Evaluation Tool/Resource Allocation System (Children aged 6-11 only) This form is completed before support is put into as part of the assessment process and again during the formal review of support interventions. The section is to record parent’s view of the current situation using a traffic light system. Each colour represents the following answers: No, not at all Partly/sometimes/ not enough Yes always/completely/ not an issue The second section is completed by the worker and parent the guidance notes to identify what level of support is needed to achieve or maintain the outcomes. Please ensure that the assessment contains evidence of levels of support required. There is room for additional comments if required. 1 Very high levels of help are needed to achieve this 2 Lots of help is needed to achieve this 3 Some extra help is needed to achieve this 4 No additional help is needed to achieve this Name of Child: D.O.B. Name of parent/carer completing form: Post code of family home: Date Completed: LP/SW: Before Assessment At 12 month Review (please tick as appropriate)
1. Child a. My child can travel safely in vehicles. How much support is needed to achieve this? 25 15 5 2 Guidance Very high levels of help Lots of help Some extra help No extra help Specially adapted disability vehicle (wheelchair accessible). Is unable to travel without support due to complex medical needs which require frequent interventions. Is unable to travel without support due to frequent behaviours which put self and others at significant risk of harm. Has access to a mobility vehicle. Can only travel short distances without support due to complex medical needs which require interventions on long journeys. Uses a specialist car seat/harness in vehicles to manage behaviour. Is unable to access public transport with support due to behaviours which put self and others at risk of harm but these risks could be reduced with support. Displays behaviours which can be difficult to manage in a vehicle (e.g. kicking, trying to hit out etc, attempting to remove seat belt etc). Has difficulties getting in/out of vehicles. Can only travel short distances without support due to likelihood of behaviours which put self and others at significant risk of harm. b. My behaviour does not put themselves or other people at significant risk of harm. How much support is needed to achieve this? 25 15 5 2 Guidance notes Very high levels of help Lots of help Some extra help No extra help Evidence of individual ongoing risk assessment in throughout each day. Child displays behaviours that put self and others at significant risk on an ongoing Individual behaviour support plan and individual risk assessment process in place. 2:1 support needed at (not all the time). Child sometimes displays self-harming behaviours which put them at significant risk of harm. Regular reminders about behaviour expectations. Distraction techniques.
How much support is needed to achieve this? 25 15 5 2 Guidance Very high levels of help Lots of help Some extra help No extra help Specialist feeds only. No oral feeds. Has regular input from dietician/health professional regarding specialist diet. Diet has significant impact on child’s health. Child is fed via tube feeds. Requires full support with feeding. Child follows diet such as ketogenic, gluten free etc. Is on a specially formulated diet. Requires food cut up or mashed. Child is unable to prepare simple snacks (in line with peers) and requires a lot of support to do this. Requires some help with eating. Refuses/needs encouraging to eat some foods. Parent/carer needs advice and support re nutrition and healthy eating. Parent has to monitor child’s intake of food as they are unable to do so independently. Child is able to prepare snacks etc with some support and could learn to do this independently as they get older. f. My is able to take care of own personal care in line with age. How much support is needed to achieve this? 25 15 5 2 Guidance notes Very high levels of help Lots of help Some extra help No extra help OT assessments indicates child needs manual lifting and full assistance with personal care. OT equipment (e.g. hoists, slings etc to bath, wash and equipment to help carers care safely etc) already in place. Uses continence pads (day or or both). Needs support from carer to be washed/bathed. Child has assistive equipment (eg: bath lift to help get in/out bath and/or supportive toilet equipment to help get on/off toilet. Reminding of Assistance to use toilet. Child needs regular reminders re personal care, is able to do some tasks independently and requires support with others. can learn some new care skills with support.