What is a care and support plan?

Care and support planning is the process that takes place with an adult, their carers, social workers and other professionals involved. It results in a care and support plan being produced which says how the person’s needs will be met in ways that work best for them, as an individual and if they are part of a family.

There are lots of ways their needs can be met, depending on them and their particular circumstances and wishes. For instance, they might be best met in a care home or in their own home with home care services, or other types of home support such as equipment and adaptations. Care and support is often not provided directly by the council, it maybe by a local community group or going to a day centre for example.

When does it happen?

After an assessment of the person’s needs is carried out by social care staff, a care and support plan must be provided if their needs meet conditions (as set out in the Care Act) to receive care and support from the council. This is known as eligibility.

Why is it important?

Each person’s needs are unique to them and how people would like their needs to be met will depend on their particular circumstances, values, wishes, beliefs and their goals in life.

‘Meeting someone’s needs’ is more than just arranging services. The process of care and support planning makes sure everyone involved can contribute and can agree how the person’s needs identified in the assessment will be best met.

Care and support planning must also identify any areas of risk or if the person is experiencing abuse or neglect. If the risk of abuse or neglect is identified, a safeguarding enquiry should be carried out. Any actions put in place to safeguard the person and to minimise risk should be included in the care and support plan.

Who is involved?

The person should be at the centre of the plan – known as person centred care – and must be able to participate as much as they can, and want to, in developing it. They must be given all support they need in order to do that, using speech and language therapists or other specialists such as interpreters for example.

It should also include the person’s carers, independent advocates, friends, staff from other agencies or community groups and any other person the person would like to be involved in the process.

For people who have a lot of difficulty in taking part in care and support planning and have no friends or relatives to help them, an independent advocate must be involved.

The Mental Capacity Act says that staff must think that people have the capacity to make decisions for themselves, unless this is shown to be otherwise. So every person has the right to make their own decisions in the care and support planning process. The principles of the Mental Capacity Act should be followed for people who do not have mental capacity.

Some people will need a little help to be involved, others will need much more. Social workers or other relevant professionals should first have a discussion with the person to know what is important to them and what support they feel they need to be involved.

How is it put into practice?

It is important that enough time is taken to make sure the plan is right to meet the person’s identified needs and is agreed by them, their carers and advocates.

The plan must be person centred, so it is important that people are given every opportunity to take part in planning it. This means the council involves them in regular planning meetings. These may be face to face, on the telephone or by video.

The care and support plan should also record which needs are being met by their carer.

When developing the plan, there are some things which must always be included. These are:

• the person’s needs that were identified in the assessment;
• whether those needs are eligible for council support;
• what needs the council is going to meet, and how it will do that;
• the outcomes that the person wants to achieve, their wishes and preferences;
• the outcomes the carer wants to achieve, their wishes about providing care alongside their work, education and recreation and where support could be useful to them;
• if the person’s needs change, the plan should show how this will be responded to; and
• plans should include dealing with any sudden change or an emergency, such as a carer becoming ill.

The role of social care staff is to produce the plan and sign it off with those involved, making sure that it meets the person’s needs and minimises any risk to them.

When developing it, the council must inform the person which, if any, of their needs may be met by a direct payment.

Sometimes it can be difficult to reach a plan that is agreed with the person. If so, the council should give the reasons for this and the steps which will be taken to ensure their safety and wellbeing.

If this does not settle the disagreement and the council feels that it has done everything it can to address the situation, it should suggest the person makes a complaint, using the council’s complaints procedure which will hopefully resolve it.