Stage Four: Care Planning
4. To identify the most appropriate ways of achieving the objectives identified by the assessment of need and incorporate them into an individual care plan.
Process
4.1 Wherever possible, the practitioner responsible for assessing needs should carry on to relate those needs to the available resources including the support provided by carers. This will help to ensure that assessment does not become a theoretical exercise but is firmly rooted in practical reality.
4.2 As with the assessment of need, it is helpful if practitioners approach care planning as a series of linked activities:
- Determine the type of plan.
- Set priorities.
- Complete definition of service requirements.
- Explore the resources of users and carers.
- Review existing services.
- Consider alternatives.
- Discuss options.
- Establish preferences.
- Cost care plan.
- Assess financial means.
- Reconcile preferences and resources.
- Agree service objectives.
- Co-ordinate plan.
- Fix review.
- Identify unmet need.
- Record the care plan.
Determine the type of plan
4.3 Care plans will vary according to the complexity of need. If it is a simple need which can be met by a single service, the care planning can be very swiftly accomplished. All users in receipt of a continuing service should have a care plan, even if only a very brief one, which defines the user's needs and the objectives to be met by any service provided.
4.4 At the other extreme, care plans may be very complex, involving the co-ordination of services from a number of different agencies. The earlier that practitioners responsible for care planning are able to identify the contributing agencies and individuals the better they will be able to effect this co-ordination.
Set priorities
4.5 The assessment should have prioritised the user's needs so they should be tackled in that priority order. Although, ideally, all needs should be assessed before progressing to the care planning stage, in practice, because of urgent needs, some services will have to be planned and arranged while other needs are still being assessed.
4.6 Care planning also has to be sufficiently flexible to adjust priorities as the needs of the user change.
Complete definition of service requirements
4.7 The needs should have been defined at the assessment stage but more detail may be required to specify the service requirements. The aim of the care planning stage is to target any intervention as precisely as possible on the identified needs. To do this and work out how any intervention may cause as little disruption as possible, the practitioner will require an understanding of the individual's daily pattern of living.
4.8 Throughout, the practitioner will want to identify the factors that might help or hinder the achievement of the objectives defined at the assessment stage, such as the user's level of motivation or the flexibility of the service provider. These will help to frame the tactics that the practitioner adopts in negotiating the final plan with the user, carers or service providers. The example at the end of this guidance illustrates how these factors can be incorporated into an action plan. The service requirements will also include reference to the level of risk agreed with the users and carers at the assessment stage, in compliance with any agency guidelines on risk-taking.
Explore the resources of users and carers
4.9 For the majority of users, the aim will be to promote their independence. For this reason, practitioners should begin by focusing on the resources of the user and how any strengths and abilities can be brought to bear to compensate for any difficulties, for example, tapping any determination to learn new skills. Similarly, ways and means of making better use of carers' resources should be examined at this stage, for example, asking them to visit at another time of day to meet a care need. However, the practitioner must not exploit the goodwill of carers or make unrealistic demands of users. Formal intervention should be kept to the minimum necessary in the interests of all concerned. From the agency's perspective, and often that of users and carers as well, care planning which enables users and carers to manage on their own is the most effective intervention of all.
Review existing services
4.10 A majority of users will already be in receipt of some services and existing service providers will have been consulted in the course of the assessment. It may be that these services could be adjusted beneficially in the light of the objectives agreed during the assessment stage. If additional or new services are to be introduced, they will have to be interwoven with the existing services.
Consider alternatives
4.11 However, in taking a fresh look at users' needs practitioners should not be constrained by the existing set of services. They should be equipped with the knowledge, or access to the knowledge, about the full range of services, not only in the statutory sector but also the independent sector. Even so, they may still have to undertake individual investigations in relation to specific needs, for example, identifying a community resource in a particular locality.
4.12 Care planning should not be seen as matching needs with service 'off the shelf' but as an opportunity to rethink service provision for a particular individual. Within resource constraints, practitioners should give full rein to their creativity in devising new ways of meeting needs, picking up clues from users and carers about what might be most relevant and effective. Clearly, those who have some or all of the budget delegated to them, will have greater scope to create alternatives or to press service providers into arranging different forms of service.
Discuss options
4.13 Once identified, these options should be fully discussed with the user and any relevant carers. This may also result in a discussion of direct payments as an appropriate option. This may involve service providers being invited to discuss the detail of their services directly with users, or users being taken on observation visits. For those users who have limited knowledge of what services provide or have difficulty with the concept of choice, for example those with learning disabilities, this exploration of options has to be as practical as possible so that they can begin to understand what it will mean for them personally.
Establish preferences
4.14 Wherever possible, users should be offered a genuine choice of service options, appropriate to their ethnic and cultural background. This enables them to feel that they have some control over what is happening to them and reinforces their sense of independence. The degree of choice available will be affected by the level of devolved responsibility held by the care planner.
4.15 Some users, or those referring them, may have had very clear preferences about the service response from the outset. As a consequence, they may resist consideration of alternative options. However, the practitioners must satisfy themselves that the selected option is the one most suited to the identified needs. In exploring any alternatives, practitioners will have to demonstrate that they have given full consideration to the wishes of users and carers themselves. Where a practitioner is unable to accede to their preferences, users should receive a full explanation and be reminded of the complaints procedure.
Cost care plan
4.16 Where practitioners have any delegated budgetary authority, it will be vital to have an accurate costing of the care plans. However, even where this is not the case, it is likely that practitioners will have to concern themselves with at least indicative costings as agencies strive to improve their cost-effectiveness. This will be particularly important as budgets are increasingly allocated to meeting needs (rather than to services) with prescribed ceilings of expenditure for specified levels of dependency or disadvantage. Users should always know the estimated cost to themselves of any options under active consideration.
4.17 Costing will obviously depend upon the availability of service costs. It is recognised that progress on this front may be variable as between health and social services/work authorities and between the private and voluntary sectors.
Assess financial means
4.18 If charges are to be levied in respect of any services, then care planning will involve an assessment of the user's financial means and ability to pay. As a point of good practice, no user should agree a care plan before they have been advised in writing of any charges involved.
4.19 Local authorities cannot charge for care management and assessment but, within their discretion, are encouraged to levy charges on other services, subject to the user's ability to pay.
4.20 Local arrangements for financial assessment are included in SSA training and local policy on procedures.
4.21 Local authorities have reviewed their charging policies to ensure that there are no financial incentives that run counter to the policy aim of maintaining people in the community. It is necessary for local authorities to enable users to use their own money or money from other sources to supplement any financial entitlement from the local authority. By doing this, users will increase their choice of service options in the independent sector.
4.22 The extent to which users are able to purchase statutory services over and above that determined by the assessment process will be defined as a matter of local policy. Any such income generation should be used to enhance, and not undermine, the capacity of the local authority to respond in an equitable way to need, irrespective of the user's financial means. Those with financial resources should not be allowed to take precedence over others with equal needs.
Reconcile preferences and resources
4.23 Having established the wishes of the user and the cost of the selected options, these have to be reconciled with the available resources. This may be done by the practitioners alone, if they hold delegated budgets, or in conjunction with the relevant managerial and contracting staff.
4.24 In order to ensure consistency of resource allocation between users with similar needs, authorities or agencies may wish to issue guidelines to their staff on the levels of expenditure appropriate to different needs. Some discretion will be necessary if flexible, individualised responses are to develop.
4.25 It is at this stage that the practitioners have to balance their accountability to users and to their employing authority. This is more difficult where the practitioners have full financial responsibility and are responsible both for defining the needs and allocating the resources. In such circumstances, users may wish to avail themselves of independent representatives to promote their interests.
4.26 In order to decide on such matters, users should be informed where the responsibility for a resource allocation lies and the means of making representations under the complaints procedure, if dissatisfied. For their part, practitioners will require the support of their managers in discharging their responsibilities. They will inevitably experience the stress of identifying needs for which no resources are available.
Agree service objectives
4.27 Having confirmed the service options that can be resourced, the next stage is to finalise the agreements with all the agencies and individuals who are to contribute to care plans. This will include the contribution of the user and carers themselves. The objectives of their inputs should be made clear to all contributors. These should be consistent with the objectives agreed with the user during the initial assessment stage. There should also be a common understanding of how the achievement of these objectives will be measured. For example, the rehabilitation of a depressed person may be gauged by the resumption of former interests or the establishment of new ones.
Co-ordinate plan
4.28 Having negotiated a range of inputs, practitioners must integrate the parts into a coherent whole that makes sense to the user and their carers. All contributors to a care plan should be aware of the overall objectives as well as their own specific objectives so that they can be mutually supportive of one another. In complex situations, this may require a meeting of all parties but this should not be necessary in the majority of circumstances.
4.29 The care plan should also be sufficiently flexible to cater for contingencies and deal with difficulties and emergencies through contributors providing cover for one another. For example, a day centre might provide a meal if a relative is ill.
Set review
4.30 The user should be told the name of the practitioner responsible for the implementation, monitoring and review of the care plan. This applies particularly where this responsibility is shared between a number of workers. The lead assessor will undertake the task of setting the review date. In addition, a date should be set for the first review of the care plans. This is a simultaneous review of all the inputs so that their combined impact on the user's needs can be reassessed.
4.31 The interval between the formulation of the care plan and the first review will vary according to the changeability and complexity of needs. All parties should also be aware of the factors which will warrant the triggering of an earlier review.
Identify unmet need
4.32 Having completed the care plan, the practitioner should identify any assessed need which it has not been possible to address and for what reason. This information should be fed back for service planning and quality assurance. It needs to be recorded and collated in a systematic way.
4.33 There may be benefit in differentiating between types of unmet need. These will include those that are:
- Statutory obligations, for example, those included in the Disabled Persons' ( SCR) Act.
- Defined as entitlements under local policies, for example, failure to provide services within defined timescales.
- New needs, identified by assessing staff but falling outside current policies or criteria.
4.34 There should also be a ready means of prioritising these unmet needs, according
to local protocols.
4.35 There will continue to be situations in which there is a mismatch between the solutions provided by the existing services and the solutions identified by users, carers and practitioners. Care planning has a contribution to make in minimising this mismatch by defining the disparity and promoting the appropriate changes in service.
Record the care plan
4.36 Care plans should be set out in concise written form, linked with the assessment of need. The document should be accessible to the user, for example, in Braille or translated into the user's own language. A copy should be given to the user but it should also, subject to constraints of confidentiality, be shared with other contributors to the plan.
4.37 A care plan should contain:
- Overall objectives
- Specific objectives of
- service providers
- Criteria for measuring the achievement of these objectives
- The services to be provided by which agency
- The cost to the user and the contributing agencies
- The other options considered
- Any point of difference between the user, carer, care manager or other agency
- Any unmet needs with reasons - to be separately notified to the service planning system
- The named person(s) responsible for implementing, monitoring and reviewing the care plan
- The date of the first planned review.
4.38 The care plan does not have a legal standing as a contract but, to reinforce the sense of commitment, contributors (including the user) may be asked to signify their agreement by signing. With or without signatures, the expectation is that contributors will honour their commitments and the care plan will be the means of holding them to account. As such, a care plan may be used as evidence in the consideration of a complaint.
4.39 A care plan should be a blueprint for action. It may, therefore, be framed as an action plan. An example is attached at Annex A.