Care and support - Care and support planning

The Care Act and its Guidance sets out exactly what a Care and Support Plan is, but it is for Councils and their partners to decide how it should be used and in what context


Under the Care Act, care planning can be undertaken in flexible and proportionate ways led by the adult concerned. It can be undertaken by the adult themselves, their carer, family or friends, or by a specialist broker or support organisation as requested/ organised by the person accessing services.

However, whilst the care and support plan can be worked on by any of the above people in conjunction with the Council, the decision as to the appropriateness of the plan (sign-off) rests with the Council.



What are the outcomes we want to achieve?

  • The person understands and is happy with how their agreed outcomes will help meet their eligible unmet needs and improve their wellbeing
  • As far as possible the person is in control of how their outcomes are defined, as long as they coincide with the ones in the regulations, and of the way in which those outcomes are going to be met
  • The process is tailored to the individual and proportionate to the outcomes they are seeking to achieve
  • The person is actively involved and feels empowered and supported to take control of the resources available to meet their needs
  • The person and their family and/or carer are given sufficient time to consider their options available to meet their needs
  • The person has received a range of information and advice that can help them plan how to maintain their independence and resilience
  • The person has improved personal skills knowledge and abilities, and greater capacity for strengthening their circle of support and improving their involvement in the local community
  • If the person lacks mental capacity to make decisions about their own care and support, decisions are made in their best interests in line with the Mental Capacity Act
  • The option of direct payments is set in the context of the support available including peer support and is understood as a realistic option with a well-rounded appreciation of the pros and cons associated
  • The plan has some flexibility in relation to how outcomes may be met and does not prescribe a single method which must be followed no matter what


What tools and resources do we need to do a good job? What are the steps we have to go through?

  • The outputs of the assessment
  • Assessment of the individual's mental capacity to take relevant decisions
  • Independent advocacy and interpreter where relevant
  • Skilled and motivated staff
  • Flexibility to meet potential fluctuating needs
  • Creativity and access to independent support planning options
  • Information about mobile equipment/ technology
  • Information sharing protocol if needed
  • Choice of time, location and format
  • Understanding of the council's role in 'sign-off'


What are the products we will have at the end of this process?

  • Agreed care and support plan:
    • Outlining the goals the person aims to achieve
    • Designed by the person as far as possible and as far as they wish
    • Based on the agreed health and wellbeing outcomes the person wants to achieve rather than what will happen in detail such as individual tasks
    • Focused on improving the person's resilience, consolidating and enhancing their circle of support and improving their connections with communities that are meaningful for them
  • Single signed off care and support plan, where relevant this will be:
    • Combined plan with spouse or carer
    • Integrated plan
  • Summary of the plan (public facing), that:
    • Is sufficient for sign off
    • Includes what people are happy to share with others
  • Confirmation of how the budget will be managed
    • Direct Payment
    • Council managed
    • Council contracted Individual Service Fund (ISF) or direct payment basis for ISF
    • Mixed package
  • Review date


When does this process start and end and within what timescales should this process be completed?

  • Led by the individual as far as possible taking into account the urgency and the time the person requires to explore the options available and develop a sustainable long-term plan; in light, however, of the fact that the needs will already have been found to be eligible and unmet
  • Ends when plan is approved


Who needs to be involved and what is their role? Who is taking the lead?

The Third National Personal Budget Survey (POET 2014) has shown that support from external non-statutory sources increases the likelihood of people taking up direct payments, which in turn will improve the likely effectiveness of personal budgets.

In all cases where the Council agrees to authorise it, as per the Act, the plan should be led by the person. There is discretion to provide resources to the person to enable them administer the budget. There is a right on the part of the person to involve anyone they choose, including family and friends. All support provided should focus on empowering the individual to lead the process as far as possible and make informed decisions from a range of options about how best to meet their outcomes.

  • Person
  • Family, carer or other who the person chooses to be involved
  • Independent advocate or chosen representative
  • Interpreter
  • Care coordinator
  • Staff from another organization with delegated authority
  • Peer support networks
  • Support planners
  • Providers and voluntary sector agencies
  • Support from social care and health professionals may be best accessed by exception or in cases where there is a significant level of complexity


The care and support plan or support plan in the case of a carer must specify the following information: the identified needs; the extent to which they meet the eligibility criteria; which of the needs the council will meet, the personal budget and the information and advice provided. Where some or all the needs are to be met by direct payments, the plan should specify which needs are to be met in this way and the frequency of direct payments.

In preparing the care and support plan the council must involve the person for whom it is being prepared, any carer(s) and person(s) whom the adult asks to be involved. If the adult lacks capacity, the council must judge who should be involved (or who is interested in their welfare if the adult lacks mental capacity to decide who should be involved).

For carers the council must prepare a support plan, involving the carer, the adult needing care if the carer asks for this, and any other person the carer requests.

The council must give copy of the care and support plan or support plan to all relevant parties i.e. the adult for whom it has been prepared, any carer or cared for person on request, and any other person requested to see it by the person for whom it has been prepared.

How this is all done is up to each individual council to work out.



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