support planning€¦ · 3.1 teams in the learning disability service and the adult mental health...

Support Planning Adults’ Services

Practice Guidance

[S.25 Care Act 2014]

This guidance document explains how support plans are made with

individuals who have had a Care Act assessment by Adults’ Services and whose need for support in meeting their assessed outcomes around

health and wellbeing are being met or partially met, by Adults’ Services.

The arrangements in place to support adults who are funding their own care and support are also described, as are the arrangements for

identifying and taking action where a person may need to be subject to the Deprivation of Liberty Safeguards under the Mental Capacity Act.

Version: 3.2

Effective from:

20th August 2018

Review by:

August 2021

West Sussex County Council Adults’ Services

Support Planning (S.25 Care Act 2014): practice guidance

Author: Greg Slay, Adult Social Care Improvement and Quality Team

Copyright © West Sussex County Council / Version 3.2 / 20th August 2018

Status Updated

Version 3.2

Issue Date August 2018

Author Greg Slay, Lead for Quality Assurance (v3.2)

Edward Armstrong, Service Development Worker (v3.1)

Owner Dave Sargeant, Interim Director of Adults’ Services,

(2018)

Signed off by Tracie Thomas, Head of Safeguarding and Adult Social Care

Date November 2015

Issue

number

Date Author Principal Changes

1.1

2.1 Nov 2015 Wendy

Shepherd

Updated Practice Instructions following the

implementation of the Care Act Revised

Support Plan document

3.1 Jan 2017 Ed

Armstrong

Updated: sections 7, 8, and referencing to

Direct Payments practice guidance

3.2 Aug 2018 Greg

Slay

Added Appendix 1. General refresh of

linked websites.

Feedback: We welcome feedback about our policies and procedures. If you have any

comments about this document please e-mail:

[email protected]

Equality and Diversity

As part of our commitment to equality and diversity, and in line with the requirements of the Equality Act 2010, the County Council will ensure that

all people using our services are treated with fairness, dignity and respect irrespective of any of the protected characteristics.

mailto:[email protected]





Contents

This document should be read alongside:

a) ‘Achieving and evidencing good practice’; b) ‘Assessment’, ‘Eligibility’, and ‘Review and Re-assessment’ practice

guidance documents; c) ‘Direct Payments’ practice guidance;

d) Charging Policy; and

e) Mosaic user guidance.

Separate practice guidance has been prepared for support planning in

relation to carers.

All of the above can be accessed in the Professional Zone on the West Sussex Connect to Support website:

https://www.westsussexconnecttosupport.org.

This document is divided into the following sections:

Principles and legal duties;

Meeting needs; Support planning process;

Personal budgets;

Respite and replacement care; Contingencies and accruals;

Charging for arranging and administering a care package; and Recording in the support plan.

Appendix 1 provides information about arrangements for ‘Deprivation of

Liberty Safeguards in the Community.

https://www.westsussexconnecttosupport.org/





1. What are the principles and legal duties underlying the support planning process?

1.1 The key principles underlying the Care Act also apply to support planning. These include:

• Promoting wellbeing for individuals and their carers/family; • Preventing, reducing and delaying the development of needs;

• The importance of the individual participating as fully as possible in

decisions about them; and • Responding in a proportionate and flexible way.

1.2 The Care Act statutory guidance also provides some more specific

principles and duties with respect to support planning which are:

• The local authority must take into consideration the individual’s

preferences including when an individual wants to take more control over the support planning process, or wishes to have more support with

this; • The plan must detail the needs to be met, how the needs will be met,

and must link back to the outcomes that the adults wishes to achieve in day- to-day life and to the wellbeing principle;

• The support plan should be holistic;

• The support plan should reflect the individual’s wishes, their needs and

aspirations, and what is important to and for them, where this is

reasonable; • The plan should be person centered, and involve the person as much as

possible. Where the person has substantial difficulty being involved and no suitable representative, then an advocate should be involved;

• The plan should give the person choice and control over how to meet their needs, creativity should be encouraged;

• There should be no constraint on how the needs are met as long as this

is reasonable; and

• The council should refrain from any action that could be seen to restrict

choice and impede flexibility.

1.3 Furthermore, the Care Act Statutory Guidance (chapter 10,

paragraph 10.27) ( https://www.gov.uk/government/publications/care-act-statutory-guidance) clarifies the duties of the local authority and what

factors may be considered in agreeing whether a support plan and

personal budget is “reasonable”. This includes for example:

Not duplicating services provided under the Housing Act 1996 (or

equivalent and subsequent housing legislation) or provided by the NHS; Where there are overlapping entitlements, the council should take steps

https://www.gov.uk/government/publications/care-act-statutory-guidance






to support the individual to access the support they are entitled to

under other legislation, and discharge their duty in this way. For example, supporting an individual to apply for disability related

benefits; and The council may take into reasonable consideration its own finances

and budgetary position, including ensuring there are finances available to meet the needs of the entire population. This means that the council

may, when considering available alternatives, reasonably choose the option to meet identified need which delivers the persons outcomes for

the best value.

2. Meeting needs

2.1 The purpose of a support plan is to outline how a person’s eligible

needs will be met. The support plan will consider those outcomes which an

individual is unable to achieve as a result of their needs, consequently having a significant impact upon their wellbeing, and will identify how the

individual will be supported to achieve those outcomes.

2.2 Eligible needs may be met through a number of different avenues,

including:

supporting an individual to make best use of their own personal assets

and resources, and those in their local network and community;

advice and information; referral to other agencies which provide universal or targeted services;

supporting an individual to make use of entitlements to housing, NHS

healthcare, and to maximise their income through the social security benefits;

telecare;

equipment;

reablement; or provision of a personal budget – either as a one-off payment, a council-

managed budget (CMB) or a direct payment (DP).

2.3 An individual should have one, holistic support plan which identifies

how the total extent of their eligible needs will be met. Where a practitioner recognises during the assessment and support planning

process, that expertise from another professional is needed to identify the best way of meeting a need, this should be clearly noted. When a second

professional, updates a support plan started or completed originally by a practitioner from a different discipline, they should ensure the new

support plan describes how all eligible needs are met, in ways that are still appropriate and relevant. For example an Occupational Therapist may

need to consider if an element of a care package is made redundant by a





piece of equipment provided, and if so work with social workers and/or

support brokers to make the relevant changes to the support plan. Other elements of the care package may remain relevant to meeting eligible

need and should remain on the support plan.

3. Support planning process

3.1 Teams in the Learning Disability Service and the Adult Mental Health

Service use their own commissioning services and not the support brokerage teams. With these exceptions the County Council’s aim is, as

far as possible, to facilitate people to access to the support brokerage teams.

3.2 Older people mental health teams create support plans themselves

and/or work with support brokerage, depending on what is most relevant to each individual’s need.

3.3 Hospital social work teams and Adults CarePoint2 are able to complete initial assessments as well as short term services plans, to

provide a support plan for people where advice and information, a short term intervention, referral to the Community Reablement Service, or a

simple piece of equipment is needed and a personal budget is not

required.

3.4 Staff working in our Independent Living Service are able to create

support plans for individuals themselves. If a need for a care package or direct payment is identified for change, they should discuss with social work

and/or support broker colleagues.

3.5 For those cases where an assessment is completed, and a person

has eligible needs but does not require the support of the local authority to meet these needs, this can be noted on the “action plan” in the

assessment rather than proceeding to the support plan work step on Mosaic. The action plan is a proportionate response in this situation. This

option could be used for individuals whose eligible needs can be met solely by advice and information, or individuals who have the means and ability

to arrange (and pay for) their own care and do not require help with support planning.

3.6 When a person is being referred to a support brokerage team the

support planning episode will need to be passed to the local brokerage team (North, South, or West). The only managed exceptions (defined

below) to this process should be identified at assessment stage and recorded in the assessment form.





Managed exceptions

Managed exceptions are only allowed in the following circumstances:

Where the social care worker identifies a level of risk that would mean that

full transfer of the adult to the support brokerage team after assessment

may result in any one of the following:

An increased risk in crisis placement;

Hospital admission; Safeguarding concerns developing;

Lack of engagement from that person; and Where legislative requirements take precedent (for example where the

Mental Health Act determines that an adult must receive support).

Where a ‘Managed Exception’ is raised then the support broker should

communicate through the allocated worker and not directly with the person unless instructed to do so.

3.7 A Welfare Benefits Advisor referral must have been completed prior

to the support planning episode being started, when the support plan requires a personal budget. It is important to check this is in place so that

any charges the adult may need to make towards the cost of his or her care package are clear as soon as possible.

4. Personal budgets

4.1 A personal budget may be considered to meet eligible needs where

no other options can be identified. This includes where the role of a carer is becoming unsustainable and no other options have been identified to

provide replacement care.

4.2 The purpose of an indicative budget, calculated via the ‘Resource Allocation System’, is to provide guidance as to what budget is

proportionate to meet that person’s need. The indicative budget is based on an evidence based assessment. The indicative budget enables the

person (with support) to plan how to meet their needs and achieve their desired outcomes. Universal, preventative and community options should

be considered where possible.

4.3 The following checklist should be considered before a support plan is agreed and a personal budget is finalised and signed-off:





Tick Checklist

Is the support plan

reasonable?

Have

opportunities for

reablement been

maximised?

Irrespective of adult group and;

Including equipment or assistive technology?

Have you considered

strengths and assets?

Has what the person might already have

available been fully explored, for example, family

and friends?

Have other routes available to meet needs and achieve outcomes been explored, before considering if a personal budget is needed?

Have you considered the persons personal strengths, informal support, universal and preventative services?

Does the support plan

identify how all of

the eligible needs

identified in

assessment will be

met?

This either could be by:

Reablement;

Drawing on the person’s own strengths and

support/community networks; or

By a personal budget where there is no alternative.

Is this an effective use

of resources

to meet the

individual’s desired

outcomes,

and have all

alternatives been fully

explored?

Effective can be defined as ‘having a positive impact

on wellbeing’. The support plan should balance the

impact upon the wellbeing of the person and their

carer.

Are decisions and

costs based on

local market

conditions and

availability of

resources?

Is the plan sufficient

and does the plan

allow for a

contingency

A contingency plan may include some flexibility in

the personal budget; but should also consider other

resources available to that individual.





Is the support plan

sustainable?

Will the plan work longer term as well as

considering short- term outcomes. For example,

if a carer wishes to use much

of the personal budget up-front, are they able to sustain the caring role throughout the rest of the year without support and what is their contingency plan? Sustainability of plans should be openly discussed with both carers and cared-for individuals.

Is the person managing the budget clear about

their responsibilities in this respect?

Is the support plan safe?

Is positive risk-taking enabled including the

person having choice and control over

decisions made?

In hospital discharge scenarios, there should be

an expectation that opportunities for positive risk

taking will be reviewed at a later date (that is,

3-6 weeks after discharge).

Is the support plan

proportionate to the

individual needs,

circumstances and

outcomes desired?

How will the impact on

the person’s

outcomes and

wellbeing be

measured at review

and has this been

agreed with the

person?

4.4 Members of the public will increasingly use West Sussex Connect to

Support (https://www.westsussexconnecttosupport.org) to find and purchase services. This website is also a tool which should be utilised in

support planning by all staff.

Any service provider that does not have a page/presence on the West Sussex Connect to Support website

(https://www.westsussexconnecttosupport.org) but is already being

commissioned by Adults’ Services should be encouraged to create a website presence there. Information on setting up a presence on the

website is available, by clicking on the ‘Information for providers and local groups’ tile on the home page.







4.5 The following support plan sign-off arrangements have been

agreed for Adults’ Services:

• For Independent Living Service – team managers and supervisors will sign off support plans. The sign off is optional in

assessment but mandatory in support plan and review. For Social Work - Team managers (and nominated reps) will sign

off the assessment and the indicative personal budget, ensuring assessment is evidence-based and the Resource Allocation System

calculator is completed according to evidenced need.

• If the proposed support plan is over the agreed limit of £342 (Area teams) or, over £500, or over 10% of indicative personal budget if

that budget is under £500 (in Learning Disability teams or Physical Impairment), then this should go to a senior manager or panel for a

decision. • If the proposed support plan is under the agreed limit this will be

signed-off by the support broker manager for area teams, or team manager in Learning Disability teams, and the relevant area Lead

Social Care Professional in Adult Mental Health Services - as long as the principles set out above have been followed.

Contingency arrangements should be part of the support plan. Support broker managers can agree short-term variations of up to

£50 – they will need to clarify this variation in amount - per week on only one occasion per year. If a further variation is required then the

person will need to be re-assessed.

• Sign-offs need to be timely and should not delay either the person receiving the support they need or the service providers receiving

due payments. The personal budget will not be confirmed until the support plan is

signed-off.

4.6 Individuals can choose to receive their personal budget as either a Council Managed Budget, as a Direct Payment or as a combination of

both. For further information please refer to the Direct Payments practice guidance accessible in the Professional Zone on the West Sussex Connect

to Support website (https://www.westsussexconnecttosupport.org).

5. Respite and replacement Care

5.1 This should be discussed with the individual and carer including the respite/replacement care options available/required and how many

nights/sessions are required. When nights and banding are entered onto the support plan this will calculate how much budget is left.

5.2 If respite is being purchased, a ‘Short Stay Basic Charge’ (SSBC)

form must be sent to the individual to sign. SSBC covers a financial year.






This can be created in the support plan workstep on Mosaic, and once

completed must be uploaded there. If the person already has a package of care from Adults’ Services then staff should check that a SSBC form has

already been signed and uploaded. This can be recorded on the support plan.

5.3 Where replacement care is to meet a carer’s eligible needs this

should be captured in both the adult’s and carer’s own support plans; however the budget to provide the care is only included in one plan.

6. Contingencies and accruals

6.1 Individuals can build up (accrue) money in their personal budget to

make sure they are able to cover unexpected expenses that meet their agreed outcomes. However, accruals must be agreed by the council.

Currently, if the person has more than eight weeks of their personal budget allocation unspent, the support broker will look into the reasons

why this has happened.

6.2 Individuals who choose to receive a direct payment can accrue up to eight weeks’ worth of their personal budget. Any more than this will be

regarded as surplus. They will be expected to return surplus money to the council. For adults with a council-managed budget this can be taken back

centrally.

7. Charging for arranging and administrating a care package 7.1 Individuals who have savings and investments above the ‘upper

capital limit’ are regarded as ‘self-funders’. Individuals who choose not to disclose their financial circumstances, or decline to undergo a financial

assessment are assumed to have savings and investments above this amount. The current applicable ‘upper capital limit’ is set out in the

Charging Policy, available in the Professional Zone on the West Sussex Connect to Support website.

7.2 Following the implementation of the Care Act, self-funders with

eligible social care needs can request Adults’ Services to arrange, and to carry out the on-going administration of a care package on their behalf.

West Sussex County Council charge fees for this service. The current fees are shown in the Charging Policy, available in the Professional Zone on

the West Sussex Connect to Support website.

There are three parts to this service:

1. Searching the market to find a provider service(s) able to meet the

individuals care needs (a one off arrangement fee is charged);





2. Carrying out the ongoing administration of paying provider services’

invoices on behalf of the individual (a weekly administration fee is charged); and

3. Updating or altering the package of care received by the individual (further one off arrangement fees are charged for each alteration).

7.3 The fees attached to these services are updated every financial

year and published in the current version of the ‘Your life, Your choice’ information booklet.

7.4 These fees apply to all individuals who have savings and investments

above the ‘upper capital limit’ - including those with learning disabilities or

from a mental health background (unless S.117 Mental Health Act applies: for information on this read our policy and practice guidance on

S.117 Mental Health Act, available in the Professional Zone on the West Sussex Connect to Support website).

7.5 Individuals in long term residential or nursing care are not liable for

the fees described in 7.2 regardless of their financial circumstance.

7.6 The ‘AS164 Agreement to Pay a Charge’ form explains the financial threshold and brokerage fees and should be signed by individuals at the

point of first contact with Adults’ Services, with the full signed document being uploaded to their Mosaic case record.

7.7 Self-funders who do not have the mental capacity to consent to the

brokerage fee (or to arrange their own care) will not have the brokerage fees applied unless, or until, an appropriate person has been appointed to

manage their finances. An appropriate person to manage such individuals’ finances includes someone appointed with:

Enduring Power of Attorney for Property and Affairs (EPA) – preferably

now registered with the Office of the Public Guardian*; Lasting Power of Attorney (LPA) for property and affairs;

property and affairs Deputyship under the Court of Protection; any other person dealing with that person’s affairs (e.g. someone who

has been given appointeeship by the Department for Work and Pensions for the purpose of benefits payments); or

the Financial Adult Safeguarding team once Deputyship has been given

by the Court of Protection.

*For more information, visit: https://www.gov.uk/enduring-power-attorney-duties

The fact that a customer is mentally incapacitated to make certain

specific decisions must not be taken to mean that no charge will be applicable.

https://www.gov.uk/enduring-power-attorney-duties

https://www.gov.uk/enduring-power-attorney-duties





7.9 Self-funders whose care package consists of just a day care service only accessible via adults’ services (for example a West Sussex County

Council in house day care centre, or a Shaw Trust day care centre) will only be charged the weekly admin fees (and not the one off arrangement

fee).

7.10 Arrangement and administration fees will not be charged for any post-Community Reablement Service provision.

7.11 Self-funders are not able to access rates which West Sussex County

Council has agreed with service providers as part of their framework or

contractual agreements. Instead self-funders will pay rates set privately by the service providers – the service we offer involves contacting service

providers and scoping the rates they will charge the adult. The service will then be purchased via the electronic recording system (Mosaic) via the

variable Commissioned Dom Care - Private Rates Element.

7.12 Some individuals will have already begun receiving a package of care from Adults’ Services before they are identified as a self-funder. In

these situations the brokerage fees should be back dated to the start date of their service (fees can only be backdated to April 2015). If these

individuals choose to request Adults’ Services to continue administrating their package of care then they should be moved to private rates going

forward.

7.13 Individuals choosing to use the ongoing administration service will

be invoiced the cost of their personal budget. This may prove to be unequal to the actual cost of their ongoing care. An annual reconciliation

process will result in individuals having any over payment returned and any underpayment invoiced to them.

7.14 Failure to pay charges for the package of care or arrangement and

administration fees will be followed up through the usual debt recovery route. Guidance on debt recovery is included in the Charging Policy,

available in the Professional Zone on the West Sussex Connect to Support website.

8. Recording in the support plan

Deprivations of a person’s liberty

8.1 Before completing a support plan for a person who lacks mental

capacity to make decisions about their care and support needs, consideration needs to be given to whether the support plan will lead to a

possible deprivation of liberty according to the Mental Capacity Act 2005.





The “acid test” immediately below (UK Supreme Court, March 2014

[UKSC 19]) determines if someone is being deprived of their liberty:

‘Is the person subject both to continuous supervision and control and not free to leave?’

8.2 This test applies to anyone who lacks the mental capacity to make

decisions about their care and support needs whilst in hospital or living in residential care. The “Managing Authority” (the service provider) has a

duty to refer to the County Council’s Deprivation of Liberty Safeguards team for a specialist assessment and the granting of a Standard

Authorisation. In all other cases please familiarize yourself with Appendix 1 to this document.

8.3 For area teams, the majority of cases where the Deprivation of

Liberty Safeguards might apply will be dealt with as managed exceptions. Support brokers will need to be aware of the issues related to the

Deprivation of Liberty Safeguards and refer back to the social work team if they are concerned that a support plan they are developing will lead to a

deprivation of liberty occurring.

8.4 Mental health and learning disability teams need to consider possible

deprivation of liberties occurring and take appropriate action when they are developing support plans.

8.5 If at any stage in the support planning process you have concerns about the person’s mental capacity please liaise with the allocated social

care worker.

Eligible needs

8.6 The support plan must include a record of how all eligible needs are

to be met - even if not met by funded services.

8.7 Learning Disability teams may also use health interventions to meet

eligible needs and Mental Health teams only use the support plan where funding/purchasing is required, and if this is not required should use the

care planning options on CareNotes as usual.

8.8 In summary, the following diagram summarises what key elements

of the support plan which should be recorded:

Sign-off

8.9 Practitioners must take all reasonable steps to reach agreement with

the person for whom the plan is being prepared. Wherever possible, local

authority sign-off should occur when the person, any third party involved in the preparation of the plan and the local authority have agreed on the

factors within the plan, including the final personal budget amount (which





may have been subject to change during the planning process), and how

the needs in question will be met. This is a key part of the planning process and the agreement should be recorded and a copy placed within

the plan. Where an independent advocate has been involved, they should not be asked to sign-off the plan – this is the responsibility of the local

authority.

Timescales 8.10 Whilst there is no defined timescale in statute for the completion of

the support planning process, the Care Act Statutory Guidance (https://www.gov.uk/government/publications/care-act-statutory-guidance)

states the plan should be completed in a timely fashion, proportionate to the needs to and not unduly delaying the assessed needs being met.

Appeals Process

8.11 The approach developed specifically by Adults’ Services is used by

the person if they wish to appeal against the decisions reached, or about the level of choice the individual has had about their support plan, or

regarding their personal budget (the amount of money allocated to the adult to meet their outcomes).

8.12 Upon completion, the local authority must give a copy of the final

plan - which should be in an accessible format - to the person for whom the plan is intended, any other person they request to receive a copy of it,

and their independent advocate if they have one (and the person agrees).






Appendix 1

Deprivation of Liberty Safeguards in the Community

As a result of a Judgment in the UK Supreme Court in March 2014 [UKSC

19], arrangements have now been put in place for the Court of Protection to receive applications from local authorities in respect of people who are

believed to be deprived of their liberty whilst living at home or in supported accommodation - but who are not in care homes or hospitals.

The County Council has developed a comprehensive toolkit containing a

number of documents which can be used when preparing an application to

the Court of Protection for formal authorisation of a Deprivation of Liberty Safeguards in the Community. The Toolkit has a variety of checklists,

background information factsheets, blank precedents and redacted examples of the relevant forms.

This Toolkit was devised by Legal Services, in conjunction with Adults’

Services, and can be accessed on Sharepoint.

To whom do these additional Safeguards apply?

Known as the ‘streamlined process’ these arrangements only apply where the following criteria are met:

1. People are aged 16 years* or older; and

2. They lack the mental capacity to consent to (make the decision about)

their care arrangements; and 3. They receive care in their own homes, or in supported living

arrangements, or in residential schools, or through the Shared Lives scheme; and

4. They are being deprived of their liberty as a result of those arrangements; and

5. The arrangements in place are imputable to the State (that is, the local authority has had some involvement with the making of the

arrangements or in monitoring the person’s care there).

*People aged 16-18 only may be covered by other legal arrangements: contact Legal Services for more information.

What is a deprivation of liberty in such cases?

The UK Supreme Court has ruled that ‘deprivation of liberty’ relates to the degree of supervision and control of a person’s life by others, and where

that person is not free to leave the arrangement of their own choosing.





How does the Court of Protection deal with such cases?

In such situations, presented with the relevant evidence (a current assessment of a person’s mental incapacity, and a description of the

control arrangements in place), the Court of Protection will grant an authorisation of that Deprivation of Liberty for the person. The Court will

sit in private to review pre-submitted evidence and make this decision without the need for the person themselves to be made a party to the

proceedings or for a face to face hearing to take place.

The ‘streamlined process’ described above has developed as a result of a case brought to the attention of the Court of Protection in England and

Wales (Re: X [2014] EWCOP 25). It relies on the full and frank disclosure

of all the relevant facts and other matters that could have an impact on the Court’s decision.

The ‘streamlined process’ is also designed to enable Judges in the Court of

Protection to quickly and easily pick out cases that are potentially contentious. A hearing will only be required where the Court of Protection

is not satisfied with the evidence submitted to it in advance or has a query about whether the proposed care arrangements are in the person’s

best interests.

What about the other Deprivation of Liberty Safeguards?

If you are working with a person who is living in a care home (or nursing home) or is in hospital, and they lack the mental capacity to make the

decision about their care arrangements there and they are deprived of

their liberty, they come under the main provisions of the Mental Capacity Act’s Deprivation of Liberty Safeguards. You must refer that person to the

West Sussex Deprivation of Liberty Safeguards Team, based at Centenary House in Durrington, and not use the streamlined process.

How do I find out more? To find our more about the ‘streamlined process’ for Deprivations of

Liberty in the Community, read the detailed guidance on the County Council’s Sharepoint site. When you have read that guidance, speak with

your line manager in the first instance so that you can work out the next steps required.

If you are still unsure what needs to happen next, please contact Gemma

Knowles in Legal Services, or one of her other colleagues there who deal

with matters relating to Adults’ Services.

support planning€¦ · 3.1 teams in the learning disability service and the adult mental health...

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