Appendix 6: Model Needs Assessment and Support Plan

Managing Housing Benefit Claims in Supported Housing | Part E: Tools and Appendices

This appendix is a model form for assessing a tenant’s needs and planning the care, support or supervision they will receive. It puts Chapter 14 (14.2 and 14.3) and Chapter 15 into practice. It has four parts:

  • Part A: needs assessment
  • Part B: support plan, including supervision, move-on and reviews
  • Part C: notes on completing the form
  • Part D: a worked example

Status of the model. No particular form is required by law. A provider’s own assessment and plan, completed by trained staff using a structured form, is suitable for Housing Benefit purposes (Chapter 14, 14.2). Providers can adopt this model, adapt it, or check their own forms against it. Councils should accept any form that answers the same questions.

Why it is designed this way. The form follows the questions the case law asks (Chapter 15, 15.1): what the tenant needs, what is provided and by whom, how often, how it differs from ordinary housing management, and whether it is likely to make a real difference to the tenant’s ability to live in the accommodation (MMcF v Sefton BC [2016] UKUT 403 (AAC), paras 14 and 15). It also separates eligible housing-related support and supervision from ineligible care and personal support, so the same document supports both the exempt accommodation decision and the service charge decision (Chapter 9).

National Supported Housing Standards. The government has confirmed that the person-centred standard will require an individual needs assessment and a tailored support or supervision plan with agreed outcomes for each resident (Chapter 13, 13.4). This model is designed to meet that requirement. [Placeholder: check against the final standards when published.]

Part A: Needs assessment

Complete at or before move-in. In an emergency, complete a short initial assessment within the first few days and the full assessment as soon as practicable.

A1. The tenant and the referral

FieldEntry
Tenant name and date of birth
Scheme, address and move-in date
Referral route and referrer (name, organisation, date)
Self-referral: emergency or “hard to reach” reason, and date notified under the council-approved referrals framework
Other agencies involved, with contact details
Tenant’s consent to share information, and with whom

A2. Needs and risks

Record what is known in plain terms, specific to the tenant. Leave an area blank if there is no need. The third column is the most important: it links the need to living in the accommodation and keeping the tenancy.

AreaNeed or risk identifiedEffect on living in the accommodation and keeping the tenancySource
Managing the tenancy: rent, rules, neighbours
Looking after the home: damage, neglect, repairs
Safety: fire, self-neglect, self-harm
Risk from others: exploitation, cuckooing, abuse
Behaviour and relationships with other tenants
Mental health
Physical health and mobility
Substance use
Offending and licence conditions
Money and benefits, including Housing Benefit
Daily living skills
Personal care
Education, training and work
Wellbeing and social contact
Readiness for move-on

A3. Why this accommodation and this support

FieldEntry
Why the tenant needs supported housing rather than general needs housing
Why this scheme is suitable for them
What is likely to happen without the support (for example, tenancy breakdown, harm, return to rough sleeping)
Potential needs: support that may not be used every week but has a real prospect of being needed (for example, crisis or relapse)
Third-party indicators, if any (PIP, care package, probation, care or treatment plan, personalised housing plan)

A4. Assessor and tenant

FieldEntry
Assessor name and role
Relevant training, qualification or experience (DWP guidance, para 145)
Date of assessment
The tenant’s own views on their needs and goals
Tenant signature and date (or reason not signed)

Part B: Support plan

Complete with the tenant, from the needs in Part A. Each action should link to a need.

B1. Planned care, support or supervision

Use the “Type” column to show whether each action is eligible for Housing Benefit:

  • HRS: housing-related support, including tenancy sustainment and help with Housing Benefit (eligible)
  • IHM: intensive housing management and maintenance, including repairs and works arranged around the tenant’s needs (eligible)
  • SUP: supervision, including welfare checks and on-call cover (eligible)
  • CPS: care or personal support, such as personal care, counselling, emotional support or life skills (not eligible; record who provides and funds it)
NeedWhat will be doneTypeWho and how oftenAgreed outcome

B2. Supervision and out-of-hours cover

FieldEntry
Staff cover at the scheme (on-site hours, on-call hours)
How the tenant can reach staff, day and night
Response expected, and what staff will do
The tenant’s risks that make supervision necessary
Welfare checks or monitoring agreed, and how often

B3. Move-on plan

FieldEntry
Expected length of stay
Move-on goal (for example, general needs tenancy, other supported housing, return to family)
Steps towards move-on, and who will help
Support to claim housing costs in the new home

B4. Reviews

Review the plan at the interval agreed below and whenever the tenant’s needs change significantly. SHP suggests at least every three months.

Review dateProgress against outcomesChanges in need or riskChanges to the planNext review

B5. Agreement

FieldEntry
Review interval agreed
Tenant signature and date
Staff member name, role, signature and date

Part C: Notes on completing the form

For providers:

  • Be specific. Write about this tenant, not the client group. Plans that are identical for tenants with very different needs are unlikely to be enough (CH/1289/2007, paras 29 and 30).
  • Link every action to a need. Support is not provided unless there is some need for it (MMcF v Sefton BC, para 12).
  • Say how it differs from ordinary management. The comparison is with general needs social housing (Chorley BC v IT [2009] UKUT 107 (AAC), para 71). Routine tasks that any prudent landlord would carry out are not support on their own.
  • Record potential needs. Support that is available counts where there is a real prospect of it being needed more than very occasionally (DW v Oxford CC [2012] UKUT 52 (AAC), para 79). Say why.
  • Frequency, not hours. Record how often support is given. There is no minimum number of hours (DWP guidance, para 151; Chapter 15, 15.3).
  • Classify each action. The Type column shows which actions are eligible. Care and personal support must be identified and its funding recorded, even where it is provided by another organisation (DWP guidance, paras 160 to 162).
  • Do not overstate. Plan only what will be delivered, and record what is delivered (Appendix 7). Support that exists only on paper is not support (R(H) 6/08).
  • Involve the tenant. Record their views and goals, and give them a copy.

For councils:

  • Accept the provider’s own form where it answers these questions, and do not ask for a new one in a prescribed form (Chapter 14, 14.2).
  • Ask for the parts needed for the decision. Usually that is A1, A3, A4, B1 and B5. The detailed needs and risks in A2 can be summarised, with full detail only where a specific question requires it (Chapter 12, 12.6).
  • Read the plan as a whole. A single weak entry does not show that support is minimal.

Part D: Worked example

This example is fictional. It is based on a common model: a five-bedroom shared house for single homeless adults, let by a not-for-profit provider, with staff who visit each weekday and 24-hour on-call cover. There are no staff on site overnight. In smaller providers, the housing officer and support worker roles are often combined in one housing support officer.

D1. Summary of the assessment

FieldEntry
ReferralCouncil housing options team, from temporary accommodation, under the council’s temporary accommodation to exempt accommodation strategy
BackgroundAged 34. Two years of rough sleeping and sofa surfing. Previous tenancy ended with rent arrears and damage to the property
Main needs and risksAlcohol use, with periods of relapse; anxiety that makes dealing with letters and officials difficult; risk of exploitation by former associates; poor upkeep of the home when drinking, including fire risk from smoking
Effect on the tenancyWithout support, there is a high risk of arrears, damage, disputes with other residents and the room being taken over by others, leading to eviction and a return to rough sleeping
Potential needsCrisis support and intervention during relapse, which is likely to be needed more than very occasionally
Third-party indicatorsPersonalised housing plan from housing options; engaged with the local drug and alcohol service
AssessorSenior support worker, trained in structured needs assessment, with five years’ experience in homelessness services

D2. Support plan

NeedWhat will be doneTypeWho and how oftenAgreed outcome
Arrears risk; anxiety about lettersTenancy sustainment session; check rent account; help with Housing Benefit and change reportsHRSSupport worker, weeklyRent account up to date; no missed reviews
Poor upkeep of the room; fire riskRoom and fire safety check; agree a plan to remove hazards; repair damage linked to needs without rechargeIHMHousing officer, fortnightly, and as neededRoom safe and in good repair
Anxiety about contractorsArrange repairs at agreed times, explain in advance and accompany contractorsIHMHousing officer, as neededRepairs completed without distress
Risk of exploitation; disputes in the houseCheck the house and visitors on each visit; act early on concerns and disputes; safeguarding referral and police liaison where neededSUPScheme staff, each weekday, and as neededNo takeover of the room; tenant feels safe
Relapse and crisisOn-call cover; welfare check after any incident; agree a relapse planSUPOn-call staff, 24 hours; support worker after incidentsCrises managed without loss of tenancy
Low confidence; daily living skillsEmotional support and help with shopping and cookingCPSSupport worker, about 30 minutes in the weekly sessionCooking for self; more confident
Alcohol useTreatment and recovery key workCPSDrug and alcohol service, weekly; not provided or charged by the landlordTreatment maintained
Move-onPlan for a general needs tenancy after about 12 monthsHRSSupport worker, at reviewsReady for move-on with floating support

How the example works for Housing Benefit.

  • Exempt status. The housing-related support, intensive housing management and supervision together are more than minimal and are likely to make a real difference to the tenant’s ability to keep the tenancy (Bristol CC v AW [2009] UKUT 109 (AAC), para 31). The scheme does not rely on the care and personal support to qualify.
  • Eligible charges. The housing-related support, intensive housing management and supervision are eligible (Chapter 9).
  • Ineligible support. The emotional support and living skills help is personal support and is not eligible (Schedule 1, para 1(f)). Because the same support worker delivers it, the scheme’s build-up apportions that part of the worker’s time out of the service charge (Chapter 9, 9.3), and the plan records how it is funded. The alcohol treatment is provided and funded by another service, so no deduction arises for it (Chapter 3, 3.4.1).
  • What the example leaves out. Cleaning the tenant’s own room would be an ineligible day-to-day living expense (Schedule 1, para 1(a)), so the plan deals with the room’s upkeep through safety checks, hazard plans and repairs, not cleaning.

D3. How the plan changes for other schemes

Scheme typeWhat usually changes
Dispersed self-contained flatsNo shared-house checks; supervision rests more on visits, welfare checks and on-call cover. Dispersed accommodation can be exempt (Chapter 3, 3.4.2)
Prison leaversLicence conditions and risk management plans shape the plan; liaison with probation and, where relevant, MAPPA arrangements
Young people aged 18 to 25More time on living skills, which is personal support and must be apportioned and funded. Accommodation for 16 and 17 year olds is regulated by Ofsted (Chapter 22, 22.3)
Women at risk of domestic abuseSafety planning, controlled access and liaison with domestic abuse services weigh more heavily in supervision
Mental health step-downCare elements are often commissioned by the NHS or the council and recorded as CPS, with the landlord’s housing-related support and supervision alongside

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This template is licensed under CC BY 4.0: you can adapt it, with credit to SHP. See Rights and licence. Supported Housing People Ltd, Version 1.0, October 2026.