

Second line tools

There are a range of other tools available as part of the FACE toolset to complement
the first line tools and enable more detailed specialist assessments. These are:

Activities of daily living

Carers Assessment
Communication
Lifestyle and personal strengths
Physical wellbeing
Risk profile
Social
Welfare Benefits check

Other specialist FACE tools in development

Primary care referral

COPD
Diabetes
Heart Failure
Hospital Discharge
Mental Capacity Assessment & guidance (available for use from April
07 )

If a professional or organisation identifies value in making use of any of the above

second line tools then permission should be sought from your own organisations
SAP lead. Each organisation may vary in their application of second line tools. The
list is designed to assist staff in seeing what is already available and avoid the need
for unnecessary duplication of tools development. Please note that none of these
second line tools will be available on eSAP.
Feedback or queries about SAP FACE tools
If you would like to provide feedback or have queries on any of the already-adopted
FACE tools, please contact your local SAP lead. The SAP lead will ensure that your
query will be forwarded on to the eSAP management arrangements, FACE user
group (meets quarterly) or other relevant forums.
Completing the tools
In accordance with the policy principles for SAP, each assessment tool should be
completed with the user and carer at the forefront and in proportion to the persons
needs.
This means that not every section needs to be filled in - this must be based on
the service user's opinion and your professional judgement.

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

Each FACE tool should be used as a guide only. There is an "Assessment Checklist"
(available from www.devon.gov.uk/sap ) which can be used for training purposes
and/or in conjunction with the tools. FACE guidance notes are also available from
the SAP programme office or your local SAP lead.
If there is additional information you think should be added and there is insufficient
space to do so on the tool, then complete a separate sheet and attach to the
appropriate tool. Any queries or comments about the tools can be directed to the
SAP project team, whose contact details are at the end of this guidance.
Equality and Diversity
All assessments must ensure peoples equality and diversity needs are taken into
account. This includes completing the appropriate tool's section, which asks for
ethnic and religious information. This needs to be done with an understanding of
why this is being asked, that is, to ensure the person receives the appropriate
services and treatment and that all aspects of the person's equality and diversity
needs are taken into account. It is not a purely bureaucratic process.
The SAP tools can be obtained from the SAP website as PDF or word template
versions, on www.devon.gov.uk/sap-pro or ordered in hard copy through EROS for
NHS staff and Local Authorities' usual forms printing process.
Other useful information
The SAP flow chart (showing the SAP process), SAP at a glance (one page chart
giving information about each tool, who should complete it, when and what for) and
the SAP assessment checklist can all be obtained from the SAP website under
information for south west peninsula health and social care staff, see
www.devon.gov.uk/sap-pro

SAP Policy and Implementation Guidelines

Section 5 - SAP Tools

March 07

Person Held Record

What is a Person Held Record?
A person held record (sometimes called yellow folder) is a folder that contains a
record of assessment and care planning information, which is kept in the home of the
person receiving services or treatment. It has been designed for situations where
there are several staff visiting peoples homes and communication can be a problem
e.g. people with long-term conditions or there are likely to be emergencies where out
of hours staff would find it useful to have easily accessible information to make
urgent decisions. A sticker is placed on the persons fridge to highlight the existence
of a person held record. The record should be kept by the fridge or phone if possible
for easy access.
The folder contains useful information for the service user and carers such as:

Contingency plans
SAP assessment and care planning information
GP information
Diary sheets
Contact sheets
Self care information

What are the criteria for issuing a Person Held Record?

The Person Held Record is issued and owned solely by the PCT and will be
distributed to people who have been identified by GPs, District Nurses and other
health and social care staff as having multiple and/or complex care needs with health
and social care input. The Person Held Record is therefore applicable for people
who:

Have complex care packages delivered in their own homes.

Have treatment and care delivered and managed by a number of
practitioners/agencies.
Are known to request frequent unscheduled care from the GP (including out of
hours services) or their District Nurse.
Have required a number of unscheduled admissions to hospital in the last year.
Are at `risk of needing emergency care.
Are managed for a `Long Term Condition or `Complex Care Pathway.

How can I set up a Person Held Record?

If you consider the person would benefit from a personal held record then you should
first discuss this with your line manager or the persons GP (check agreed process in
your organisation from your SAP lead). The folders are issued by the PCT; so if you
work for social care, discuss this with the health member of staff involved. If social

SAP Policy and Implementation Guidelines

Section 6 - Personal Held Record

March 07

care only is involved it is unlikely a folder will be required (see criteria) but in certain
circumstances it may be possible to set one up (see line manager or SAP lead)
How will the Out of Hours services know about the Person Held Record or
Yellow Folder?
The Out of Hours services, such as South Western Ambulance Trust, Devon Doctors
and social care emergency duty teams have all signed up to the personal held record
and welcome the opportunity to use this and be informed when it is in place. A
record of the issue of a folder must be put on your local PCT database and sticker
placed on the persons fridge showing there is a folder in place.
Where can I find out more about the Person Held Record?
The Person Held Records Protocol explains the procedure for issuing folders,
ownership arrangements, storage and retrieval. There is also a training PowerPoint
presentation available. For further information, see www.devon.gov.uk/sap-pro .
A Person Held Record process flowchart can be found overleaf.

SAP Policy and Implementation Guidelines

Section 6 - Personal Held Record

March 07

PERSON HELD RECORD PROCESS FLOWCHART.

Staff member identifies need for person held record

GP Discussion

Staff member obtains personal held record from PCT supply sourceconversation and agreement with person

Staff member requesting / initiating personal held record becomes manager in

charge of person held record and notifies database

Database informs A&Es, OoHs Doctors, SWAST, Social care

If member of staff changes agreement needs to be reached for change of

manager for personal held record. Notify database re change

If person dies or moves out of area the key professional notifies database and
returns person held record to archive system..

Database informs A&E, OOH Doctors, SWAST, Social Care of archiving

arrangements

Person Held Record is archived with organisation that issued the record.

SAP Policy and Implementation Guidelines

Section 6 - Personal Held Record

March 07

SAP Education, Training and Development

Outline of SAP and eSAP training
Training for the Single Assessment Process (SAP) consists of the following different
types of training:
SAP Basic awareness 6 modules :

1. Implementing SAP in your area- PowerPoint presentation, Success with

SAP DVD, SAP Policy and Legal context.
2. Effective assessment skills- exercises and handouts on what makes a
good assessment.
3. Person centred approach to assessment- includes 20 min film Keeping
Milly Happy, exercises and handouts
4. Sharing and protecting information how to complete consent form and
guidelines for staff linked to information sharing protocol.
5. Person held record an introduction to its use what it consists of , what are
the criteria for issuing one etc.
6. Introduction to FACE tools provides a basic understanding about what
are FACE tools, what they replace and how to complete them.
NB: More detailed FACE Tools training is available on the use of FACE Tools
and can be purchased at an additional cost from FACE on a train the trainer basis
but should not be completed before the SAP basic awareness training.
eSAP training - This training will be designed to enable you to use the peninsula-

wide eSAP system and will be provided about 4 weeks prior to using the eSAP
system to ensure skills can quickly be put in to practice.
NB- eSAP training can only be completed following basic IT skills training
This should be part of the mainstream training provided by each organisation and is
needed in preparation for the electronic single assessment process (eSAP) system.
How will training be delivered?
Each organisation has a responsibility to ensure each member of staff is trained and
each local implementation team should have a joint health and social care education,
training and development plan in place prior to SAP implementation. A key element
of SAP and eSAP training is learning to work together across health and social care
and to trust each others assessments. Wherever possible SAP training must be
undertaken on a joint agency basis.

SAP Education, Learning and Development Framework

March 07

Training materials
The SAP training has been designed by a group of learning and development leads
from each organisation. The aim of the material is to ensure a consistent approach
to SAP training across the peninsula. There is one set of agreed training materials.
These are:
1. SAP Basic Awareness learning and development pack
-contains 6 modules with exercises and handouts and reference to the following
additional training resources:
SAP basic awareness PowerPoint presentation - a ten minute introduction to

SAP
SAP basic awareness learning and development pack - a set of modules and

handouts for team meetings or a half-day workshop www.devon.gov.uk/sap-pro

"Success with SAP" - A four-minute DVD with service-user and carers

experience of SAP and the person held record with a short explanation of what
eSAP will do.
"Keeping Milly Happy" - A 20 minute film (video or DVD) telling the true story of

a husband and wifes experience of health and social care providing a discussion
vehicle for person centred care and improving assessment skills.
"Listen To what I am Saying" - person- centred care and the single assessment

process-national DVD.
Large pull up poster boards - featuring a SAP cartoon and case study-

available from SAP programme team.

Handouts - As listed in SAP Basic Awareness Learning and Development Pack.
e-Learning SAP Basic Awareness - An e-learning module that introduces SAP.

This can be found at www.devonlearning.net (available from March 07).

2. FACE Tools
FACE tools supplier provides the following guidance and training materials which
include case vignettes and a completed overview assessments.
FACE overview assessment v5 - Users guide
FACE SAP Tool set v5 - Training materials
Meeting the Standard - The FACE overview tools

These are available on the SAP website at www.devon.gov.uk/sap-pro

SAP Education, Learning and Development Framework

March 07

3.

eSAP Training

Training materials and handbook for eSAP training - (This training is not yet
available. It will be developed with the eSAP supplier IBM.)

Before this takes place each member of staff should have completed some basic
IT skills training and a training needs questionnaire to assess the level of IT skills.
This should be part of existing IT programmes and available from each
organisations IT department. A sample IT training needs questionnaire is
available form the SAP website www.devon.gov.uk/sap-pro

Aspects of training not covered in SAP

Basic IT skills training
Training on the business processes/procedures used within each
organisation.
Training on the use of each organisations existing or planned IT
systems.
Equality training (apart from awareness raising and good practice within
SAP)
Risk management
Continuing health care (but SAP basic awareness be carried out prior
to this)
Other specialist assessment training

SAP Education, Learning and Development Framework

March 07

Queries or Complaints about SAP

Note: To avoid unnecessary complaints, please ensure all staff are fully
aware of the content of the implementation guidelines and adhere to these in
carrying out SAP to high quality standards.
What do I do if a Service User or Carer Complains?
The SAP Information leaflet should be given to service users and carers at the start
of an assessment. This leaflet explains the SAP process and provides phone
numbers of each organisation and details about how to make a complaint. Staff
should direct the service user or carer to the most appropriate person within the
organisation to take the complaint or the complaint should be put in writing.
All complaints about the Single Assessment Process should be dealt with in
accordance with the internal complaint procedure of the organisation receiving the
original complaint.
It will be important that reception staff have some knowledge of SAP and what to do
in the event of a query, comment or complaint. Service users or carers may also be
directed to the local Patient Advice and Liaison Service (PALS).
Where can I get copies of the Single Assessment Process Leaflet?
Printed leaflets should be available from your organisation or can be downloaded
from the SAP website www.devon.gov.uk/sap. These can also be offered in different
formats if the person requires such as other languages, braille, large print or audio
versions.

SAP Policy and Implementation Guidelines

Section 8 - Comments, Queries or Complaints about SAP

March 07