KEY POINTS

  • All care and support planning should involve the person as much as they wish.
  • Take a holistic approach which covers the person’s wishes and aspirations in their daily and community life, rather than a narrow view purely designed to meet personal care needs.
  • Show how the person is going to meet their outcomes through the assets and opportunities in their networks and communities with the local authority filling gaps.
  • Customers or their representatives should receive a copy of their care and support plan which includes their personal budget amount.

December 2018: This chapter has been revised as a result of local review. In particular, Section 2, What is Care and Support Planning? and Section 3, What should be included in the Care and Support Plan? are new.

1. Introduction

People who have been assessed as eligible for ongoing support funded by Lincolnshire County Council (LCC) must have a Care and Support Plan which is proportionate to the needs to be met. This must be developed in partnership with the customer, their carer/s and Adult Care. Customers, and those people the customer has specified, must be given a copy of their final Care and Support Plan along with a letter detailing their actual personal budget amount in a format that is accessible to them. Where the customer has an Independent Advocate they must also be given a copy, if the customer agrees to this.

The Care and Support Plan should set out how the person’s assessed needs and outcomes will be met within their indicative budget, whether that is taken as a directly provided package or a Direct Payment.

2. What is Care and Support Planning?

The starting point should be an exploration of the person’s own support networks, their family, friends, social and community networks, tapping into as much local knowledge as possible. Consideration of the needs to be met should take a holistic approach that covers aspects such as the person’s wishes and aspirations in their daily and community life, rather than a narrow view purely designed to meet personal care needs. Care and support plans must detail what outcomes will be met through informal support, with the local authority filling gaps.

Care and support should put people in control of their care, with the support that they need to enhance their wellbeing and improve their connections to family, friends and community. A vital part of this process for people with ongoing needs which the local authority is going to meet is the Care and Support Plan. It outlines how an indicative budget might be used to meet them. Good support planning enables choice and control over the services they receive whist promoting their long term independence and quality of life.

To enable a customer to remain as independent as possible, practitioners should consider:

  • what strengths (skills, knowledge, experience or expertise) does the customer already have, and how could these be enhanced in order for the customer to remain as independent as possible; and
  • what other skills, knowledge, experience or expertise do people directly involved in the customer’s life already have or need to acquire in order to enable a customer to remain as independent as possible.

Before the local authority provides support to meet an outcome it is important to be confident that every other option been explored in terms of using the person’s own personal resources and those in the wider community to achieve the outcome. Consider – are you confident that other funding streams have been explored e.g. if there is any charitable funding / grants? Eligible needs will be addressed by the Care and Support Plan, and it should state how these needs are to be met through a combination of the person’s own resources, informal support, or through goods or services purchased with the personal budget.

The Care Act sets out when the local authority has a responsibility to meet someone’s care and support needs, and gives local authorities a legal responsibility to provide a Care and Support Plan. The Care Act provides people with a legal entitlement to a personal budget, and the personal budget must be included in every plan, unless the person is only receiving intermediate care or reablement support to meet their identified needs. In most instances, customers have a right to a Direct Payment to meet some or all of their needs, provided that the Direct Payment is used to meet the needs and outcomes identified in the plan.

When an assessment says that someone does not have needs that the local authority should meet, the local authority must advise customers about what needs they do have, and how to meet them or prevent further needs from developing. Practitioners must do everything they reasonably can to agree the plan with the person. The local authority has a legal responsibility to review the plan to make sure that the person’s needs and outcomes continue to be met over time. If anything has changed a new assessment must be carried out. The customer themselves also has the right to request a review of their Care and Support Plan, if they wish.

People should be encouraged to take ownership of their care planning, and be free to choose how their needs are met, whether through local authority or third-party provision, by Direct Payments, or a combination of the three approaches. Where a customer requires assistance to be involved in the support planning process and support is otherwise unavailable from an appropriate family member or friend, an Independent Advocate must be offered.

  • A customer may create a support plan in any format they choose, e.g. a document, a video or pictures. However, its content should be translated into the structured format of the Care and Support Plan in the customer’s electronic record.
  • Where people ask assessors to create a Care and Support Plan on their behalf, the Care and Support Plan on the customer record should be used unless someone specifically requests a different format as well.

In all instances the person or their representative must be given a copy of their Care and Support Plan. The plan must detail the needs to be met and how the needs will be met, and will link back to the outcomes that the adult wishes to achieve in day-to-day life as identified in the assessment process, and to the wellbeing principle in the Care Act. This process is central to the provision of person-centred care and support that provides people with choice and control over how to meet their needs (see Chapter 10, Care and Support Planning of the Care and Support Statutory Guidance).

The Care Act 2014 requires local authorities to “take into account the person’s own capabilities, and the potential for improving their skills, as well as the role of any support from family, friends or others than could help them to achieve what they wish for from day-to-day life” (Care and Support Statutory Guidance, Section 2.49). In order to do this, the approach should look at the person’s life holistically, considering their needs in the context of their skills, ambitions and priorities.

Guidance regarding a strengths-based approach is included in the Assessment chapter. Additionally, SCIE have provided the strengths-based approaches area as a resource for further information. As a starting point there should be an emphasis on a person’s assets and capabilities rather than focusing on deficits; put simply this is a ‘glass half full’ approach. This should include the support and strengths that they have in their communities as well as their own abilities.

3. What should be included in the Care and Support Plan?

The Care Act highlights additional information which must always be incorporated in the final plan:

  • the needs identified by the assessment;
  • whether, and to what extent, the needs meet the eligibility criteria;
  • the needs that the authority is going to meet, and how it intends to do so;
  • the individual’s desired outcomes requiring care and support;
  • the personal budget;
  • information and advice on what can be done to reduce the needs in question, and to prevent or delay the development of needs in the future;
  • where needs are being met via a Direct Payment, the needs to be met via the Direct Payment and the amount and frequency of the payments.

The Care and Support Plan should also include:

  • any needs currently being met by a carer;
  • contingencies for fluctuating needs, sudden change or emergency;
  • an anticipated review date if the person would find that helpful.

It is good practice for the person’s Care and Support Plan to include the following about them:

  • About me (where I live, who with, age, past history, employment);
  • What is important to me? (religion, friends, family, pets, hobbies);
  • What is working? (what parts of my life I am happy with);
  • What is not working? (what is not going well that I would like to change);
  • What I want to achieve (what I want my individual budget to do, to help the change, e.g. services, equipment, ensuring it reflects the assessed eligible unmet need);
  • How risks will be managed (being honest about risks, who will manage the risk and understanding the responsibilities)/
  • Who I want to care for me (who will do what and how, what could support them in their caring role);
  • My contingency plan (if my regular care fails or cannot provide the care that I want to happen).

The plan must detail the needs, how they are to be met, and how they link to the individual’s desired outcomes and to the wellbeing principle in the Act. Outcomes should reflect the individual’s wishes, aspirations and what is important to and for them, where this is reasonable. The Care and Support Plan may include any additional elements where relevant and be presented in a format that makes sense to the person.

For additional guidance and resources, the Think Local Act Personal website and Skills for Care both provide information on delivering Care and Support Planning.

4. Contingencies

The person’s Care and Support Plan should cover what contingency arrangements are in place should the care and support in place fails. When considering the customer’s needs and how they may be met, consideration should be given for any needs that are being met by a carer. The person may have assessed eligible needs which are being met by a carer at the time of the plan; in these cases the carer must be involved in the planning process. Provided the carer remains willing and able to continue caring, the local authority is not required to meet those needs. However, the local authority should record the carer’s willingness to provide care and the extent of this in the plan of the person and also the carer, so that the authority is able to respond to any changes in circumstances (for instance, a breakdown in the caring relationship) more effectively.