Actions Following a Care and Support Plan Review

1. Using this Procedure

This procedure should be used to carry out a range of actions following a Care and Support Plan Review.

If you have undertaken a carer's Support Plan review you should see Actions Following a Support Plan Review (Carers).

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

1. Hospital Pathway Team;
2. First Response Teams;
3. Review Teams;
4. All Age Learning Disability.

2. Deciding the Timeframe for the Next Review

Statutory timescales for review

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.

For further guidance about Direct Payment reviews see: Reviewing a Direct Payment.

Deciding the timeframe for the next review

Decisions about the timeframe for review must consider:

1. The complexity of the needs being met by the plan;
2. The likelihood of deterioration or improvement in the person's needs or circumstances;
3. The complexity of the plan itself (for example the level of on-going involvement required to manage the plan);
4. The level of on-going risk to the person (from fluctuating needs or abuse and neglect);
5. The risk that the plan will breakdown; and
6. Whether any on-going monitoring activity is planned in between scheduled reviews.

Decisions about the timeframe for review must have regard for:

1. The views of the person about the timeframe for review;
2. The views of any carer about the timeframe for review;
3. The views of anyone else involved in the Care and Support Plan; and
4. The impact on Wellbeing of the timeframe proposed.

If you are unclear about an appropriate timeframe for review you should seek the advice of your line manager.

If the person (or their representative) is not happy with the timeframe for review that has been decided you must make them aware of their right to complain.

Recording the timeframe for review

The agreed timeframe for the next review should be clearly recorded on the review record and the Care and Support Plan.

Where a short timeframe has been agreed you should record the rationale for this, especially if another person or team may be asked to carry out the next review.

Where you are making arrangements for someone else 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 review takes place 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).

3. When there are no Changes required to the Plan or the Personal Budget

If both the Care and Support Plan and the personal budget remain unchanged following a statutory review you should follow local processes to update the plan.

The updated plan should contain the following information:

1. The personal budget for the next review period; and
2. The next planned review date.

The updated Care and Support Plan must be provided to the person.

A copy of the updated plan should also normally be shared in full with any carer unless the person has capacity and has asked you not to share the plan, or to share only part of the plan. In this case you will need to discuss and agree which elements of the plan are to be shared having regard for confidentiality.

In all other cases a copy of the updated plan can only be shared with the person's consent (or in their best interests if they lack capacity to consent).

If the person consents (or lacks capacity and a best interest decision is made) a copy of the plan should be shared with any service provider who will be responsible for providing Care and Support to the person.

A copy must also be shared with anyone that the person requests you share a copy with, even if they were not involved in the review itself.

4. Revising a Care and Support Plan

General Guidance

Whenever you revise a Care and Support Plan you should refer to the various sections of the Care and Support Planning Procedure as required, facilitating an effective conversation.

Changes to a Care and Support Plan are only proposed changes until they have been signed off by an authoriser.

Whenever you revise a Care and Support Plan you should also consider the need to revise any carer's Support Plan at the same time.

Changing the method of managing the personal budget

A change in the method of managing the personal budget should be considered whenever:

1. The person requests it (or their representative if they lack capacity);
2. The Local Authority identifies a different method of managing the budget as more appropriate (to meet needs, outcomes or promote Wellbeing); or
3. There are issues with the current method of managing the budget (for example misuse of a Direct Payment).

Promoting Direct Payments

The Care Act expects you to promote the use of Direct Payments. This means that whenever you identify that a Direct Payment may be an appropriate way to manage all (or part) of a personal budget you should discuss the benefits of doing so and support access to a Direct Payment.

See the Direct Payment Procedure.

Ending, varying, suspending or arranging a Direct Payment

All Direct Payments should be ended, varied, suspended or arranged in line with local processes and requirements.

You must end a Direct Payment agreement if:

1. The person becomes subject to a requirement, license or order to undergo drug or alcohol rehabilitation, behaviour therapy or testing; or
2. The person will be moving (or has moved) into a care home.

You should consider ending a Direct Payment if any of the following situations apply and no resolution to continue the Direct Payment can be found:

1. The person managing the Direct Payment has breached a condition of the Direct Payment Agreement;
2. The person managing the Direct Payment has not been using the Direct Payment to meet eligible needs;
3. The person has become incapacitated and there is no suitable person to manage the Direct Payment;
4. The Direct Payment is being used to pay for a family member living in the same household as the person to provide care without prior agreement;
5. A Direct Payment is no longer deemed the most effective way to meet the person's needs.

See the Direct Payment Procedure for further guidance.

Changing the provider of formal services

When a decision has been made during the review to change the provider of formal services you should use the Commissioning and Brokerage Procedures to end current services and arrange a new one.

Concerns about a provider

If the current service is being ended because you have concerns about the provider you have a responsibility to:

1. Take any appropriate action under safeguarding; and
2. Raise general concerns.

See the Safeguarding Adults Procedure.

See Section 13, Reporting Concerns about a Service Provider.

Changing the Personal Budget

Examples of changes in circumstance that decrease a personal budget

1. An informal carer intends to provide increased levels of care (reducing the need for formal support);
2. The person no longer wishes to attend a day service, but will be going to a community group with a reduced cost instead;
3. There is going to be a change in service provision and the cost of this is less than the current provision;
4. Some needs are going to be met by an alternative provision, such as health or housing.

Examples of changes in circumstances that do not change the personal budget

1. The person will be changing the days that they receive formal support because of a change in college/work patterns;
2. The person has new outcomes that existing services will be supporting them to meet;
3. A new contingency plan within the same budget has been agreed.

Examples of changes in circumstance that increase the personal budget

1. The service provider has failed and the only appropriate alternative has an increased cost;
2. The needs of the person have not changed but an informal carer is no longer able to provide the same level of Care and Support;
3. The person was sharing costs of support with another person and that person no longer requires the support.

Revising the Care and Support Plan and sign-off

You must revise the Care and Support Plan so that all of the changes being proposed are reflected in it. The date of the next planned review should also be clearly recorded.

The plan should then be submitted for sign off.

See: Signing Off a Care and Support Plan and Agreeing a Final Personal Budget for further guidance.

When signed off the updated Care and Support Plan must be provided to the person.

A copy of the updated plan should also normally be shared in full with any carer unless the person has capacity and has asked you not to share the plan, or to share only part of the plan. In this case you will need to discuss and agree which elements of the plan are to be shared having regard for confidentiality.

In all other cases a copy of the updated plan can only be shared with the person's consent (or in their best interests if they lack capacity to consent).

If the person consents (or lacks capacity and a best interest decision is made) a copy of the plan should be shared with any service provider who will be responsible for providing Care and Support to the person.

A copy must also be shared with anyone that the person requests you share a copy with, even if they were not involved in the planning process itself.

5. Ending a Care and Support Plan

Circumstances when the person can request the Plan is ended

The person (or their representative if they lack capacity) may only request that the Care and Support Plan is ended in the following situations:

1. When all eligible needs are to be met through informal care and/or alternative services outside of a personal budget (for example health provision); or
2. When the person has become self funding and intends to arrange and manage their own services without involvement of the Local Authority.

Any request to end the Care and Support Plan in these situations should be considered but should only be agreed if you are satisfied that:

1. Informal carers are willing and able to meet eligible needs; and/or
2. The informal and alternative services proposed are appropriate to meet eligible needs; and
3. The alternative services are available; and
4. If the person lacks capacity there is an appropriate person to arrange and manage services; and
5. The person is not at risk of abuse or neglect.

In addition, there may be a benefit in maintaining the Care and Support Plan with the person's consent (or in their best interests if they lack capacity) when:

1. Needs are complex or likely to deteriorate without on-going Local Authority involvement;
2. Circumstances are likely to change or deteriorate without on-going Local Authority involvement;
3. Risks to the person are likely to increase without on-going Local Authority involvement.

If you are at all concerned about ending the plan you should discuss the benefit in maintaining the plan with the person and any carer, although you are only able to continue the plan if:

1. The person has capacity and consents to continuing the plan; or
2. The person lacks capacity and a best interest decision is made to continue the plan; or
3. The person is at risk of abuse or neglect (in which case the plan must be continued).

If the plan continues you will need to consider any revisions that are required to it, in particular:

1. Changes to the services and support to meet eligible needs;
2. Changes to the personal budget and the way that it is managed; and
3. Changes to the contingency plan to manage risk.

Circumstances when the Local Authority can decide to end the plan

There are only three situations when the Local Authority can consider ending the plan:

1. The person is self funding or intends to use alternative support and makes a request for the plan to end (see above); or
2. The person no longer has eligible needs; or
3. The person is self funding (or becomes self funding at review), is having their needs met in a care home (or will be moving to a care home), has capacity to arrange and manage their own services (or has an appropriate person to do so on their behalf) and the Local Authority has not previously agreed to maintain the plan.

Ending services in the Care and Support Plan

If a person has eligible needs and the decision is made to end the Care and Support Plan the duty for the Local Authority to meet their eligible needs is not discharged until:

1. Alternative support/services are in place; and
2. Alternative support/services are meeting eligible needs.

You will therefore need to consider any support that the person may need in order to arrange alternative services. This could involve:

1. Supporting the person directly to arrange an alternative service;
2. Monitoring when the person has arranged the service themselves;
3. Liaising with another person to do so (for example a carer or an advocate).

When alternative support/services are arranged you can end the support that was being provided by the Local Authority. This could be a staged approach to terminating services, in line with the time that different alternative services begin, or an all-encompassing approach with a clear end date for all services.

Ending the financial contribution

Whenever services are no longer provided through a personal budget you must notify the team responsible for financial assessment so that arrangements can be made to:

1. Cancel any financial contributions after the date that services ended; and
2. Reimburse any monies that may be owing to the person.

Ending the Care and Support Plan

You can end the Care and Support Plan itself when you are satisfied that:

1. Alternative services are in place;
2. Eligible needs are being met; and
3. The services provided by the Local Authority have ended.

Upon ending the Care and Support Plan you must:

1. Provide the person 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 contingency plan;
5. Explain to them what they should do if the informal or alternative support breaks down in the future;
6. Agree any monitoring arrangements you deem necessary;
7. Explain to them what to do if they change their mind about arranging their own services (where a person has requested the Care and Support Plan is ended);
8. Explain to them what they should do if their needs or situation changes (for example if the financial resources of a person self-funding a care home placement reduce); and
9. Carry out any Care and Support processes with the carer as agreed.

All of the above information should be confirmed in writing.

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 (or their representative if they lack capacity) knows what to do should their circumstances change or they no longer wish to arrange their own services.

6. Reassessment of Need

Whenever a review has identified that the person's need for Care and Support has changed a proportionate reassessment of need must take place. This applies regardless of whether the change indicates an increase in needs for support or a decrease. No revision of a Care and Support Plan can be made until current needs have been established and eligibility determined.

The process of reassessment is the same as the process of assessment, but it must take into account all of the information gathered at review to:

1. Avoid unnecessary duplication; and
2. Establish changes in need as quickly as possible.

7. Arranging Urgent and Interim Support

If the review has identified that there has been a change in need or circumstance you will need to consider the need to provide urgent or interim support to ensure that the duty to meet needs is fulfilled during the time that:

1. The reassessment of need is taking place; or
2. The Care and Support Plan is being revised; or
3. Steps are being taken to resolve issues with informal or alternative support provision.

See: Urgent or Interim Support, which provides guidance on when support should be considered, deciding how to meet urgent needs and arranging funding for urgent support.

8. Monitoring

Arranging to monitor a Care and Support Plan

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 (or their representative if they lack capacity) 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.

Recording monitoring arrangements

Monitoring arrangements must be clearly recorded.

Where you are making arrangements for someone else 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 monitoring activity takes place at the agreed time.

Monitoring

Monitoring should take place as agreed unless:

1. There is a need to revise the monitoring arrangements (due to an unexpected change in need or situation);
2. There is a need to carry out a different Care and Support function (for example a reassessment); or
3. Monitoring is no longer proportionate or necessary.

Any monitoring activity carried out should be clearly recorded and you should use supervision effectively to discuss and agree the need for continued monitoring.

When reducing or ending monitoring activity you should do this with regard for:

1. The person's views about the need to monitor;
2. The carer's views about the need to monitor; and
3. The impact on the person's Wellbeing of any decision (including their personal resilience).

Future reviews

Where monitoring of a Care and Support Plan is on-going consideration should be given to any subsequent statutory reviews being 'light touch; in nature.

Ending monitoring activity

If monitoring is no longer appropriate or required you should:

1. Ensure that a statutory review date is agreed and clearly recorded;
2. Explain to the person (or their representative) what steps to take should their needs or situation change;
3. Provide any information and advice as required; and
4. Cease monitoring activity.

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

If the person (or their representative) is not happy with any decision to reduce or end monitoring arrangements you must make them aware of their right to complain.

9. The Provision of Information and Advice

The duty to provide good information and advice about Care and Support applies at all times.

See: Providing Information and Advice for 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.

Following the review process it is important that you:

1. Offer information and advice as appropriate, including signposting to other sources;
2. Give the person and anyone else involved opportunities to ask questions or seek clarity.

See: Providing Information and Advice, which includes access to local and national information and advice resources (general and specialist).

10. Accessing a Prevention Service

Under section 2 of the Care Act the Local Authority must take opportunities to provide directly (or provide access to) prevention services whenever these may be of benefit in preventing, reducing or delaying needs for Care and Support.

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.

If, following a review you feel that a prevention service may be an appropriate service for the person you must support them to access it.

11. Requesting a Financial Reassessment

Following the review process you should consider any need to request a reassessment of the person's financial resources.

It is not lawful for the Local Authority to charge a person more than they can afford. Equally people should contribute what they are able to, so you have a duty to notify the team with responsibility for financial assessment if you become aware that:

1. A person's financial situation has changed (either improved or deteriorated);
2. A person is having difficulty making their contribution;
3. The personal budget is going to be changed;
4. The person is going to be using informal or non-chargeable services to meet some or all of their needs.

You should explain to the person (or their representative if they lack capacity)that you are going to be requesting a further financial assessment and why. You should provide them with information and advice as required about the financial assessment process. This is particularly important if the person has not had a financial assessment before.

See the Financial Assessment Procedure for further guidance.

12. Safeguarding Concern

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.

See the Safeguarding Adults Procedure, which also includes information about how to raise a children's safeguarding concern.

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 dialing 999.

13. Reporting Concerns about a Service Provider

Why it is important to report concerns

Under section 5 of the Care Act the Local Authority has a duty to maintain an effective and efficient market of services for meeting Care and Support needs in the local area. A key part of maintaining a market place is understanding what is working and not working about the marketplace. It is therefore important that you report any concerns you have about any organisation providing any kind of Care or Support.

The local marketplace includes:

1. Services that are commissioned by the Local Authority;
2. Services that are provided by the Local Authority (for example, Reablement);
3. Services used by self funders and people who have a Direct Payment;
4. Universal services available to all residents; and
5. Services provided by partner agencies (for example health or voluntary services).

Managing risk to the person

In all cases, you must take appropriate steps to manage the risk to an individual posed by the poor practices of a service provider. Effective ways of managing the risk could be:

1. Raising a Safeguarding concern;
2. Arranging an alternative provider (there is a duty to do this when a regulated provider fails);
3. Agreeing monitoring arrangements.

Regulated Care and Support services

The commissioning service are responsible for ensuring that regulated Care and Support services are safe and of a high standard when:

1. They are commissioned by the Local Authority (services provided in the Local Authority area or outside of it); or
2. They are being used by people who have a Direct Payment (services in the Local Authority area); or
3. They are available to people who self fund or use a Direct Payment (services in the Local Authority area only).

You should notify the commissioning service if you have general concerns about any of the following:

1. Domiciliary Care Providers commissioned by the Local Authority (either in the local area or outside of it);
2. Domiciliary Care Providers available in the local area but not commissioned (used by people with a Direct Payment or self-funders);
3. Residential and nursing homes commissioned by the Local Authority (either in the local area or outside of it)
4. Residential and nursing homes available in the local area but not commissioned (used by self-funders);
5. Reablement services provided by the Local Authority;
6. Regulated day services (those providing personal care) commissioned by the Local Authority or available in the local area;
7. Any other regulated Care and Support provision (for example Care and Support provided as part of a residential college placement).

Where you are providing details about a particular incident involving a person with Care and Support needs you should:

1. Make the person aware that you are raising the concern and why; and
2. Establish whether they consent to be contacted as part of any further information gathering if required.

The commissioning service will determine the most appropriate response to the concern that has been raised, which could include:

1. Contract renegotiation with a commissioned provider;
2. Agreeing and monitoring an action plan with the provider;
3. A temporary stop on the use of a provider;
4. A large scale safeguarding response;
5. Joint work with another Local Authority (when the provider is not local);
6. A recommendation to information and advice services not to signpost to a provider;
7. Notification of concerns to the Care Quality Commission;
8. A letter to people who use a service.

You may be asked to support the commissioning service by providing additional information or assisting in any investigation process they undertake. You are required to co-operate with any request under the Care Act unless doing so will:

1. Prevent you from effectively carrying out other duties under the Care Act; or
2. Prevent you from effectively carrying out duties under any other legislation.

Unregulated Care and Support services

Unregulated Care and Support services are generally services that do not provide personal care, and so do not have to be registered with the Care Quality Commission. They include:

1. Some day services;
2. Prevention services provided by housing;
3. Health services;
4. Colleges and training centres;
5. Advocacy services;
6. Voluntary and charitable services.

If the services are commissioned by the Local Authority you should report concerns to the commissioning service in the same way that you would report a concern about a regulated Care and Support service.

If the services are provided by a partner organisation (such as health, housing or education) there will be local arrangements in place to report concerns. If you do not know what these arrangements are you should:

1. Speak to your line manager; or
2. Speak to the commissioning service.

Where you are providing details about a particular incident involving a person with Care and Support needs you should:

1. Make the person aware that you are raising the concern and why; and
2. Establish whether they consent to be contacted as part of any further information gathering if required.

Personal assistants

When concerns arise about the practice of a personal assistant you should discuss your concerns with:

1. The person with Care and Support needs (or their representative if they lack capacity);
2. Any carer; and
3. The person receiving the Direct Payment (if this is not the person or the carer).

Depending on the nature of the concern it could be resolved through:

1. A conversation with the personal assistant to discuss the concerns and identify action required to resolve them;
2. The provision of training to the personal assistant (for example manual handling training);
3. A review of the working conditions and requirements in the contract to make sure that the tasks to be completed are clear.

If specialist information or advice is required or requested (for example relating to employment law) you should contact a suitably qualified person or organisation as required.

If presenting issues cannot be resolved or you remain concerned about the continued suitability of the personal assistant you should consider:

1. Any monitoring arrangements required;
2. The need to add a condition to the Direct Payment, that the Direct Payment cannot be used to employ the personal assistant; or
3. The need to end the Direct Payment.

Any decision must have regard for:

1. The views of the person with Care and Support needs;
2. The views of any carer;
3. The views of the person receiving the Direct Payment (if this is not the person with Care and Support needs); and
4. The impact on the person's Wellbeing.

You should seek the advice of your line manager and the team responsible for managing Direct Payments as required.

Concerns about a personal assistant providing support to others

If you know that the personal assistant is providing Care and Support to other individuals in the local area you must consider any further action required. This could be:

1. Notifying the team responsible for managing Direct Payments of the concerns so they can take appropriate action to notify others;
2. Raising a safeguarding concern in respect of another individual being supported by the personal assistant.

Concerns about a personal assistant who is part of a local register

When a personal assistant is part of a local register of PA's it is important that any unresolved or on-going concerns are reported to the organisation or person responsible for managing the register.

This will allow for the register to be updated and consideration given to the on-going suitability of the PA to be included on it.

Managing concerns about a provider

When raised, concerns should be managed in line with the London Borough of Sutton Provider Concerns Protocol.

This can be located in the Safeguarding section of the Local Resources.

14. Whistleblowing

When to raise concerns

The Local Authority values openness, transparency and candour and encourages you to raise concerns as soon as possible about the practice of any individuals (whether they are employed by the Local Authority or not) that you feel:

1. Compromises the safety or Wellbeing of a person with Care and Support needs; and/or
2. Compromises the safety or Wellbeing of a carer with support needs; and/or
3. Compromises the safety of a child.

Examples of individuals employed by the Local Authority include:

1. A social worker;
2. An occupational therapist;
3. Unqualified workers in social work or occupational therapy services;
4. Support workers in Local Authority day or provider services;
5. Individuals employed in other areas of the organisation (such as housing officers and teachers in Local Authority schools or colleges).

Examples of individuals employed by other organisations include:

1. Health professionals (for example a community or district nurse, a GP, a Psychiatrist or Psychologist, a Speech and Language Therapist. An Optician or a Dentist);
2. Police Officers;
3. A support worker in a charitable organisation;
4. An advocate.

The legal context for Whistleblowing

Whistleblowing is part of the Public Interest Disclosure Act 1998 (PIDA). Under the Act you:

1. Must be provided with a safe space in which to raise the concerns;
2. Must be taken seriously;
3. Cannot be subjected to any detrimental or unfavourable treatment and victimisation by the Local Authority or individuals as a result of making a disclosure.

Providing evidence of concerns

Legally you do not have to provide any hard evidence to support a whistleblowing disclosure, but if you have any evidence you should always provide it. This could be:

1. Details of when a specific incident occurred;
2. A witness statement written by you or that has been provided to you;
3. Other documentary evidence (for example an e-mail or letter).

Further advice

If you require further advice about whistleblowing before making a disclosure you can contact the Whistleblowing Helpline:

1. By telephone on 08000 724 725;
2. by e-mail at enquiries@wbhelpline.org.uk.

Raising a concern