Health and DisabilityApplication for Assessment

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2 Health and Disability: Application for Assessment

3Health and Disability: Application for Assessment

Guidance NotesThis form should be completed if someone within the household has a health condition or disability which is affected by the current accommodation and you require re-housing because of this.

What you should do:• Complete all questions on the application form, giving as much detail as possible.

Failure to do so could result in the application being returned.• Please remember that you must submit a recent ‘Assessment of Need and a Care

Plan’ from the Care Manager from the Health & Social Care Partnership• If further assistance is required to complete this application please contact your

local housing office.• Sign and date the form• Return the form in person to your local housing office or by post to East Ayrshire

Council who will deal with your application on behalf of the SEARCH partners: East Ayrshire Council

Housing Register Team Housing Service P.O. Box 13 John Dickie Street Kilmarnock KA1 1HW

What happens next?• The information you provide will be used to make an assessment of your housing

need by the Housing Occupational Therapist• In order to complete the assessment, the Occupational Therapist will contact you,

either by telephone call, home visit or at an office appointment• We will write to you when a decision regarding your application has been made

4 Health and Disability: Application for Assessment

InformationWhat is a Health and Disability Assessment?A health and disability assessment is the process we use to determine if your current accommodation is unsuitable for any member of your household relating to a health condition or disability.

The assessment focuses on an individual’s inability to access essential facilities and complete day to day tasks as a result of the home environment. It is not primarily based on an individual’s diagnosed medical condition or disability.

How do I apply for a Health and Disability Assessment?You need to complete this Health and Disability Application for Assessment. You will need to provide details of your current circumstances and return the form to your local housing office for assessment. It is very important that you complete all the questions on the application and give us as much information as possible; this will help us to carry out an accurate assessment of your circumstances.

What should I do if more than one person in the household has a health condition or disability that requires to be considered?A separate Health and Disability Application for Assessment should be completed for each person requiring consideration in the household. All applications will be considered but only one priority will be given to the household, which will be based on the assessment of the person with the highest needs.

Do I need a letter from my doctor or medical professional?No, you do not need any letters of support from your doctor or medical professional to apply. However, if you already have any information relating to your health or disability circumstances then you can enclose a copy of these with the application.

Who will carry out the Health and Disability assessment?An Occupational Therapist will make an assessment of your housing need on behalf of the following partners:

• Atrium Homes

• Cunninghame Housing Association

• East Ayrshire Council

• Irvine Housing Association

• Shire Housing Association

What will happen during the assessment?We will assess your application within 20 working days. The Occupational Therapist will contact you or your representative to discuss your circumstances in more detail. This may be carried out by telephone or a home visit or office appointment. In the course of a home visit the Occupational Therapist may ask you to show how your current home is affecting your health or disability, for example, climbing steps or stairs or accessing toilet facilities. The Occupational Therapist may discuss adaptations that may be carried out in your current home to make it more suitable for your needs. Additionally, they will discuss any specific housing requests that you may have, for example, housing for older people.

What priority can I be awarded?There are three levels of priority that can be awarded. These are:

Priority 3: Where the person’s quality of life is severely and adversely affected by their current housing situation. For example the current home environment makes it impossible for an individual to access all essential facilities, perform day to day tasks or poses a danger to life- 30 points.

Priority 2: Where the person’s quality of life is significantly adversely affected by their current housing situation. For example it has been assessed the current home environment severely restricts an individual’s ability to access most essential facilities, carry out day to day tasks or is significantly adversely affecting a health condition or disability- 20 points.

5Health and Disability: Application for Assessment

Priority 1: Where the person’s quality of life is mildly affected by their current housing situation. For example it has been assessed the individual is able to access essential facilities to perform day to day tasks however experiences difficulty and places a strain on health condition or disability- 15 points.

No Priority: No priority will be awarded were the person’s health or disability is not affected by their current housing situation and a move of house would not improve or alleviate their condition. For example it has been assessed the individual’s home environment is not affecting their ability to perform day to day tasks, they can access essential facilities without difficulty and does not exacerbate a health condition or disability.

What circumstances are unlikely to be awarded any priority?• If you are experiencing financial difficulties with your

current property. In these circumstances please contact your local Citizens Advice Bureau.

• If you are experiencing issues with outstanding repairs. Please report these issues to your Landlord.

• If you have a temporary condition which is expected to return to normal within 12 months, for example, if you are recovering from an operation or an injury or if you are pregnant.

• If you have difficulty accessing your property with a pram.

• If you find yourself in a potentially homeless situation. In these circumstances you should speak to a Homeless Persons Officer employed by your local Council or contact your local housing office.

• If you are overcrowded. Overcrowding is recognised as a priority factor and points are already awarded within the framework of the Allocation Policy for this.

• If you only want to move to Housing for Older People, A separate assessment will be carried out for applicants who wish to move to this type of accommodation. Contact your local housing office for more information.

What if my circumstances change?If your circumstances change you should tell us as soon as possible. If your health condition or disability has worsened then you may be asked to complete a new Health and Disability Application for assessment. If your condition has improved or your property has been adapted to meet your needs, your housing situation may be re-assessed and any health and disability priority you were initially awarded will be reviewed.

Can I re-apply?You should not re-apply for assessment unless your circumstances have changed or your health or disability has worsened.

How do I appeal?If you are unhappy with the outcome of the assessment you can appeal in writing within 28 days of the date of the decision letter. Please address any appeal to:

The Housing Register Manager Housing Register Team Housing Service P.O. Box 13 John Dickie Street, Kilmarnock KA1 1HW

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Application for Health and Disability AssessmentAll information provided will be treated in the strictest confidencePlease answer all the questions as fully as possible to help us consider this application.

If this form is not fully completed we will not be able to carry out an assessment.

A separate application form should be filled in for each person requiring consideration in the household. Only the highest priority will be considered for the whole household.

What is the Application for Housing Reference Number that this application relates to (if you have it)?

Name of main applicant

Current address

Name of joint applicant

Current address

Telephone number(s)

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Section 1: Information about the household member who has a health issue or disability

Name of household member with health issue or disability

Date of birth

Relationship to main applicant

Name of GP

Address of GP

Telephone number of GP

Please detail any prescribed medication the person is currently taking:

Does the person receive any health or social care support in their home, for example, home care, district nursing, occupational therapy? Please give brief details

Does the person receive any support from a Social Worker or health professional? If YES, please give name and address

YES: NO:

Name:

Address:

Phone Number:

Profession:

How often does the person see them?

When did the person last see them?

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Section 2: Information about the person’s current accommodation

Current accommodation type (please tick all that apply)

Sheltered Housing/Housing for Older People

Maisonette (Ground floor)

Amenity Housing Maisonette (Upper floor)

Flat (ground floor) House (three-storey)

Flat (upper floor) House (end-terrace)

Multi-storey flat House (mid-terrace)

Basement flat House (semi-detached)

Attic flat House (detached)

Bedsit upper Bungalow

Bedsit lower Other (please give details)

Four in a Block (Ground floor)

Four in a Block (upper floor)

How many bedrooms does your current accommodation have? (If you have a separate dining room you should count this as a bedroom)

Layout of current accommodation (please tick all that apply)

Bathroom upstairs Bedroom upstairs

Bathroom downstairs Bedroom downstairs

Toilet upstairs Curved internal stairs

Toilet downstairs Straight internal stairs

Number of external steps: Front door Number of external steps: Back door

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What does the person’s current home have? (Please tick all that apply)

Level access entrance Stair lift

Ramped entrance Tracking hoist fixed to the ceiling

Door entry system (not a communal one)

Handrails inside over stairs

Handrail(s) outside over steps Adapted kitchen (e.g. lowered worktops, special sink etc)

External lift Adaptation(s) for people with a hearing impairment

Community Alarm/Telecare Adaptation(s) for people with a visual impairment

Walk-in shower (wet floor area or level shower base)

Other (please give details)

Step-in shower

Over-bath shower

Specialist toilet/bath

Wider doors for wheelchair access

Specialist Equipment: Please detail any medical equipment, for example hospital bed, mobile hoist, ventilator, oxygen etc and/or other specialist equipment, for example, bathing, showering or toileting equipment, special seating, walking aid, that is currently used in the accommodation.

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Are you a wheelchair user?

If YES, where do you use it?

YES: NO:

Indoors: Outdoors: Both:

Section 3: Information about the difficulties the person is having in the current accommodation

Health and Disability: Points are awarded to applicants who have difficulties within their home, both in relation to their physical and mental health and there is clear evidence that a move of house would alleviate any current difficulties.

Please detail the applicant’s health conditions/disability including physical and mental health.

11Health and Disability: Application for Assessment

Please detail how these conditions are affected by your home

Please tell us if the person has any difficulty within their current property with any of the following (please tick all that apply)

Climbing outside steps Getting into rooms due to the width of the doors or hallways

Getting in/out bath or shower Other (please give details)

Getting on/off toilet

Climbing the stairs inside the accommodation

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Section 4: Information about Preferences

What would the person prefer to do? (Please note that it is not always possible to have properties adapted)

Remain in current accommodation (if it could reasonably be made suitable for the person’s needs)

Move to a house that has already been adapted, for example with a ramped access, shower or a stairlift.

Move to ground floor accommodation

Other (Please give details below of the reasons why this is the preferred option:)

Does the person require an additional bedroom due to their health needs or disability outwith their bedroom entitlement within the Allocation Policy? If YES, please give details:

YES: NO:

13Health and Disability: Application for Assessment

Please detail any other information that you think is relevant to this application

If the person wants us to deal with someone else on their behalf (a representative) about this application please give their details below.

Name

Address

Relationship to you (if any)

Telephone number(s)

If this application was completed by anyone other than the above please provide details below.

Name

Relationship to applicant

Signature Date:

14 Health and Disability: Application for Assessment

Declaration

Please read this declaration carefully

•I confirm that the details I have given on this application form are true and accurate.•I understand that if my circumstances change, I must tell East Ayrshire Council.•I understand that if I give any false or misleading information, or do not provide

relevant information, that any points awarded to my application can be withdrawn.•If I get a tenancy based on false or misleading information, I understand that the

landlord may take court action to evict me.•I understand that East Ayrshire Council can ask for additional information

from other agencies and health and social services professionals in connection with my application.

•I authorise these agencies and Health and Social Services Professionals to disclose any information needed in connection with my housing application to East Ayrshire Council .

• I understand that the information provided on this form, the assessment and any supporting evidence will form part of my housing application and may be shared with any or all of the SEARCH partners.

Applicant’s Signature Date:

Joint Applicant’s Signature Date:

If the person detailed in this application is not the applicant or joint applicant and is aged 16 years or over then they also need to sign this declaration.

Household member with health issue or disability:

Signature Date:

15Health and Disability: Application for Assessment

East Ayrshire Council Housing OfficesNorth West Kilmarnock Western Road, KILMARNOCK, KA3 1NQ Tel: 01563 555 670

Kilmarnock Central and South Council Offices, John Dickie Street KILMARNOCK, KA1 1BY Tel: 01563 576 618

Irvine Valley and Ballochmyle Council Offices, John Dickie Street KILMARNOCK, KA1 1BY Tel: 01563 554 664 or 554 653

Cumnock Rothesay House, 1 Greenholm Road CUMNOCK, KA18 1LH Tel: 01290 427 727 or 01290 427 728

Doon Valley Dalmellington Area Centre, 33 Main Street DAMLELLINGTON, KA6 7QL Tel: 01292 552 887

SEARCH Partner LandlordsAtrium Homes 14 Central Avenue, Shortlees, KILMARNOCK, KA1 4PS Tel: 01563 528 816

Cunninghame Housing Association 42 Campbeltown Drive, KILMARNOCK, KA3 1JX Tel: 01294 607 550

Irvine Housing Association 44-46 Bank Street, IRVINE, KA12 0LP Tel: 0345 112 6600

Shire Housing Association Netherthird House, Netherthird CUMNOCK, KA18 3DB Tel: 01290 421 130

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DATA PROTECTION

SEARCH is a Partnership involving East Ayrshire Council and Registered Social Landlords, Atrium Homes, Cunninghame Housing Association, Irvine Housing Association and Shire Housing Association. Contact details for all of the Partners can be found at the end of this document.

East Ayrshire Council will process your application on behalf of all of the partners. The Council and partners are data controllers in common. Any data protection queries can be directed to the Council’s Data Protection Officer using the details noted below. If your issues are not resolved following internal discussions, further enquiries or complaints can be made to the Information Commissioner’s Office, contact details below:

Data Protection Officer: Council Headquarters, London Road, Kilmarnock, KA3 7BU Tel: 01563 576094 Email: information.governance@east-ayrshire.gov.uk

Information Commissioner’s Office: 45 Melville Street, Edinburgh, EH3 7HL Tel: 03031231115 Email: scotland@ico.org.uk

It is necessary to process this information to perform a public task which is of substantial public interest – in other words to allow us to assess your current accommodation against any health issues or disabilities you are suffering to assess what assistance can be provided.

Your information will be available to all of the SEARCH partners. In order to fully assess your application, the SEARCH partners can ask for additional information from other agencies and Health and Social Services professionals in connection with your application.

You have the right to request any data held about you, the right to have inaccurate data corrected, the right to restrict or object to the processing of your data and the right to data portability in certain circumstances.

Your information will be retained for 5 years following cancellation of your application, or 5 years following the termination of your tenancy agreement if rehoused.