Care and Support Planning

1. Using this Procedure

This procedure should be used by anyone working in adult Care and Support carrying out Care and Support Planning following an assessment or review.

Anyone Support Planning with a carer should see: Support Planning (Carers).

Note: This procedure is used by all of the following teams and services:

1. Sensory Team;
2. Community and Hospital Assessment Team;
3. Locality Teams;
4. Enablement and Assessment Team; and
5. Long Term & Move on Review and Support Teams.

2. Introduction and Legal Requirements

What is a Care and Support Plan?

A Care and Support Plan is a document prepared by the Local Authority which specifies;

1. The needs identified by the needs assessment;
2. Which of those needs are eligible (applying the national eligibility criteria); and
3. Which needs the Local Authority is going to meet and how it is going to meet them.

When a Care and Support Plan must be completed

Legally you must complete a Care and Support Plan when;

1. The person has eligible needs; and
2. The Local Authority is going to meet (or in the case of self-funders in the community, make arrangements to meet) some or all of those eligible needs.

A Care and Support Plan must also be completed if an agreement has been reached to meet ineligible needs following assessment.

Who must be involved in completing a Care and Support Plan

Whenever you complete a Care and Support Plan you must involve;

1. The person whose plan it is;
2. Anyone else that the person has asked you to involve;
3. Any carer that the person has;
4. Where the person lacks capacity any other individual who appears to the Local Authority to be interested in the person's welfare.

This means that if the person has capacity you cannot involve anyone else in their Care and Support Plan other than their carer without their consent to do so.

What information a Care and Support Plan must contain

The Care Act defines what must be included in any final Care and Support Plan. It is important that you understand what must be included so that any Care and Support Plan that is developed meets the statutory requirements.

Click here to read the requirements of a Care and Support Plan under the Care Act.

3. When the Person intends to Arrange their own Support or Services

When Care and Support Planning should be carried out

Whenever a person intends to arrange their own support or services (because they are self-funding or because they intend to use informal networks or alternative services) a Care and Support Planning process should still be carried out whenever;

1. The person requests it; or
2. You feel it would be beneficial due to the complexity of their need and the person consents; or
3. The person lacks capacity and their representative requests it; or
4. The person lacks capacity and does not have an appropriate person able to explore and make a decision about the best way to meet needs; or
5. The person lacks capacity and the Local Authority decides it would be in their best interests to carry out Care and Support Planning;
6. The person is at risk of abuse or neglect.

The purpose of Care and Support planning when a person intends to arrange their own support or services is to;

1. Use professional support to explore all of the available options to meet needs;
2. Decide the best way to meet needs from the available options;
3. Make the best use of their financial resources for the longest time (if they are self funding); and
4. Decide the best method of arranging services.

Whenever Care and Support Planning is being carried out at the request of a person who is self-funding, or who intends to use informal or alternative support to meet their needs (or by their representative or in their best interests) the process is the same as it would be if the Local Authority were to meet needs.

Opportunities should still be taken to explore Local Authority options to meet needs alongside the intended informal or alternative options so that the person can make an informed final decision about how to meet their needs through the process.

Arranging services after Care and Support Planning

If the Local Authority will be meeting eligible needs in the community

If the process of Care and Support Planning has concluded that Local Authority support is required to meet some/all eligible needs in the community you must use these procedures to;

1. Submit the draft plan for sign-off;
2. Agree the final personal budget and how it will be managed;
3. Arrange services to be provided by the Local Authority;
4. Support the person to arrange any other services/support in the plan where required; and
5. Arrange for the Care and Support Plan to be reviewed.

If the Local Authority will not be meeting eligible needs

If the person still intends to arrange all of their own support/services they can choose whether to maintain the Care and Support Plan or whether to end it unless;

1. The person lacks capacity and their legal representative decides it would be in their best interests for the Local Authority to maintain the plan;
2. The person lacks capacity and the Local Authority decides it would be in their best interests to maintain the plan; or
3. The person is at risk of abuse or neglect (in this case there must be a Care and Support Plan).

If the person wishes to maintain the Care and Support Plan you must use these procedures to;

1. Submit the draft plan for sign-off;
2. Agree the final personal budget (to which the Local Authority contribution will be zero and the person's contribution/contribution from other sources will be the full amount);
3. Support the person to arrange services/support in the plan where required; and
4. Arrange for the Care and Support Plan to be reviewed.

If the Local Authority is requested to arrange services by a person who is self funding and has capacity they are legally entitled to charge an administration fee for making these arrangements. The Local Authority's position in respect of administration fees should be clearly set out in the Care and Support Charging Policy, which can be found by clicking here.

If the person will be living in a care home and is self-funding

Where the Care and Support Planning process determines that the person's needs are best met in a care home setting (including a nursing home) there is no legal obligation for the Local Authority to meet those needs, arrange these services or maintain the Care and Support Plan. However, a decision can still be made using powers under the Care Act to do so if;

1. The person  requests it and the Local Authority agrees;
2. The person lacks capacity, their legal representative requests it and the Local Authority agrees;
3. The person lacks capacity and has no legal representative or suitable person to arrange services on their behalf;
4. The person has complex needs, or needs that are likely to change (if so it may be beneficial for the Local Authority to arrange their service and maintain a statutory review function);
5. The person's situation is unstable, or at risk of becoming unstable without support from the Local Authority;
6. The likely need for future Local Authority involvement is high if arrangements are not made on the person's behalf.

If the Local Authority decides to arrange services for a person in a care home they are not permitted to charge an arrangement fee for doing so.

If the Local Authority agrees to maintain the Care and Support Plan to arrange services in a care home you should use these procedures to;

1. Submit the draft plan for sign-off;
2. Agree the final personal budget (to which the Local Authority contribution will be zero and the person's contribution/contribution from third parties will be the full amount);
3. Arrange the care home placement; and
4. Arrange for the Care and Support Plan to be reviewed.

Ending the Care and Support Plan

If there is no requirement for the Care and Support Plan to be maintained and the person wishes for it to end you should arrange to do so. However, you must be mindful that the duty to meet eligible needs is not discharged until alternative services are in place.

If you are not already familiar with the process for ending a Care and Support Plan seek the advice of your line manager as required.

Upon ending the Care and Support Plan you must;

1. Provide the person (or their representative) with any information and advice they request (or you feel would be beneficial) about available appropriate services to meet their needs;
2. Provide them with information and advice about ways they can prevent, reduce or delay needs;
3. Provide them with any other information that they request or that you feel will be beneficial;
4. Consider the support the person may need to arrange alternative services (the duty to meet eligible needs is not discharged until alternative services are in place);
5. Consider the support the person may need to contingency plan;
6. Explain to them what they should do if the alternative support breaks down in the future;
7. Agree any monitoring arrangements you deem necessary;
8. Explain to them what to do if they change their mind about arranging their own services;
9. Explain to them what they should do if their needs or situation changes; and
10. Continue to carry out any planned Care and Support processes with the carer.

All of the above information should be confirmed in writing using the general Local Authority letter template. Click here to access it.

Closing the case

You should consider closing the case when;

1. The Care and Support Plan is ended;
2. There is no need to monitor the situation; and
3. The person knows what to do should their circumstances change or they no longer wish to arrange their own services.

4. Delegating Care and Support Planning

Overall Responsibility

The Local Authority is legally responsible for the entire Care and Support Planning process.

However, under the Care Act the function of Care and Support planning can be delegated to anyone deemed appropriate who is;

1. Asking to carry out the function (so long as the person consents or it is deemed in their best interests if they lack capacity);
2. Willing to carry out the function (when asked to do so by the person or the Local Authority).

Someone can choose to complete the whole of their Care and Support Plan without your support or they can choose to complete a part of it.

Where a Care and Support Planning function is delegated (either in full or part) you will still need to co-ordinate and manage the process to ensure that it is completed in a timely and appropriate way.

Care and Support Plans completed by anyone other than a Local Authority representative still have to be signed off and agreed by the Local Authority.

Considerations before delegating to the person (or their representative)

Under the Care Act the person is able to complete some or their entire Care and Support Plan without your support if they request to do so and you deem it appropriate. They are able to do this independently, with the support of an advocate or with the support of any other person of their choosing.

Before agreeing to delegate the Care and Support planning function you must provide the person (or their representative) with information about the process and purpose of the function. This will enable them to make an informed choice about carrying it out and the level of support they may need to be able to do so.

Considerations you will need to make before delegating include;

1. The views and wishes of the person;
2. Whether the person (or their representative) understands the process and purpose of Care and Support planning;
3. The support the person may need to ensure their involvement is maximised (and whether the advocacy duty applies); and
4. The appropriateness of whoever will be supporting the person (and whether they are agreeable to doing so).

The process of delegating to the person (or their representative)

Before Care and Support planning can begin the person carrying out the Care and Support planning function must be provided with the information they need to be able to do so. This includes information about;

1. The Care and Support planning process itself;
2. The requirements of a Care and Support Plan;
3. The needs that are to be met through the Care and Support Plan;
4. The indicative personal budget amount;
5. Appropriate services available in the local marketplace and the cost of these services;
6. The prevention services available in the local area and any cost attached to these;
7. Any general or specific information and advice relevant to or requested by the person (for example around finances or risk); and
8. Where available the amount they will need to contribute financially to any Care and Support Plan.

If the format is accessible to the person you can provide a blank copy of the Care and Support Plan template used by the Local Authority to record plans as a tool to support them. This can be accessed by clicking here.

If the template is inaccessible, or the person wishes to use their own format they are able to do so (see below for guidance around the format of the plan).

There are also a range of other tools that available that may be appropriate to consider. Click here to access them.

When you are satisfied that the person (or their representative) has everything they need to complete the plan you should agree with them;

1. A timeframe for the plan to be completed; and
2. How you will monitor progress of the plan; and
3. What to do if further support is required or the person no longer wishes to complete the plan.

5. The Format of a Care and Support Plan

Statutory Requirements

The Care Act defines what must be included in any final Care and Support Plan. It is important that you understand what must be included so that any Care and Support Plan that is developed meets the statutory requirements.

Click here to read the requirements of a Care and Support Plan under the Care Act.

The Care and Support Plan format

Because the final Care and Support plan must meet all of the statutory requirements set out in the Care Act, the Local Authority uses a single format template.

If the format of the template is accessible to the person you can use a blank copy as a tool to support the planning process. This can be accessed by clicking here.

Using a different format

If the format of the template used by the Local Authority is not accessible, or will not ensure maximum involvement of the person it is appropriate to adopt a different Care and Support planning style for some/all of the plan.

Examples include;

1. Picture or drawing formats;
2. Video or audio formats;
3. Alternative written formats.

Recording when a different format is used

Wherever possible, as long as it meets all the statutory requirements the Care and Support Plan should be recorded in its accessible format.

If the plan format does not meet statutory requirements, or if it is not possible to record and file it as it is (for example the technology used by the Local Authority does not enable electronic filing of audio or video) you should explain this to the person (or their representative) and use the information to complete a final plan in a format that does meet statutory requirements (the Local Authority single format).

The final Care and Support Plan should;

1. Reflect all of the things from the original plan; and
2. Explain that a plan in a different format exists and where this can be located.

If it has not been possible to reflect everything in the original plan within the final plan then a copy of the original plan should be attached to the final plan whenever it is provided.

6. Tools and Practice Guidance for Care and Support Planning

General practice guidance

These procedures contain comprehensive general practice guidance to support an effective Care and Support planning process.

Legal Requirements and Statutory Guidance

Using a tool is not a statutory requirement but can be useful to support conversations during the process of Care and Support planning. However, any tool should;

1. Facilitate and ensure the person's involvement;
2. Support the process of exploring needs from a strengths based approach;
3. Be flexible and adaptable; and
4. Be appropriate and proportionate to the situation and needs of the person.

See below for details of the tools that are available for you to use as required.

Considerations when using tools

Care and Support planning involves having a skilled conversation about;

1. Wellbeing and outcomes;
2. Ways to meet eligible needs; and
3. Risk.

From the assessment (or other process to establish needs) you should have identified how best to communicate with the person and support their engagement in Care and Support processes and any tool that you subsequently use should reflect what you know about the person.

If you not feel that the tools available to you will be appropriate you should speak to your manager about how they can be adapted.

Available tools

There are a range of tools available to you to support effective conversations during the Care and Support planning process. You should consider the tool/s that you feel are best suited to the person and will maximise their engagement and you should agree with them that a tool will be used.

The following are tools available to you that may enhance any Care and Support planning conversations and accessibility.

Click here to access a range of tri.x person centred tools that can;

1. Support a person to think about what matters most to them, now and in the future;
2. Support a person or family member to think about Wellbeing;
3. Support a person or family member to think about needs and what a good day/bad day looks like; and
4. Support a person or family member to think about what is working/not working about a Care and Support Plan and any services or support they receive.

Think Local Act Personal have also produced an online tool to support everything from preparing a person for an assessment, to having a skilled conversation and developing a Care and Support Plan through to review. This can be accessed by clicking here.

The Local Authority subscribes to Research in Practice for Adults (RiPfa) who provide a range of tools and resources to support skilled conversations.

RiPfa can be accessed by clicking here.

If you have difficulties accessing the resources speak to your line manager.

'Supporting Outcomes-Focused Practice' is a supplementary RiPfa website, available without normal subscription. It can support you to develop your skills, knowledge and practice in working with outcomes. Click here to access it.

7. Mental Capacity and Engagement Difficulties

Care and Support planning when the person lacks capacity

Some people will lack capacity to understand or engage in the Care and Support planning process (verbally or through another means). For example, they may be too unwell to do so or have a significant learning disability. Where this is the case the duty to ensure their involvement still applies.

There are a range of ways that you can ensure the involvement of a person who lacks capacity, including but not limited to;

1. An appropriate other person or independent advocate to support the person to engage and ensure that they are represented;
2. Spending time with the person can show you what they enjoy about life and what may be most important to them (this could be a person, a place or something they do with their time);
3. Consulting with a range of people who know the person before reaching a judgement about Wellbeing, outcomes or how to meet eligible needs (speaking to a family member, a health professional, a paid carer, a college tutor and a day services manager will give a much better picture of what appears to matter most to the person than relying on the views of one person);
4. Use other available evidence to support you to understand Wellbeing and what matters most (for example ABC charts and other records that show behaviour changes clearly linked to an event, person or place).

All information gathering and sharing should be carried out with regard to the Caldicott Principles and local information sharing policies.

Use the tri.x Resources tab to access further information about the Caldicott Principles in the glossary.

Click here to access the Information Sharing Policy.

Care and Support planning when the person has substantial difficulty engaging

If a person does not lack capacity but does have substantial difficulty being involved in any Care and Support process you must take all reasonable steps to ensure their involvement.

You must;

1. Ensure that you have provided information in an accessible way, or that the person has an appropriate person to support them to understand it;
2. Arrange to carry out Care and Support planning in an appropriate format so that it is accessible. This is likely to be face to face, unless the person's difficulty arises when engaging in face to face communication;
3. Consider whether the person has an appropriate person to support their involvement and, if not, whether the advocacy duty applies.

Click here to access the advocacy procedures, including how to establish whether a person needs an advocate and how to make a referral.

Managing Disengagement

If the person does not engage in the Care and Support planning process taking place you should;

1. Establish whether the reason for their disengagement is related to substantial difficulty or mental capacity, and if so ensure they have the right support in place (an advocate or an appropriate other person);
2. Provide them with information to support them to understand the purpose of a Care and Support plan, the process and the benefits of being involved.

If the person continues to disengage from the process you should establish whether they still wish for the Local Authority to meet the eligible needs identified in the assessment.

If the person no longer wishes for the Local Authority to meet eligible needs

If the person has changed their mind and no longer wishes for the Local Authority to meet their eligible needs you must;

1. Be satisfied that the person has capacity;
2. Be satisfied that there is no legal requirement to proceed with Care and Support Planning.

If there is no requirement to proceed with Care and Support Planning you should;

1. Provide them with the information and advice they request (or you feel would be beneficial) about available appropriate support to meet their needs;
2. Provide them with information and advice about ways they can prevent, reduce or delay needs for Support;
3. Provide them with any other information that they request or that you feel will be beneficial;
4. Consider the support the person may need to access any alternative services;
5. Consider the support the person may need to contingency plan;
6. Explain to them what they should do if the informal or alternative support becomes unavailable in the future;
7. Explain to them what they should do if their needs or situation changes; and
8. Continue to carry out any planned Care and Support processes with the carer as agreed.

All of the above information should be confirmed in writing using the general Local Authority letter template. Click here to access it.

Where you feel there is a risk that the person will not make appropriate arrangements to meet their eligible needs you should make proportionate arrangements with them to monitor the situation, as the duty for the Local Authority to meet eligible needs is not discharged until alternative support/services are in place.

When informal or alternative services are in place and there is no need to monitor the situation you should consider closing their case.

Click here to access the checklist for closing a case.

If the person confirms that they still wish for the Local Authority to meet eligible needs

If the person confirms they still wish for the Local Authority to meet the eligible needs identified in the assessment you should;

1. Explain to them that a Care and Support plan is a legal requirement as part of the duty to meet their eligible needs;
2. Establish if there is anyone else that the person wants to represent them in the process; and
3. Explain that you will proceed to complete a Care and Support Plan based on the information gathered in the assessment and available services to meet eligible needs.

If the person continues to disengage you should proceed to develop a Care and Support plan based upon the information available from the assessment and the available services to meet eligible needs. This should be done in consultation with any carer and, if the person lacks capacity you should involve anyone else that you feel it would be in the person's best interests to involve.

A copy of the draft Care and Support Plan must be provided to the person and they should be invited to review it before it is submitted for sign-off.

Following sign-off a copy of the final plan must be provided to the person in the normal way. If at any point the person regains capacity or changes their mind about engaging the plan should be reviewed if this is appropriate and beneficial to the plan and the person's Wellbeing.

Refused access to a person requiring a Care and Support Plan

Sometimes another person may obstruct you from carrying out Care and Support planning with a person who has Care and Support needs. You should establish whether;

1. The person with Care and Support needs has asked the person to obstruct the process, and if so whether they still wish for the Local Authority to meet their eligible needs;
2. The person obstructing the process is doing so out of concern for the person with Care and Support needs (for example would the process cause anxiety);
3. The person with Care and Support needs is at risk of abuse or neglect.

Wherever possible you should provide information and advice relating to the Care and Support planning process to the person obstructing it, to support them to understand the benefits and engage in the process.

If the person continues to obstruct the process, and you are not able to establish from the person with Care and Support needs that this is at their request you must take action to ensure the process is carried out. By obstructing the Care and Support planning process the person is;

1. Putting the person with Care and Support needs at risk through lack of support;
2. Preventing the person from being involved in how their Care and Support needs are met; and
3. Preventing the Local Authority from fulfilling its duties under the Care Act to meet eligible needs.

A Care and Support planning process in this situation can be carried out based on the information gathered during assessment if this is the only option available. This should be done in consultation with any carer and, if the person lacks capacity you should involve anyone else that you feel it would be in the person's best interests to involve.

The advocacy duty should be considered and it is likely that a referral would be appropriate to ensure that the person's involvement in the process is maximised.

Opportunities to review the Care and Support Plan must be provided at such time when the person is involved, and all information sharing should give regard to confidentiality.

Click here to access the Information Sharing Policy.

Depending on the circumstances consideration should also be given to raising an adult safeguarding concern.

8. Using Independent Advocacy

If the need for independent advocacy has not already been established at assessment and you feel that the person may lack capacity or have substantial difficulty being involved in Care and Support planning then you must consider whether the duty to make independent advocacy applies and, if so make the necessary arrangements.

9. Co-ordinating the Process

The responsibility of co-ordination

As the local authorities representative you have a co-ordinating role regardless of whether you are completing the Care and Support Plan with the person or it is being delegated to the person, their representative or another organisation.

Care and Support planning is a person centred and person led process by law, and you must take steps (or be satisfied that the person delegated is taking steps) to ensure the person's involvement at all times.

Preparing the person

To ensure the person's involvement you must;

1. Provide the person (or their representative) with accessible information about the Care and Support Plan purpose and process before it begins and with sufficient time for them to digest it;
2. Answer any questions the person (or their representative) has about the process or support them to access appropriate information sources;
3. Provide information to enable the person to decide whether they wish to complete the Care and Support Plan independently from the Local Authority (see delegating responsibility above);
4. Provide the person (or their representative) with the indicative personal budget and explain what this is and how it has been decided; and
5. Consider the need for an independent advocate or appropriate person to maximise involvement.

Preparing others

In some cases the only person who will need to be involved in the Care and Support Plan is the person with Care and Support needs. In other cases more people will need to be involved because;

1. The person has a carer (carers have to be involved);
2. The person has asked you to involve another person;
3. The person will be using independent advocacy or an appropriate person; or
4. The person lacks capacity and a decision has been made in their best interests to involve another person.

It is important that everyone who is to be involved in the process is aware of;

1. The purpose of a Care and Support Plan;
2. The process of Care and Support planning;
3. The indicative personal budget; and
4. The need to ensure the involvement of the person.

Deciding different roles

It is important that everyone who is involved in the Care and Support planning process understands the role they have in it. Unless the person is completing their own Care and Support Plan independently roles should be discussed and agreed with them before planning starts, and their involvement should always be maximised. A few examples of roles could include;

1. Finding out information about available local services in the community;
2. Finding out about how to access a health service that may be beneficial to reduce a need;
3. Supporting the person to understand the information provided to them;
4. Co-ordinating a family meeting to talk about informal support that could be provided;
5. Speaking to a range of care providers;
6. Exploring risk and contingency;
7. Supporting the person to think about their most important outcomes and the things they could do to achieve them;
8. Writing a draft plan; or
9. Calculating the total cost of draft Care and Support Plan.

When roles are agreed it is important to also agree when different tasks and functions will be completed as this will affect how long the Care and Support Plan takes to develop. It may be useful to prepare a simple written action plan for this purpose that can be shared with everyone involved and used to monitor progress.

Click here to access a tri.x tool that can be used to action plan.

Deciding the format

Because the final Care and Support Plan must meet all of the statutory requirements set out in the Care Act, the Local Authority uses a single format template.

If the format of the template is accessible to the person you can use a blank copy as a tool to support the planning process. This can be accessed by clicking here.

If the format of the template used by the Local Authority is not accessible, or will not ensure maximum involvement of the person it is appropriate to adopt a different Care and Support planning style for some/all of the plan.

Click here to access the guidance about adapting the format of a Care and Support Plan.

Deciding the timeframe

The Care Act does not set out a timeframe to complete a Care and Support Plan but it is important that the Care and Support Plan is completed in a timely way so that;

1. It is able to build on any conversations about ways to meet eligible need that took place during the assessment process in as seamless a way as possible for the person; and
2. There are no unnecessary delays in the meeting of eligible need.

If the need to meet needs is urgent you may need to arrange interim services to ensure that urgent needs are met during the Care and Support planning process. If this is the case you can access the procedures for arranging urgent or interim support and services by clicking here.

Monitoring progress

When a timeframe is agreed it is important that you take steps to monitor progress, particularly where you have limited involvement in developing the plan yourself. The method of monitoring progress should be agreed with the person and should be proportionate and appropriate, maximising the person's involvement and control over the process.

Some of the factors that should influence the level of monitoring include;

1. The level of urgency to meet eligible needs;
2. The number of different people and tasks involved;
3. The motivation of the person and people involved to complete the plan.

There are likely to be several practical tasks involved in a Care and Support planning process and it may be useful to prepare a simple written action plan to monitor progress of different tasks and ensure that the broader timeframe agreed for plan completion is met. You will need to make sure that the tasks assigned to you are completed as agreed as well as monitoring general progress of everyone involved.

Click here to access a tri.x tool that can be used to action plan.

The function of monitoring can be formal or informal, depending on what is agreed with the person and most proportionate.  For example monitoring could include;

1. Face to face via a meeting;
2. Telephone conversations;
3. E-mail; or
4. Text.

Proportionate recording of monitoring activity should always be made.

If a plan is not progressing as agreed you will need to take appropriate action which could include;

1. Arranging advocacy support for the person if the person supporting them is no longer deemed appropriate;
2. Arranging a formal meeting to discuss progress and agree a way forward;
3. Taking responsibility for individual tasks to ensure they are completed; or
4. Where the Care and Support Plan is delegated, making a judgement that the delegation is no longer appropriate.

All of the above actions and decisions should be made with regard for the person's views and wishes, and should continue to ensure their involvement and control over the process.

Urgent Care and Support planning

Sometimes the timeframe within which to Care and Support plan is not conducive to all of the considered planning and preparation as outlined in this procedure. For example, there may always not be the time to research and make the best use of available information or to consult with others before arranging to meet with the person. However, even when the timeframe is short it is of paramount importance that you still;

1. Take all available steps to ensure the involvement of the person in the process;
2. Consider consent and mental capacity;
3. Provide independent advocacy where it is required; and
4. Prepare the person as much as possible.

10. The Skilled Conversation: Outcomes

Affirming Wellbeing status

You have a statutory duty to promote individual Wellbeing at all times. During the process of assessment or establishing needs you should have spoken to the person about their Wellbeing and the things that matter most to them (their outcomes).

It is important to affirm during Care and Support planning that the person's Wellbeing has not altered, and if it has, to ensure that any changes are acknowledged. Wellbeing can change quickly and quite dramatically and if this is the case you will need to understand the person's sense of Wellbeing now.

Click here to access the procedure for talking about Wellbeing.

Understanding outcomes

Put simply an outcome is anything that the person;

1. Wants to achieve;
2. Wants to change; or
3. Wants to stay the same.

Outcomes are personal and will be different for each person. Outcomes can be related to eligible needs but equally they may not be.

Outcomes should reflect the things that the person wants to achieve and not what other people want to happen.

Outcomes always relate to a sense of Wellbeing, but this is not always in a negative way.

The Local Authority's role in meeting outcomes

The Local Authority is not responsible for meeting outcomes, only for taking steps to support them to be met. As long as you can demonstrate that you have taken steps to support the person to meet their outcomes for the purpose of promoting Wellbeing this is all that is required (regardless of whether the outcome is ultimately achieved or not).

Understanding outcomes to promote Wellbeing

Because Wellbeing and outcomes are so intrinsically linked you must understand a person's outcomes in order to fulfil the duty to promote their Wellbeing.

These are the things you need to understand;

1. What the person's outcomes are;
2. What not meeting the outcomes now means for their sense of Wellbeing;
3. What impact meeting the outcomes would be likely to have on their sense of Wellbeing;
4. What impact not meeting the outcomes would be likely to have on their sense of Wellbeing.

When establishing the likely impact of meeting or not meeting an outcome on Wellbeing you should use all available evidence to justify your professional opinion. Often, if a person is experiencing a crisis their anxiety levels can affect their ability to rationalise the impact of an outcome on Wellbeing and your role is to;

1. Support the person to gain insight into their own situation; and
2. Make a judgement based on evidence.

Meeting outcomes to promote Wellbeing

When an outcome is likely to have (or is having) an impact on a person's Wellbeing you should promote Wellbeing by supporting the person to explore and take steps to achieve the outcome. This should be done through a strengths based approach.

You should support the person to;

1. Think about the steps they may need to take to achieve their outcome (and to break this into manageable chunks if the steps are overwhelming);
2. Think about the support they may need to take the steps to meet outcomes (including who can support them); and
3. Think about some of the barriers and challenges to meeting the outcomes (and the things they can do to overcome them).

Click here to access an NHS Choices resource that summarises 5 simple steps to promoting individual Wellbeing. These steps can form the basis of an effective strengths based conversation with a person and their family.

Providing services to meet outcomes

There is no duty to provide a Care and Support service with the sole intention of meeting an outcome. However, you should explore whether any of the services that are to be provided as part of the duty to meet eligible needs could also be used to support the person to achieve outcomes at the same time.

Unrealistic outcomes

Sometimes a person will have an outcome that you know is outside of their means to achieve (for example something outside of their financial or physical means). Whilst it is important for people to have a goal to work towards, having an outcome that is not realistic will ultimately only have a detrimental impact on Wellbeing because it will likely never be achieved.

You should be sensitive in your approach but you must endeavour to support the person to realise that the outcome they have may not be achievable. You should begin by following the 3 steps outlined in the previous section.

You could also encourage the person to break the outcome down into smaller, more realistic outcomes that may achieve the same positive effect on their Wellbeing.

Monitoring whether outcomes have been met

It is important to monitor whether outcomes have been met whenever a Care and Support Plan is reviewed and whenever needs are reassessed.

However, because of the potential impact on the person's Wellbeing you may decide that there is a need to monitor outcomes more frequently.

11. The Skilled Conversation: Ways to Meet Needs

There is a range of ways that the Local Authority can meet eligible needs under the Care Act, ranging from the provision of information and advice to professional support to the provision of a service. Click here to read more about them.

Strengths Based Approach

When talking about meeting needs the starting premise should always be that the solution can be found somewhere from within the person, their existing networks of support or their local community. Whenever available these solutions are always the most proportionate, the most likely to sustain a person's independence and the most effective in avoiding the need for formal intervention. They support the person to take control of their own life and promote resilience.

Click here to read more about a strengths approach, including access to a strengths based resource.

Information and Advice

The duty to provide good information and advice and to prevent, delay or reduce needs applies at all times. Good information and advice supports the person to make an informed choice about the best way to meet their eligible needs.

Click here to access information about the duty to provide good information and advice, including the duty to make sure that information and advice is accessible to the person receiving it.

As well as proving any information and advice specifically requested by the person you should provide the following information and advice as part of the Care and Support planning process;

1. Information about appropriate available types of service to meet eligible needs and the cost of these;
2. Advice about which ways of meeting needs may or may not be appropriate, based on evidence and your own professional knowledge;
3. Information and Advice about ways to prevent, delay or reduce needs (including signposting or exploring referrals to a prevention service);
4. Information about how services are arranged (including where relevant how services are arranged for self funders);
5. Information about the Sign-off process of the Care and Support Plan;
6. Information about how a final personal budget will be decided; and
7. Information about options to manage the personal budget, including Direct Payments.

You should also ensure that you have given the person and anyone else involved time to ask questions or seek clarity about the process and available options to meet needs.

Choosing which service to use

'Meeting needs' is an important concept under the Care Act and intentionally moves away from the previous terminology of 'providing services' for a reason. The Act expects you to take a diverse approach to the meeting of needs, which includes being able to support the person and any carer to also take a diverse approach to the meeting of needs.

When you have decided with the person the type of service to best meet needs (for example informal care, a community based service, home care, residential care) you will need to explore available options.

It is important that the person's involvement in this decision is maximised. To do this you may need to consider a range of ways to explore options, depending on the person's needs and circumstances.

Examples could include;

1. Providing accessible information about different services;
2. Allowing time for the person (or their representative) to research the providers online or through making direct contact with them;
3. The use of photographs to support a person to visualise a placement;
4. Arranging for the provider to visit the person at home;
5. Arranging for the person to visit a placement and meet staff and people who live there;
6. Testimonies of people already using a service.

Managing different views about the best way to meet need

Exploring how to meet needs from a strengths based approach can involve having some challenging conversations, particularly when the person (or their carer/representative) has traditional service-led ideas about the meeting of needs. However it is your role to support the person and any carer to explore the full range of options available to them and to make an informed decision about which would best meet needs.

You should also make effective use of supervision to explore and develop skills that will support you to have difficult and sensitive conversations with people in a positive way.

You may also find the tool 'Six Tips to Help You Have Difficult Conversations' useful. This can be accessed from the tri.x Resources by clicking here.

Where differences in views about meeting needs persist you are responsible for ensuring that the Care and Support Plan that is submitted for sign-off;

1. Meets all of the statutory requirements;
2. Has explored all of the available options; and
3. Reflects the most appropriate option to meet the person's eligible needs.

You are also responsible for ensuring that all reasonable steps have been taken to agree with the person the best way to meet eligible needs. As long as you have done this then, where disagreement remains you are ultimately responsible for making the decision about how best to meet eligible needs.

Where ongoing disagreement persists you should;

1. Seek the support and advice of your line manager as required; and
2. Make proportionate records of any conversations you have had to try and resolve the differences.

You must also make the person (or their representative) aware of their right to complain about the decision that has been made.

Click here to access information about the different ways a person can complain.

12. The Skilled Conversation: Risk and Contingency

Understanding what risk is

Risk is broadly defined as 'the probability that an event will occur with beneficial or harmful consequences'.

The aim of any conversation about risk is to maximise the benefits and reduce the likelihood of harm.

Talking about risks to the person

During the Care and Support planning process there will be a need to talk about risks to the person;

1. From the impact of their assessed needs (for example from falls or medication);or
2. From the outcomes they want to achieve (where there is an element of risk taking required to achieve them).

Click here to access the general procedures for talking about risks, including how to carry out a formal risk assessment.

Talking about risks to the Care and Support Plan

As part of the Care and Support planning process you must explore potential risks to the plan itself. Not doing so could place the person or their carers at significant harm should an element of the plan break down or fail to be delivered.

The kind of risks to the plan will vary depending on each person's needs and circumstances and any conversation that you have should be proportionate and appropriate.

Examples could include;

1. Risks that informal care will not be sustainable;
2. Risks that needs will not be met if a service provider is temporarily unavailable;
3. Risks that the support or services in the plan will not be as effective at meeting needs or supporting the person to achieve outcomes as intended;
4. Risks that a Direct Payment will not be managed appropriately.

The person (or their representative) should be involved in any conversation about risk and how to manage risk. Any carer should also be involved.

You need to understand;

1. What the risk is;
2. What the impact of the risk would be to Wellbeing of the person; and
3. How likely the risk is to occur (based upon available evidence).

Depending on the level of risk a formal risk assessment may need to be carried out. Click here to access the procedures for carrying out a risk assessment.

Contingency Planning

When risks have been identified a contingency plan will need to be agreed with the person. A contingency plan is a proactive agreement about the steps that will be taken to mitigate and respond to the identified risk.

A contingency plan should include;

1. Details of the risk;
2. The likely harm to the person if the risk occurs;
3. The proactive measures that will be taken to mitigate the risk; and
4. The reactive measures to any risk that occurs.

The conversation about the contingency plan should be from a strengths perspective. If the person is able to identify their own solutions and measures to mitigate and respond to risk they will have much greater control about what happens when risk occurs and how best to resolve issues in the best way for them.

Examples of proactive measures that can be taken to mitigate risks could include;

1. Being part of a community group to build networks of local support;
2. Training for a carer to support them to manage the person's needs or carry out safe manual handling;
3. Access to a specialist health service to maintain and promote good health;
4. A sitting service for a carer to enable regular breaks;
5. Respite away from home to support the carer to take regular breaks;
6. Contacting an alternative care provider in advance to register with them in the event they are needed;
7. Assistive technology to increase security and safety at home;
8. Increased monitoring of a Direct Payment.

Examples of reactive measures to risk that occur could include;

1. Emergency care provision arranged by the Local Authority (the Local Authority has a duty to arrange alternative care provision in the event of provider failure);
2. Changing from one care provider to another;
3. Additional formal care in the absence of informal care;
4. Requesting an urgent review of a Care and Support Plan;
5. Another family member stepping in temporarily if carer breakdown occurs.

The contingency plan should be appropriate and proportionate based upon the level of risk identified and the likelihood of occurrence.

The contingency plan should be clearly recorded in both the draft and final Care and Support Plan.

13. Deciding how to Manage the Personal Budget

Responsibilities and Requirements

One of the decisions that must be made when preparing the Care and Support Plan is how the personal budget will be managed.

You must provide information to the person about the range of methods available to manage their personal budget so that they can make an informed decision about which method would work best for them.

Wherever possible, the decision about how to best manage the personal budget should be made by the person unless:

1. They do not have the mental capacity to make this decision (in which case it must be made in their best interests);
2. They request a Direct Payment but either do not meet the criteria or you deem it inappropriate for a Direct Payment to be provided; or
3. The option requested is not available in the Local Authority.

Under the Care Act, a personal budget can be managed in 4 different ways:

1. The Local Authority can manage the personal budget;
2. The person can manage the personal budget as a Direct Payment;
3. A third party can manage the personal budget as an Individual Service Fund (ISF); or
4. As a combination of these options.

Note: Not all areas provide the option to manage a personal budget as an Individual Service Fund (ISF). Before discussing ISF’s with the person, you should familiarise yourself with local policy.

When deciding the best way for a personal budget to be managed you should consider;

1. The thoughts, wishes and views of the person;
2. The availability of the services in the plan (to the person and the Local Authority);
3. The appropriateness of a Direct Payment;
4. Where appropriate, the person's capacity to manage a Direct Payment; and
5. Where the person lacks capacity, the availability of a suitable person to manage the Direct Payment.

You should explain to the person that if the method of managing the personal budget does not prove to be the right method this can be changed at a later date.

Promoting Direct Payments

Specifically the Local Authority is expected to promote the use of Direct Payments, as this provides the maximum level of choice and control. The ability to meet needs by taking a Direct Payment must be clearly explained to the person, so that they can make an informed decision about whether they wish to take this option. This may mean offering the choice of a Direct Payment more than once during the planning process and enabling that choice by providing examples of how others have used direct payments, including via direct peer support from user-led organisations, for example.

14. Deciding how the Plan will be Reviewed and Monitored

Statutory timescales for review of a Care and Support Plan

Under Section 27 of the Care Act 2014, the local authority must keep Care and Support Plans under periodic review. This means they must have a system or process in place to ensure that reviews are carried out and monitored in a manner appropriate to the needs and circumstances of the person whose plan it is.

Because every person is different, the Care Act does not specify the frequency in which a Care and Support Plan review must take place. That said, the statutory guidance does expect the local authority to endeavour to carry out a Care and Support Plan review as follows:

1. A review of a new service or Care and Support Plan should be carried out within 6-8 weeks of the service/change commencing;
2. A review of an on-going stable Care and Support Plan should take place no less than 12 months after the date of the 6-8 week review, and then no less than once every 12 months after that;
3. Where the person's needs or circumstances are likely to change reviews should be arranged as required to monitor the situation and respond to changes in a timely way (thus keeping the plan under review).

Note: If the person is in receipt of a Direct Payment, statutory timeframes for review of the Direct Payment do apply. Wherever possible, Care and Support Plan reviews should always be aligned with Direct Payment reviews to reduce duplication for both the person and the local authority.

Deciding the timeframe for the Care and Support Plan review

Because the Care and Support Plan is new, or is being revised the next review date should be no longer than 6-8 weeks' time. This should be clearly recorded on the Care and Support Plan.

Where you are making arrangements for a service to carry out the next review (rather than carrying it out yourself) you must make sure that you have recorded this in a way that will ensure the service carries out the review at the agreed time.

Information and advice about unplanned reviews

You must let the person with Care and Support needs know how they (or anyone else) can request an unplanned review outside of the agreed timescale if;

1. The Care and Support Plan is not working as intended;
2. Their needs change (increase or decrease);
3. Their circumstances change;
4. The plan is affected by any change in the circumstances of an informal carer (for example if a carer is able to provide more or less support than anticipated in the plan).

Monitoring

The Care Act requires you to make proportionate and appropriate arrangements to monitor the Care and Support Plan whenever this is required.

Examples of situations when monitoring may be required include;

1. If the plan is deemed unstable even with contingency;
2. If the person's needs are expected to change in the short term (impacting on the level of support they will need);
3. If there is a likely risk of deterioration in needs or circumstance without monitoring;
4. As part of ongoing MDT involvement;
5. If you are co-ordinating the follow up of an action plan agreed at review;
6. To manage the risk from abuse or neglect.

The arrangements to monitor must be;

1. Proportionate and appropriate to the person's situation and risk;
2. Agreed with the person and any carer; and
3. Agreed from a strengths based approach to promote resilience of the person and their informal networks of support.

If you are unclear about the need to monitor you should seek advice from your line manager.

Monitoring arrangements must be clearly recorded. Where you are making arrangements for a service to monitor the situation (rather than monitoring it yourself) you must make sure that you have recorded this in a way that will ensure the right service carries out monitoring activity at the agreed time.

15. Safeguarding and Deprivation of Liberty

Safeguarding

If, as part of any conversation you have with a person or their family you become concerned that a vulnerable adult or a child is experiencing, or at risk of abuse or neglect you must respond appropriately.

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.

If you are concerned that an adult or child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialling 999 and seek immediate medical support if necessary.

Where the safeguarding is in respect of the person whose Care and Support Plan is being developed a decision will need to be made about the need to pause the process to allow a safeguarding enquiry to take place.

There are 3 possible options;

1. The Care and Support planning process continues alongside any safeguarding process;
2. The Care and Support planning process is paused with no on-going intervention by the person carrying it out whilst a safeguarding process takes place; or
3. The Care and Support planning process is paused but urgent interim support is arranged to ensure needs are met whilst a safeguarding process takes place.

Any decision should involve the person carrying out the Care and Support planning process, the person who will be carrying out any safeguarding process, the person with Care and Support needs (or their representative) and any carer.

Deprivation of Liberty

You must consider any appropriate action required to authorise deprivations of liberty whenever;

1. The person lacks capacity to make decisions about the Care and Support provided to them; and
2. You feel the level of restriction being imposed on the person is depriving them of their liberty; or
3. You feel the level of restriction required to meet their care and support needs following assessment is likely to deprive them of their liberty.

Click here to access the Recognising and Responding to Deprivations of Liberty Procedure for further practice guidance.

16. Combining Care and Support Plans with Other Plans

Combining a Care and Support Plan with another plan for the same person

If the person has more than one plan of any kind it may be appropriate to combine the plans into one to;

1. Prevent duplication of information;
2. Prevent the person from having to take part in more than one planning process;
3. Reduce administration.

Plans can only be combined if;

1. The person is in agreement (or a decision is made in their best interests if they lack capacity); and
2. Combining plans is technologically possible.

It is your responsibility to seek clarity about which plans can and cannot be combined before suggesting this as an option for the person.

Even if it is not possible to record separate plans on the system efforts should be made to carry out a single planning process with the person in which to gather all of the information required for all of the plans at the same time if;

1. They have requested a single planning process; or
2. A single planning process would ensure their involvement.

This may require joint working with another service area or team or with another organisation (for example health or housing).

Under the Care Act you are able to request the co-operation of any other organisation or person and that person or organisation has a duty to co-operate with the request unless doing so would;

1. Prevent them from carrying out their own statutory duties under the Care Act or other legislation;
2. Have an adverse effect on their general functions.

Click here to read more about co-operation under the Care Act.

Any available referral forms for health and housing services can be accessed by clicking here.

Combining a Care and Support Plan with a Carers Support Plan

When the person with Care and Support needs has a carer it may be beneficial to combine the Care and Support Plan with the Support Plan for the carer.

Plans can only be combined if;

1. The person is in agreement (or a decision is made in their best interests if they lack capacity);
2. The carer is in agreement; and
3. Combining plans is technologically possible.

It is your responsibility to seek clarity about which plans can and cannot be combined before suggesting this as an option for the person and carer.

Even if it is not possible to record separate plans on the system efforts should be made to carry out a single planning process with the person and carer in which to gather all of the information required for all of the plans at the same time if;

1. They have requested a single planning process; or
2. A single planning process would ensure their involvement.

17. Equipment to Meet Eligible Needs

If the Occupational Therapy service has carried out an assessment and intends to provide equipment or carry out works these should be included in the Care and Support Plan whenever;

1. They are being provided under the duty to meet eligible needs; and
2. The person already has an existing Care and Support Plan.

It is the role of the Occupational Therapy practitioner to provide the following information to the practitioner or service with statutory responsibility for reviewing and maintaining the Care and Support Plan;

1. The equipment and works that have been provided under the duty to meet eligible needs;
2. The date that the equipment or works was provided; and
3. The cost of any equipment over £1000 (where the local policy is to charge a person for equipment costing more than £1000).

You should then take steps to include the equipment or works in the Care and Support Plan.

The cost of the works or equipment will be zero unless;

1. The cost of any equipment is over £1000; and
2. The local policy is to charge for equipment over £1000.

18. Recording a Care and Support Plan and Next Steps

Using information gathered through the process

To ensure the involvement of the person and to ensure that the Care and Support planning process has been carried out in an accessible way there will be at least one (but possibly a range) of informal records made. Examples could include;

1. A blank copy of the Local Authority template with handwritten notes;
2. A tool that has been used by the person to explore Wellbeing;
3. Notes made about the different available services and associated costs;
4. A pros and cons list to support decision making about the best way to meet eligible needs from the options available;
5. A record of risks used for contingency planning.

It is important that you record all of the information gathered in a logical way;

1. On the final draft plan (where there is a requirement to provide the information on the plan); and
2. In electronic records (where there is no requirement to record the information onto the plan but the information needs to be recorded nonetheless).

Any informal records should be filed, destroyed securely or returned to the person (if they have requested this) after they have been recorded with full regard for confidentiality.

Click here to access the Information Sharing Policy.

The timeframe for making a record

Timely recording will;

1. Reduce the likelihood of inaccuracies;
2. Prevent any unnecessary delays for the person; and
3. Ensure that the duty to meet eligible needs is met as close to the need being identified as possible.

The information gathered during the Care and Support planning process should be used to complete a formal record of the draft plan proposed when you are satisfied that;

1. The person's involvement in the plan has been maximised;
2. The plan promotes individual Wellbeing;
3. The person's outcomes and the steps they can take to achieve them have been explored from a strengths based approach;
4. A range of methods to meet needs has been explored from a strengths based approach;
5. The method proposed in the draft plan to meet needs is appropriate and proportionate, taking into consideration the person's needs, Wellbeing, available services and indicative personal budget;
6. Risks to the plan have been explored and a contingency plan agreed;
7. Opportunities to provide information and advice and to access prevention services have been maximised; and
8. The method of managing the personal budget has been agreed, with Direct Payments promoted where appropriate.

What should be included in a draft plan

You are responsible for establishing the current framework used by the service for recording purposes. If you are unclear you should speak to your line manager before proceeding to make a formal record of the plan.

The following information must be recorded on the draft plan before it can be signed off;

1. The needs identified by the assessment;
2. Which of these needs meet the national eligibility criteria;
3. Which needs the Local Authority is going to meet and how it is going to meet them;
4. How any risk to the plan will be managed;
5. Which needs are going to be met informally, or through alternative services;
6. The information and advice that has been given about reducing, delaying or preventing needs that the Local Authority is not going to meet;
7. How you propose the plan will be reviewed or monitored;
8. The method of managing the personal budget proposed;
9. Where a Direct Payment is proposed, which needs are to be met with the Direct Payment;
10. Where a Direct Payment is proposed, any associated employer related costs;
11. The indicative personal budget; and
12. The proposed final personal budget.

Recording respite and other services to support a carer

When services to support a carer are being provided directly to the person with Care and Support needs (for example respite services) it is important that the services are recorded appropriately to ensure that the carer is not charged for the services;

1. The description of the service being provided should be recorded on both the Care and Support Plan and the carer's Support Plan (as part of the contingency plan); but
2. The cost of the service should only be recorded on the Care and Support Plan (as the service is not being provided to the carer as part of their personal budget).

When the proposed personal budget is greater than the indicative budget

If the personal budget being proposed in the plan is greater than the indicative budget generated by the person's needs following assessment additional information will need to be provided when submitting the plan for sign-off.  This can be accessed by clicking here.

When the cost of the plan is more than the proposed personal budget

Sometimes the cost of the total plan will exceed the amount of the personal budget being requested. This is because the Care and Support Plan may detail all of the ways that a person's needs are to be met, not just those methods being provided by the Local Authority. For example;

1. The person could be accessing a chargeable service in the plan that they will fund themselves through another means;
2. The person's family could be paying for a social activity in the plan that meets needs; or
3. The local ICB have agreed to contribute some of the cost of the plan because of the person's level of health needs (known as joint funding).

Where there is a difference between the total cost of the plan and the personal budget, the amount that anyone else is going to pay should be clearly recorded on the plan.

Next steps

When the draft plan has been formally recorded you should submit it for sign-off. Click here to access the procedure for submitting a plan for sign-off and for signing it off, including the steps to take if the proposed personal budget is greater than the indicative budget amount.

You should explain to the person that;

1. The draft plan has been recorded and is now to be submitted for sign off;
2. What the sign-off process involves, including the timeframe;
3. When and how you will communicate the outcome of sign off; and
4. What they should do if they have any questions or need to contact you before then.