Care and Support Planning/Support Planning

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.

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.

If a person has eligible needs but intends to arrange alternative support (e.g. informal care or health support) or is self funding you must also complete a Care and Support Planning process 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; or
6. The person is at risk of abuse or neglect.

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.

A Support Plan

Whenever you complete a Support Plan you must involve:

1. The carer whose plan it is; and
2. Anyone else that the carer has asked you to involve.

If you feel that anybody else needs to be involved in the Support Plan (for example the person with Care and Support needs or a family member) you can only involve them with the carer's consent to do so.

The Care Act defines what must be included in any final Care and Support/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.

See: The Information that a Care and Support Plan must contain to read the requirements of a Care and Support Plan under the Care Act.

Also see: Section 18, Recording a Care and Support/Support Plan and Next Steps.

A carer with Support needs

Whenever a carer intends to arrange their own services or support, the Support Planning process should still be carried out whenever:

1. The carer requests it; or
2. You feel it would be beneficial due to the complexity of needs, situation or risk to the carer and the carer consents.

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

If the process of  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/carer to arrange any other services/support in the plan where required; and
5. Arrange for the Care and Support / Support Plan to be reviewed.

If there is no requirement for the Care and Support/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.

Upon ending the Care and Support Plan you must:

1. Provide the person (or their representative)/carer 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/carer 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/carer 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. In the case of a Care and Support Plan still to carry out any planned Care and Support processes with the carer.
11. In the case of a Support Plan, still carry out any planned Care and Support processes with the cared for person.

All of the above information should be confirmed in writing.

You should consider closing the case when:

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

Under the Care Act the person/carer is able to complete some or their entire 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/Support planning function you must provide the person (or their representative)/carer 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/carer;
2. Whether the person (or their representative)/carer understands the process and purpose of Care and Support/Support planning;
3. The support the person/carer 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/carer (and whether they are agreeable to doing so).

Before 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/Support planning process itself;
2. The requirements of a Care and Support/Support Plan;
3. The needs that are to be met through the 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/carer (for example around finances or risk); and
8. In the case of a person with Care and Support needs, where available the amount they will need to contribute financially to any Care and Support/Support Plan.

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

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).

See: Section 6, Tools and Practice Guidance for Care and Support/Support Planning.

When you are satisfied that the person/carer (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/carer no longer wishes to complete the plan.

The Care Act defines what must be included in any final Care and Support/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.

See: The Information that a Care and Support Plan must contain to read the requirements of a Care and Support Plan under the Care Act.

Because the final 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/carer you can use a blank copy as a tool to support the planning process.

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

Examples include:

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

Wherever possible, as long as it meets all the statutory requirements the Care and Support/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)/carer and use the information to complete a final plan in a format that does meet statutory requirements (the Local Authority single format).

The 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.

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

1. Facilitate and maximise the person's/carer’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/carer.

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

Care and Support/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/carer and support their engagement in Care and Support processes and any tool that you subsequently use should reflect what you know about the person/carer.

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

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

First and foremost you should have regard for any available practice guidance or good practice examples provided by the Local Authority.

These can be found in the Local Resource area.

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

tri.x has developed a range of person-centred tools that can:

1. Support a person / carer to think about what matters most to them, now and in the future;
2. Support a person/carer 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/carer or family member to think about what is working/not working about a Care and Support/Support Plan and any services or support they receive.

See: Resources for Person Centred and Strength Based Conversations.

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. See: Personalised Care & Support Planning.

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.

Some people with Care and Support needs 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, Data Protection legislation and local information sharing policies.

If a person/carer has 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/carer to support them to understand it;
2. Arrange to carry out Care and Support/Support planning in an appropriate format so that it is accessible. This is likely to be face to face, unless the person's/carer’s difficulty arises when engaging in face to face communication;
3. Consider whether the person/carer has an appropriate person to support their involvement and, if not, whether the advocacy duty applies.

See: Using Independent Advocacy, which includes guidance on how to establish whether a person needs an advocate and how to make a referral.

If the person/carer does not engage in the Care and Support/ 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/ Support plan, the process and the benefits of being involved.

If the person/carer 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/carer no longer wishes for the Local Authority to meet their needs

If the person has changed their mind and no longer wishes for the Local Authority to meet their 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;
3. If a carer with Support needs changes their mind and no longer wishes for the Local Authority to meet their eligible needs there is no requirement to continue the Support planning process.

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

1. Provide the person/carer 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. In the case of a Care and Support plan, continue to carry out any planned Care and Support processes with the carer as agreed; and
9. In the case of a Support plan, continue to carry out planned Care and Support processes with the cared for person.

All of the above information should be confirmed in writing.

Where you feel there is a risk that the person/carer 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.

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

If the person/carer 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/ 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/carer wants to represent them in the process; and
3. Explain that you will proceed to complete a Care and Support/ Support Plan based on the information gathered in the assessment and available services to meet eligible needs.

If the person/ carer continues to disengage you should proceed to develop a Care and Support/ Support plan based upon the information available from the assessment and the  available services. 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.

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 (or carer with 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 or carer (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 (or carer with 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/ 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/carer’s involvement in the process is maximised.

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

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

See Keeping People Safe.

As the local authorities representative you have a co-ordinating role regardless of whether you are completing the Care and Support/Support Plan with the person/carer or it has been delegated to the person/carer or their representation.

Care and Support/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 maximise the person's/ carer’s involvement at all times.

To ensure the person's/carers involvement you must:

1. Provide the person (or their representative)/carer with accessible information about the Care and Support/Support Plan purpose and the process before it begins and with sufficient time for them to digest it;
2. Answer any questions the person (or their representative)/carer has about the process or support them to access appropriate information sources;
3. Provide information to enable the person/carer to decide whether they wish to complete the Care and Support/Support Plan independently from the Local Authority (see delegating responsibility above);
4. Provide the person (or their representative)/carer 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.

In some cases only the person/carer who will need to be involved in the Care and Support/ support Plan. In other cases more people will need to be involved because:

1. A person with Care and Support needs has a carer (carers have to be involved);
2. The person/carer has asked you to involve another person;
3. The person/carer will be using independent advocacy or an appropriate person; or
4. The person with Care and Support needs 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/Support Plan;
2. The process of Care and Support/Support planning;
3. The indicative personal budget; and
4. The need to ensure the involvement of the person/carer.

Unless the person/carer 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.

It is important that everyone who is involved in the Care and Support planning process understands the role they have in it.

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/carer 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/carer 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 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/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.

tri.x has developed a tool that can be used as required to action plan.

See: Action Planning Tool.

The Care Act does not set out a timeframe to complete a Care and Support/Support Plan but it is important that the 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/carer; and
2. There are no unnecessary delays in the meeting of eligible need.

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/carer and should be proportionate and appropriate, maximising the person's/carer’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/carer and people involved to complete the plan.

The function of monitoring can be formal or informal, depending on what is agreed with the person/carer 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/ 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.

Sometimes the timeframe within which to Care and Support/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/carer as much as possible.

If there are urgent needs you may need to arrange interim services to ensure that these are met during the planning process. If this is the case see: Urgent or Interim Support.

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/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 you need to understand the person's/carer’s sense of Wellbeing now.

See: Talking about Individual Wellbeing.

Put simply an outcome is anything that the person/carer:

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/carer. Outcomes can be related to eligible needs but equally they may not be.

Outcomes should reflect the things that the person/carer 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 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/carer 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).

Providing services to meet outcomes

Services should not be provided with the sole intention of meeting an outcome. However, you should explore whether any of the services that are to be provided to meet needs could also be used to support the person to achieve outcomes at the same time.

Because Wellbeing and outcomes are so intrinsically linked you must understand a person's/carer’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/carer’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/carer 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/carer to gain insight into their own situation; and
2. Make a judgement based on evidence.

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

You should support the person/carer 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).

NHS Choices have an online resource: 5 steps to mental wellbeing.

Sometimes a person/carer 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/carer 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/carer to break the outcome down into smaller, more realistic outcomes that may achieve the same positive effect on their Wellbeing.

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

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

If this is the case, see Section 14, Deciding how the Plan will be Reviewed and Monitored.

When talking about meeting needs the starting premise should always be that the solution can be found somewhere from within the person/carer, 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/carer’s independence and the most effective in avoiding the need for formal intervention. They support the person/carer to take control of their own life and promote resilience.

See: A Strengths Based Approach.

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/carer to make an informed choice about the best way to meet their eligible needs.

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/carer receiving it.

As well as providing any information and advice specifically requested by the person you should provide the following information and advice as part of the Care and Support/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/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/carer and anyone else involved time to ask questions or seek clarity about the process and available options to meet needs.

'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/carer and anyone else involved to also take a diverse approach to the meeting of needs.

When you have decided with the person/carer 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/carer’s involvement in this decision is maximised. To do this you may need to consider a range of ways to explore options, depending on their needs and circumstances.

Examples could include:

1. Providing accessible information about different services;
2. Allowing time for the person (or their representative)/carer to research the providers online or through making direct contact with them;
3. The use of photographs to support a person with Care and Support needs 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.

Exploring how to meet needs from a strengths based approach can involve having some challenging conversations, particularly when the person/carer (or anyone else) 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 may also find the tool Six Tips to Help You Have Difficult Conversations useful.

You should 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.

Where differences in views about meeting needs persist you are responsible for ensuring that the Care and Support/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/carer’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 their 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/carer (or their representative) aware of their right to complain about the decision that has been made.

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.

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

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).

See: Talking about Risk.

As part of the Care and Support/Support planning process you must explore potential risks to the plan itself. Not doing so could place the person/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)/ carer should be involved in any conversation about risk and how to manage risk. In the case of a Care and Support plan, 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/carer; 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. See: Risk Assessment.

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/carer 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/carer 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/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/Support Plan.

Any cost associated with contingency should be included in the indicative budget amount and built into the total cost of the Plan.

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/carer 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/carer 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/carer 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/carer;
2. The availability of the services in the plan (to the person/carer 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/carer 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.

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/carer, 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.

See the Direct Payments Procedure and Guidance (Arranging Support, Services or Equipment), including when a Direct Payment can and cannot be arranged and the process for doing so.

Under Section 27 of the Care Act 2014, the local authority must keep 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 carer whose plan it is.

Because every carer 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 Support Plan review as follows:

1. A review of a new service or Plan should be carried out within 6-8 weeks of the service/change commencing;
2. A review of an on-going stable 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/carer’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 

Because the Care and Support/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 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.

You must let the person/carer know how they (or anyone else) can request an unplanned review outside of the agreed timescale if:

1. The Care and Support/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 network of support (for example if a carer is able to provide more or less support than anticipated in the plan).

The Care Act requires you to make proportionate and appropriate arrangements to monitor the Care and Support Plan whenever this is required (thus keeping the plan under review).

Examples of situations when monitoring may be required include:

1. If the plan is deemed unstable even with contingency;
2. If the person's/carer’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/carer’s situation and risk;
2. Agreed with the person/carer; and
3. Agreed from a strengths based approach to promote resilience of the person/carer 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.

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

If, as part of any conversation you have with a person/carer 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 Keeping People Safe, 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.

Where the safeguarding is in respect of the person/carer whose 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 planning process continues alongside any safeguarding process;
2. The planning process is paused with no on-going intervention by the person carrying it out whilst a safeguarding process takes place; or
3. The 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/Support planning process, the person who will be carrying out any safeguarding process, the person with Care and Support needs (and carer with Support needs) and any carer.

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

1. A person with Care and Support needs 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.

See: Recognising and Responding to Deprivations of Liberty.

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.

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.

See: Co-Operation to read more about co-operation under the Care Act.

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 maximise their involvement.

To ensure the involvement of the person/carer and to ensure that the Care and Support/ 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/carer 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 in a logical way.

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

The timeframe for making a record

Draft Plans should be recorded in a timely way and in line with local requirements.

Timely recording will:

1. Reduce the likelihood of inaccuracies;
2. Prevent any unnecessary delays for the person/carer; 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 / 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/carer's involvement in the plan has been maximised;
2. The plan promotes individual Wellbeing;
3. The person's/carer'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 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.

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 cost of the plan is greater than the amount of the indicative budget you need to ensure that additional information is provided in a proportionate and appropriate way to support the person signing off the plan to reach an informed decision about the need to increase the indicative budget amount.

In particular you will need to demonstrate:

1. That a strengths based approach to meeting needs has been taken;
2. The range of options that have been explored to meet needs (particularly that these have been appropriate and proportionate to the level of need);
3. The rationale for decisions when exploring the best way to meet needs (including why alternative options were not deemed appropriate, how outcomes and Wellbeing have been regarded and that there has been a positive approach to risk taking); and
4. The options to reduce, prevent or delay needs that have been explored.

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

1. The person/carer’s wants to include a social activity in their plan; or
2. 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.

When the Planning process was delegated to the person/carer or their representative you are still responsible for ensuring that the draft plan submitted meets the requirements for sign-off.

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/carer 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.