Care and Support Planning

1. Introduction

Following an assessment being undertaken by staff prior to an adult being admitted to the service, a care and support plan should be completed. This plan will be regularly reviewed as part of the ongoing care planning with the adult (see Review of Care and Support Plans). The plan should detail the adults needs and how they will be met, the outcomes that the adult wishes to achieve in their day to day life as identified in the assessment process, and the principles of wellbeing and preventing, reducing and delaying needs (see Promoting Wellbeing and Preventing Reducing and Delaying Needs).

Care and support planning gives the adult choice and control over their care and provides the support they need to ensure their wellbeing and maintain their connections to family, friends and community. The adult should be involved throughout the planning process and should be given every opportunity to produce the plan with staff, if that is what they want.  Some adults need assistance to be involved. In these circumstances, the planning process should enable supported decision making, with options and choices being presented simply and clearly.  Assistance from independent sources may be required  to support the adult to engage with the planning process where there are no friends or relatives to facilitate their involvement.

The process must be person centred and, as much as possible, person led in order to meet the needs and achieve the outcomes for the adult in ways that work best for them. Both the process and the outcomes should be built around their wishes and feelings, their needs, values and aspirations, irrespective of the extent to which they choose, or are able, to direct the process. The care and support plan must fully reflect the adult’s physical, mental, emotional and social needs, including on the grounds of protected characteristics under the Equality Act 2010 (see Equality, Diversity and Human Rights).

Where a local authority is involved in the adult’s care and support, there will also be a local authority care and support plan.

2. Producing the Plan

The planning process should take into account what is possible and should include:

• wider aspirations and wishes that are important to the person;
• consideration of the needs to be met taking a holistic approach that covers aspects such as the adult’s daily and community life, not just a narrow focus of personal care needs;
• consideration of how community based support can contribute to the plan, including support that promotes mental and emotional wellbeing and builds social connections for people;
• findings from other assessments such as speech and language therapy (SALT) assessments;
• if an adult has fluctuating needs, the plan should make provision for this, indicating what contingencies are in place in the event of a sudden change or emergency so that this is an integral part of the planning process, rather than solely a response when someone reaches a crisis point.

Where someone has substantial difficulty in being actively involved with the planning process, and they have no family and friends who are able to facilitate their involvement, the keyworker or other appropriate person should support the adult. Where a person with specific expertise or training in a particular condition or an interpreter has previously been involved, someone with similar knowledge (and preferably the same person to ensure continuity) may be involved in the production of the plan.

These elements should always be included in the plan:

• the needs identified by the assessment (see Assessment);
• for an adult needing care, for which of their desired outcomes care and support is relevant;
• 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 by a direct payment, the needs to be met by the direct payment and the amount and frequency of the payments.

The plan should be reviewed regularly and the next date agreed at the end of each review (see Review of Care and Support Plans). The planning process may bring to light new information that suggests there may be a safeguarding issue, which leads to a safeguarding enquiry being carried out (see Safeguarding Adults from Abuse or Neglect).  When a safeguarding enquiry leads to specific interventions being put in place to address a safeguarding issue, they can be included in the care and support plan.

3. Involving the Person

The planning process should involve the adult, the carer (if there is one) and anyone else they request to be involved. Where the adult lacks capacity to ask for someone to be involved, someone who appears to be interested in their welfare and any person who is able to contribute useful information can be included (see Section 4, Planning for those who Lack Mental Capacity).

The adult, and their carers, should have the best understanding of how the needs identified in the assessment fit into the adult’s life as a whole and connect to their overall wellbeing. They are well placed to consider and identify which care and support options would best fit into their lifestyle and help them to achieve the day to day outcomes they identified during the assessment process. The adult should be supported to understand what is being discussed and what options are available to them. If someone lacks the confidence to take a lead in the process, this should not limit the extent to which they can play an active role, if they wish to do so. In all cases, they can gain support from individuals who they choose to assist their involvement in the planning process.

The care and support plan should demonstrate that the adult is being supported to follow their interests and take part in activities that are socially and culturally relevant and appropriate to them, including – where relevant – in the wider community and access to education and work opportunities.

Genuine involvement as discussed above helps the development of the plan, increases the likelihood that the options selected will effectively support the adult in achieving the outcomes that matter to them and may limit disputes, as people involved will be fully aware of and will have agreed to the decisions made. There may be circumstances where it is not appropriate to jointly prepare the plan. For example, an adult may not wish their family to be involved or family members may have conflicting interests.

4. Planning for People Who Lack Capacity

See also Mental Capacity

Person centred care planning is particularly important for adults with the most complex needs. Many people receiving care and support have mental impairments, such as dementia, learning disabilities, mental health needs or brain injuries.

The Mental Capacity Act 2005 (MCA) assumes that people have capacity and can make decisions for themselves, unless otherwise established. Every adult has the right to make his or her own decisions in respect of his or her care plan and is assumed to have capacity to do so unless it is proved otherwise. It cannot be assumed that someone cannot make a decision for themselves just because they have a particular medical condition or disability. The adult should be supported to understand and weigh up information, offered choices and helped to exercise informed choice. They should be given all practicable help to make a specific decision before being assessed as lacking capacity to make that decision. People have the right to make what others might regard as an unwise or unusual decision. Everyone has their own values, beliefs and preferences which may not be the same as those of other people. People cannot be treated as lacking capacity for that reason. Sometimes the care and support plan may have unusual aspects; the question to explore is whether it will meet the assessed needs and lead to the desired outcomes.

If an adult lacks capacity to make a decision or to be involved in a plan, even after they have been offered all practicable support, a social worker or other suitably qualified professional should carry out a capacity assessment in relation to the specific decision to be made. For example, an assessment may be made about whether the adult has the capacity to decide whether family members should be involved in their care planning or whether the person has the capacity to decide on whether a particular support option will meet their needs. Someone making a decision concerning a plan on behalf of an adult who lacks capacity has to consider whether it is possible to make a decision or a plan in a way that would be less restrictive of their rights and freedoms of action. Any restriction must be in the adult’s best interests, be necessary to prevent harm to them and be a proportionate response to the likelihood of them suffering harm and the seriousness of that harm.

5. Deprivation of Liberty for People Who Lack Capacity

See also Deprivation of Liberty Safeguards, Restraint and Dealing with Challenging Behaviour.

In line with the least restrictive principle in the MCA, drawing up plans should minimise restrictions and restraints on the adult as much as possible. The MCA authorises acts of restraint only if such acts are: necessary to prevent harm to the person, a proportionate response to the likelihood of the person suffering harm and the seriousness of that harm and in the person’s best interests (see Mental Capacity Code of Practice, 2007). Disagreements should be resolved through best interests meetings, involving a wide range of people, including family members and / or an advocate to support and represent the adult. If the degree and intensity of restrictions and restraints are so significant they amount to a deprivation of liberty, this must be authorised under the Deprivation of Liberty Safeguards (DoLS) under the MCA. The difference between a deprivation of liberty and restraint is one of degree, intensity and duration.

6. Sign off and Quality Assurance

The details in the plan of how the adult’s needs will be met should be agreed with them and / or their representative, before the plan is signed off. The date of the next review of the care and support plan should be agreed and recorded in the plan. Care and support plans will be subject to quality assurance processes (see Quality Assurance).