Actions and Next Steps (Community Solutions)

1. Transferring a Contact

It is important that the person/carer making contact speaks to the right practitioner at the right time.

Transferring a telephone contact

The service will often receive telephone contacts requesting to speak to a named worker or a particular service. However, this may or may not be the best person for them to speak to.

When the person/carer making the contact requests specifically to speak to or be contacted by a particular team or person you should establish as quickly as possible whether the contact should be forwarded to that practitioner/service.

You should check available systems to establish whether;

1. The person/carer is allocated to the practitioner they have requested to speak to; or
2. The service/team is responsible for either the assessment or review of the person/carers needs.

You should not transfer a telephone call to a named worker if it is clear that the worker is not allocated to the person/carer. This will not be helpful to the worker or to the person/carer as they will not be speaking to the right person to resolve the contact.

What to do if the practitioner the telephone contact is being transferred to is not available

If the practitioner is not available you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a member of the service/team they are based in.

If you know when the practitioner is likely to become available you should;

1. Inform the person/carer of this;
2. Leave the practitioner a message alerting them to the contact, any action undertaken and confirming the information given to the person about when to expect a call back;
3. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required should the practitioner be unavailable for more than a few hours;
4. Agree with the person/carer what they should do if the practitioner does not make contact at the expected time; and
5. Make a proportionate record of all the above.

If it is not clear when the practitioner will become available you should;

1. Inform the person/carer of this;
2. Leave the practitioner a message alerting them to the contact, any action undertaken and what information has been given to the person/carer;
3. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required; and
4. Agree with the person/carer what they should do if the practitioner does not make contact within an agreed timeframe; and
5. Make a proportionate record of all the above.

Click here to see the process for sending electronic messages.

Transferring a written, e-mail or text contact

When a written contact is addressed to a named worker or a particular service you should establish as quickly as possible whether the contact should be forwarded to that practitioner/service.

You should check available systems to establish whether;

1. The person/carer is allocated to the practitioner they have addressed the written contact to; or
2. The service/team is responsible for either the assessment or review of the person/carers needs.

You should not transfer a written contact to a named worker if it is clear that the worker is not allocated to the person/carer. This will not be helpful to the worker or to the person/carer as they will not be dealing with the right person to resolve the contact.

Before transferring the contact you should;

1. Confirm that the practitioner the written communication is being transferred to is available within a reasonable timeframe for the action indicated by the contact, or that there is a mechanism in place for the written contact to be received and managed by the service in which they work;
2. Where the communication is a letter or an e-mail, whether the practitioner wishes to receive the original contact (if not this should be filed securely); and
3. Where a written response confirming the contact has been received is required or requested, agree who will provide this.

The most secure way to transfer a written contact is to send a message to the practitioner or service alerting them to the contact and where it can be found on the recording system.

Click here to see the process for sending electronic messages.

Any original copies of e-mails must be sent via internal secure e-mail systems only and any original letters must be sent via internal postal services or secure delivery only.

Click here to access the Information Sharing Policy.

What to do if the practitioner the written contact is being transferred to is not available

If the practitioner is not available within a reasonable timeframe for the action indicated by the contact you should;

1. Leave the practitioner a message alerting them to the contact, where it can be found on the recording system and any action undertaken, including what has been agreed with the person/carer if contact has been made with them;
2. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required and writing any acknowledgement letter to confirm arrival of the contact;
3. When the practitioner is not available within any timeframes indicted in the written contact or for more than a few days inform the person/carer making the contact of this;
4. Agree with the person/carer what they should do if the practitioner does not make contact within an agreed timeframe; and
5. Make a proportionate record of all the above.

2. Referral for Assessment

Gathering information for the referral

Under the Care Act an assessment begins as soon as the Local Authority receives information relating to the person or carer. How the assessment progresses will very much depend on the quality and comprehensiveness of the information provided at the referral stage.  As such, it is important that the person making the referral provides the right information in the right way, so that;

1. The RAC meeting can determine the best team for allocation; and
2. The person does not have to unnecessarily repeat what they have said should their assessment progress into a more prolonged intervention.

The following information should be gathered during referral;

1. All personal details, including the persons full name (and also preferred name or previous surname), address and preferred contact details, date of birth, national insurance number and NHS number;
2. The name, relationship and contact details of the person making the referral (if not the person themselves);
3. When and how the person consented to the referral;
4. If the person has not consented to the referral, was a mental capacity assessment carried out and is the referral being made under Best Interests;
5. What the presenting issue is from the person's perspective and what they would like to happen;
6. What the presenting issue is from the referrer's point of view (if the referrer is not the person) and what action they may recommend;
7. What options have been considered with the person to resolve the issue so far, including what support the person has had from family and community networks;
8. What information and advice has been provided to the person or what information and advice may be required;
9. What prevention services have been used, considered or may be of benefit;
10. Any specific communication needs of the person that need to be considered so they can understand and be involved in any adult Care and Support process;
11. Whether the person is likely to have substantial difficulty in any adult Care and Support process, and if so whether an independent advocate has been considered;
12. Details of any previous or current Care and Support services (whether the Local Authority is providing them or not);
13. With the person's consent the name and contact details of anyone involved in their life who should be involved in any assessment (family member, friend or professional); and
14. Any other information deemed relevant by the person or referrer (if the referrer is not the person), for example whether the referral is being made as part of a safeguarding action plan or response.

If any of the above information is missing allocation may not be possible, and further information may be required.

All allocations for assessment must be agreed at the weekly RAC meeting, regardless of the team who has received the referral. This ensures that the most appropriate team carries out the assessment.

Click here to access the RAC referral form.

Allocation should take place in a timely way so as to;

1. Avoid any unnecessary delays to the person;
2. Reduce the risk of a deterioration in the situation; and
3. Maximise the use of measures that will prevent, delay or reduce needs.

Where there are a significant number of people awaiting allocation for assessment there should be a fair and consistent prioritisation process in place that takes into account;

1. The level of risk;
2. The level of need;
3. Current support in place and the sustainability/effectiveness of this;
4. The urgency;
5. The likelihood of deterioration; and
6. The potential for fluctuation.

An element of monitoring should be incorporated into any allocation process to ensure that you remain aware of every person's situation and are able to respond appropriately to any changes or need to re-prioritise allocation.

Guidance for Allocation

The Care Act recognises that each worker (regardless of whether or not they have a professional qualification) will possess specific skills, knowledge and experience that will enable them to carry out different Care and Support functions or work with particular people well.

Because of this there is no expectation that a particular role should carry out a particular function; instead the Local Authority should allocate tasks to the most appropriate person for the job.

Allocation decisions should take into account;

1. The skills, knowledge and experience of the worker in carrying out the function or process required;
2. The skills, knowledge and experience of the worker in working with the particular needs of the person (for example health needs or communication needs); and
3. The views and wishes of the person themselves in relation to the skills required of the worker and who they feel would best support them.

Click here to access a tri.x tool that can support consistent decision making when deciding who to allocate work to.

The Duty to Provide Independent Advocacy

Whenever the outcome of a contact is that the person/carer will be involved in any adult Care and Support process (including any assessment, review, reassessment or safeguarding) the Local Authority has a duty under the Care Act to make an independent advocate available to the person/carer when;

1. There is no appropriate other person to support and represent them; and
2. They feel that the person/carer would experience substantial difficulty being fully involved in the Care and Support process without support.

Decisions about the need for advocacy should be made as early as possible because advocacy must be provided before the Care and Support function to be carried out can begin. As such if you know that advocacy will be likely you should discuss this with the person and make a referral at the same time as you transfer the request for a review or reassessment.

Click here to find out more about the advocacy duty, including how to establish whether a person needs an advocate, the different advocates that are available and how to make a referral.

The Duty to Provide Information and Advice around Financial Assessment

The Local Authority has a duty to provide good information around finances at an early stage. This provides people with an understanding from the beginning about how they may be expected to contribute financially towards the cost of any Care and Support/Support they receive so that they can start thinking about and planning how they could use their financial resources flexibly to fund a range of potential care options. You should take any opportunity to provide this information, and should particularly make sure that it has been provided whenever a transfer is made to another service that may result in an assessment, review or reassessment.

For information relating to the specific financial information that must be provided under the Care Act click here.

Click here to see the answers to some frequently asked questions around financial assessment.

3. Transferring a Review or Reassessment Request

What is a Review

A review is the mechanism by which an existing Care and Support Plan is evaluated. This can lead to a revision of the plan or further intervention, such as a reassessment of need.

Under the Care Act, when a person is already receiving Care and Support from the Local Authority they may request a review of their Care and Support Plan at any time and the Local Authority must consider the request. Where the request is deemed reasonable the Local Authority has a duty to review the plan.

Where a change is requested to a plan and there is no planned review scheduled consideration should be given to arranging an unplanned review. Any review must be proportionate to the needs of the person and undertaken in a timely way so as to reduce the risk of a crisis developing and needs not being met.

What is a Reassessment

A reassessment is an assessment of the needs of a person who is had their needs assessed previously.

A reassessment can only occur if there has been a change in the person's needs and is often identified during the review process.

Transferring a Request to an allocated worker/responsible team

Before transferring the review or reassessment request you should;

1. Confirm that the practitioner the review request is being transferred to is available; and
2. That that their availability coincides with any urgent timeframes or deadlines indicated by the review; or
3. That there is a mechanism in place for the review request to be received and managed by the service in which they work.

Click here to see the process for sending electronic messages.

If the practitioner is not available you should speak with a manager in the team in which they are based to establish whether;

1. The request should still be transferred to the allocated worker to action when they become available; or
2. The request should instead be transferred to the service/team in which the allocated worker is based.

The Duty to Provide Independent Advocacy

Whenever the outcome of a contact or referral is that the person/carer will be involved in any adult Care and Support process (including any assessment, review, reassessment or safeguarding) the Local Authority has a duty under the Care Act to make an independent advocate available to the person/carer when;

1. There is no appropriate other person to support and represent them; and
2. They feel that the person/carer would experience substantial difficulty being fully involved in the Care and Support process without support.

Decisions about the need for advocacy should be made as early as possible because advocacy must be provided before the Care and Support function to be carried out can begin. As such if you know that advocacy will be likely you should discuss this with the person and make a referral at the same time as you transfer the request for a review or reassessment.

Click here to find out more about the advocacy duty, including how to establish whether a person needs an advocate, the different advocates that are available and how to make a referral.

The Duty to Provide Information and Advice around Financial Assessment

The Local Authority has a duty to provide good information around finances at an early stage. This provides people with an understanding from the beginning about how they may be expected to contribute financially towards the cost of any Care and Support/Support they receive so that they can start thinking about and planning how they could use their financial resources flexibly to fund a range of potential care options. You should take any opportunity to provide this information, and should particularly make sure that it has been provided whenever a transfer is made to another service that may result in an assessment, review or reassessment.

For information relating to the specific financial information that must be provided under the Care Act click here.

Click here to see the answers to some frequently asked questions around financial assessment.

4. Safeguarding Concern

Where the information gathered requires further action under safeguarding;

1. Click here to access the adult safeguarding procedures, including how to recognise abuse and neglect, how to raise a concern, how to record safeguarding information;
2. Click here to access the Local Safeguarding Adults Board Multi-Agency Safeguarding Procedures; or
3. Click here to access the Local Safeguarding Children's Board Multi-Agency Procedures.

5. Actions on behalf of an Allocated Practitioner, Team or Service

Under the Care Act any contact should be managed at the earliest opportunity, by the right person and with the least impact on the person/carer. Where possible you should manage any contact outcome yourself so as to avoid the person/carer any delays in a resolution.

Occasions when a contact should normally be transferred to an allocated worker/responsible team

Contact should be transferred when;

1. The person/carer has asked to speak with a verified allocated worker and that worker is available;
2. The person/carer has asked to speak with a verified responsible team;
3. The person/carer has asked to speak to a verified allocated worker who is not available but an appropriate colleague at their service is able to manage the contact; or
4. The person/carer has not asked for a verified allocated worker, but it is known that they have one and the worker is deemed the most appropriate person to manage the contact.

Occasions when a contact should normally be managed by the service

Contact should be managed by the service when;

1. The person/carer is not known to the Local Authority;
2. The verified allocated worker is not available and there is no appropriate colleague at their service to manage the contact;
3. No worker has yet been allocated to work with the person/carer;
4. The person has not asked for a verified worker, but it is known that they have one but that worker is not deemed to be the most appropriate person to manage the contact;
5. The contact relates to general information and advice about adult Care and Support.

Reviewing functions carried out

Some of the functions carried out may require an element of review or monitoring.

Where there is an allocated worker/responsible team you should seek to reach an agreement with them about how any follow-up actions or monitoring will take place. This decision should give regard to the views and wishes of the person about how they would like any follow up action or monitoring to take place.

Where there is not an allocated worker/responsible team you should agree with the person/carer and any third party involved how any follow-up action or monitoring will take place.

Where you are making arrangements for the service to follow up on the action you have taken (rather than following up on it yourself) you must make sure that you have recorded this in a way that will ensure the service follows up on it at the agreed time.

Recording action taken and informing the allocated worker/service

Proportionate records should be made of all action carried out and any follow up action or monitoring required, including the arrangements made with the person/carer or a third party to do so.

The allocated worker or responsible service must be alerted to the action that has been taken, the recording that has been made and any action agreed with the person about how this will be followed up or monitored.

6. Providing Information and Advice

The Local Authority (and anyone representing the Local Authority) has a duty under Section 4 of the Care Act to either provide directly, or provide access to a range of information and advice relating to adult Care and Support, including financial advice. This duty applies equally in respect of all local residents regardless of whether the person with Care and Support needs or carer is known to, lives in, or is already receiving services from the Local Authority.

Click here to read more about the duty to provide information and advice under the Care Act, including how information and advice should be provided and the specific information and advice requirements around finances.

The provision of information and advice is a primary function of the service and there are a number of resources available to practitioners and people requesting the information and advice that can be accessed:

1. To access information online via our care and support hub (including the Personal Assistant Finder) click here;
2. To access information in person visit the
   Heathlands Day Centre,
   520 Heathway,
   Dagenham
   RM10 7SE;
3. Click here to see the answers to some frequently asked questions around financial assessment.

The following local organisations are also able to provide general information and advice relating to all aspects of adult Care and Support (including finances):

1. Citizens Advice Bureau Dagenham
   339 Heathway,
   Dagenham
   RM9 5AF
   Telephone: 0208 507 5969
   Website: www.bdcab.org.uk/;
2. Citizens Advice Bureau Barking
   Barking Learning Centre,
   2 Town Square,
   Barking
   IG11 7NB
   Telephone: 0208 507 5969
   Website: www.bdcab.org.uk/;
3. Independent Living Agency
   123 Rainham Road North,
   Dagenham
   RM10 7FD
   Telephone: 0208 593 6677
   E-mail: independentlivingagency@btconnect.com
   Online contact form: www.independentlivingagency.org/contact-us
   Website: www.independentlivingagency.org/.

Sometimes it is helpful to contact a well known national organisation with a dedicated information and advice service or help-line. Click here for details of some national organisations offering this service.

Some national organisations do not have dedicated information and advice services but can still provide such support upon request. Click here for a wider range of useful national contacts for adult Care and Support.

Information and advice must be provided in an accessible way so that the person for whom it is intended can best understand and make use of it.

If you feel the person for whom the information and advice is intended will need support to understand it then you should;

1. Consider whether the person has anyone appropriate who can help them to understand it;
2. Consider any steps that you can take to support them to understand it (for example talking through the information over the telephone or summarising it in a simpler format); and
3. Consider the benefit of independent advocacy.

For further information about the role of an advocate, and how to make a referral click here.

If you are not clear what the local arrangements are for the provision of independent advocacy for information and advice please speak with your line manager before making a referral.

7. Following Up on Information and Advice

Under the Care Act the Local Authority has a duty to not only provide information and advice where it is needed, but to ensure that the information and advice it provides has been effective.

Therefore, when information and advice has been provided you should make appropriate arrangements to follow up with the person/carer to whom it was given in order to review how effective it has been.

The timescales for this follow up should be agreed with the person/carer to whom the information and advice was given and should reflect the individual circumstances and level of risk.

Where you are making arrangements for the service to follow up on the information and advice you have given (rather than following up on it yourself) you must make sure that you have recorded this in a way that will ensure the service follows up on it at the agreed time.

8. Providing Information about a Person

The Local Authority has a common law and legal duty to safeguard the confidentiality of all personal information.

As an employee of the Local Authority you are bound contractually to respect the confidentiality of any information that you may come into contact with. Under no circumstances should such information be divulged or passed to any persons or organisation in any form unless you have authorisation to do so.

All information sharing that takes place must be in line with data protection legislation (namely the UK General Data Protection Regulation and the Data Protection Act 2018) and local policy.

The Caldicott Principles must also be regarded. The Caldicott Principles are a set of principles that apply to the use of confidential information within health and social care organisations and when such information is shared with other organisations and between individuals, both for individual care and for other purposes. For further information, see: The Caldicott Principles.

Any unauthorised disclosure of confidential information may result in disciplinary action of individual prosecution under the Data Protection Act 2018.

For further information and guidance see: Providing Information about a Person or Carer.

9. Accessing a Prevention Service

Under section 2 of the Care Act the Local Authority cannot provide intensive or on-going long term interventions until it is satisfied that prevention services having been explored and deemed not suitable.

There are many kinds of prevention service available. Some are provided by the Local Authority and some are provided by the community or partner organisations, such as health. The service should explore all available prevention services in the local area before transferring a referral to a service or team for the provision of a longer term intervention.

Click here to read about the different types of prevention services described in the Care Act.

If you feel that a prevention service may be an appropriate service for the person/carer you can use the links below to find out about how to access different services.

Click here to access the Care Technology procedures.

Click here to find out about accessing the Occupational Therapy service.

Click here to access the procedures for Minor Works and low level equipment.