1. Introduction

It is vital that all adults, carers and other professionals who make contact with the service regarding a referral receive a timely and professional response. This is essential for operating within required standards, and promoting confidence in the service. First impressions for adults, carers and partner agencies who contact the service are vital.

This chapter provides information to ensure that all those being referred and accepted into the service receive the same good standards of response and care.

It also outlines how the service comprehensively coordinates, monitors and records all referral and admission activity.

2. Initial Response

Although there should be one main point of contact for referrers, a referral could be received by any member of care and support or administration staff. A referral can be made by phone, personal visit or email / website for example.

All initial inquiries should be dealt with as a priority.

2.1 Initial referrer contact

Initial contact may be from the adult themselves, their carers / family member, friends or a practitioner who is involved in their care and support.

When initial contact is made, as much information as possible should be gathered regarding the care and support needs of the adult. This should include demographic information, their mental and physical health needs and any mental capacity issues, challenging behaviour or safeguarding issues. The latest care and support plan or assessment of needs / outcomes and risks should be requested from the referrer or involved practitioner.

Initial discussions should take place about how the adult’s placement will be funded, and if they are not self-funding this should include an outline plan of how funding will be secured.

3. Assessment

Arrangements for an initial assessment should be made with the designated worker in the service, the person making the referral and with the adult and their carer. The service should offer to undertake an assessment visit within the time period set out in its Statement of Purpose.

This initial assessment will gather information to establish whether the service offers the correct support for the adult concerned (see Assessment). The assessment should consider the type of service the adult needs, their thoughts and wishes about their future care, the views and opinions of their carers / family and equal opportunities and anti-discriminatory practices (see Equality and Diversity).

Following the assessment and completion of the recording process, the assessor should be able to establish if the adult’s needs can be safely met by the service. This decision may need to be made in discussion with relevant managers as required, depending on the complexity of the referral and assessment information.

3.1 Visits to a proposed supported living facility

As part of the decision making process, the adult should be encouraged to visit the service. Relevant family members and care managers should also be encouraged to visit the service. This is to help the adult and their family decide if it is suitable for them, as well as inform the assessor as to the appropriateness of the service for the adult.

A minimum half-day visit to the service should be offered, particularly if it is to be a residential placement. During the introductory visits the prospective service user should be:

  • shown around the service;
  • introduced to staff and all other service users;
  • encouraged to spend time interacting with other service users or staff and being given the opportunity to be involved in their future plans and any person centred planning, as appropriate;
  • wherever possible, and if able, service users should be given the opportunity to see documentation such as policies and procedures, health and safety issues, risk assessments and complaint procedures.

The adult should be shown which bedroom may be theirs and given the option to stay overnight where at all possible.

Other service users should be consulted about their views about the potentially new service user.

The service manager and proposed keyworker should spend time with the prospective service user and their family / representative, to discuss any questions, concerns or comments they may have. This is also an opportunity to tell the adult / family more about the services available, and also about the records that will be kept about them. The service manager should inform them of the policy and procedure on confidentiality and data protection (see Information Sharing and Confidentiality).

Any special needs the adult has should be discussed and the service manager should explain how these will be met.

4. Placement / Service not Agreed following Assessment

If the initial assessment outcome is that the service cannot meet the care and support needs of the adult, the worker who completed it should first discuss the situation with the relevant manager.

Where there is not agreement between the assessor and manager, this should be referred to a relevant senior manager for discussion and to make the final decision.

Where it is decided that the service is not appropriate for the adult, the reasons for this should be communicated to the referrer and to the adult and their family, along with all other options that may be considered more suitable for their needs. Where possible, the adult should be told in person, either by the assessor or the referrer where this is a practitioner. The decision should also be communicated in writing, stating the reasons why the service was unable to meet the adult’s needs.

5. Placement / Service Offer Agreed

Where it is agreed to offer a placement / service to the adult, full costings should be calculated and funding agreed by the appropriate source. This should be completed as soon as possible after the assessment decision has been communicated to those involved.

Prior to commencement of the service, where relevant it is essential to ensure that a Deprivation of Liberty Safeguards assessment has been completed and authorised (see Deprivation of Liberty Safeguards).

6. Disagreement

In the event that the placement / service is not offered to the adult and they, their carer / advocate disagrees with the assessor’s decision, this should be referred to the relevant senior manager for review. If the manager upholds the assessor’s decision, this should be communicated to the adult and their carer / advocate with reasons why they support the outcome.

If the adult and their carer / advocate is still dissatisfied with the decision, they should make a formal complaint to the service (see Complaints).

7. Commencing Care and Support

This section applies to both adults living in their own accommodation and those moving into supported living placements.

Following agreement of the placement / service provision, an initial care and support plan should be developed with the adult, their carer / advocate, the allocated keyworker and any other relevant involved professionals.

This should include all relevant information from the care and support plan received from the local authority, where this has been completed. This should include an initial risk management plan (see Positive Risk Taking and Risk Assessments).

Any funding for additional resources required for the placement / service provision should be agreed in advance of the intervention starting. This may include specialist resources or additional staffing hours for example. This must be included in the costings agreed with the relevant body / person. Admission / service commencement cannot take place unless this signed agreement has been received.

A transition plan should be agreed with the adult, their carer / advocate and other relevant agencies involved in care and support of the adult. The assessment findings should be used to form the basis of the transition plan, and identify key actions and individuals responsible for implementing those actions.

The plan also forms part of the introduction process to the placement / service, and should include the adult, as appropriate, and their carer / advocate being informed of relevant policies and procedures, for example health and safety and risk assessment processes.  It will also form the basis of the care and support plan (see Care and Support Planning) and should include equality and diversity issues specific to the adult, such as cultural and religious beliefs, and access to other groups and organisations as the adult requires.

All new service users (excluding those on short term or respite placements) should have a review of their care and support plan within 12 weeks following their admission (see Review of Care and Support Plans).

8. Supported Living Arrangements

As detailed in Section 2, Initial Response and Section 3, Assessment above, following receipt of a referral to the service in relation to an adult, the allocated worker should conduct an assessment with them and their family / representative as appropriate.

As a prospective tenant, the adult may wish to view the proposed property during the referral process. This should be agreed with the referrer prior to any arrangements being agreed with the adult and their family / representative. Relevant professionals, including the housing provider, should be present as appropriate during the visit, to answer any questions the adult may have. They will also provide the adult with a housing application form and example tenancy agreement, if at this stage all parties are willing to progress the tenancy.

In line with Section 5, Placement / Service Offer Agreed and funding for the placement agreed, a date should be agreed for the adult to move into the property.

The level of keyworker support the adult requires should be based on the completed assessment, which will be subject to regular reviews (see Review of Care and Support Plans).

The housing provider will confirm the rental amount for the property, as well as a schedule of items covered by the rent. The housing provider should liaise with the referrer and the adult in relation to any queries regarding the tenancy agreement or the rent.

Upon agreement to fund the tenancy based support package for the adult, the keyworker should inform all relevant parties, both internal and external to the service.

Where an adult needs to commence the supported living arrangement prior to the receipt of confirmation of funding, this can only be agreed with the written acceptance of the relevant senior manager in the service and an authorised representative of the housing provider.

The housing provider should issue the tenancy agreement for the adult to sign prior to the agreed start date for the supported living arrangement. The housing provider should confirm receipt of the signed agreement with the service as soon as it is received.

It is the responsibility of the housing provider to assist and liaise with the tenant in respect of the housing benefits claim excepting where the service is acting as appointee on behalf of the tenant. In such cases the service will process and follow up the application on behalf of the tenant, and will liaise with the housing provider at all times.

It is the responsibility of the housing provider to communicate with the allocated keyworker at the service regarding any issues that may require a change to the support current provided to the tenant.

9. Placement Review

See also Review of Care and Support Plans

The adult’s placement / service should be reviewed as part of the care management process.