Self-directed Support: Practitioners Guidance

Support planning

Having identified and analysed a person’s strengths, needs, risks, capacity and aspirations during the assessment process, the development of a support plan enables the practitioner, in collaboration with the individual (and relevant others), to consider how these needs can be best met and any potential challenges or conflicts of interest addressed.

The Act requires that support must be available to ensure an individual is able to communicate their views, questions and concerns. This will ensure and evidence that choice is informed.

In the past, people assessed as being eligible for support have sometimes been expected to ‘fit’ into existing services and care planning tended to be ‘resource led’. The principles of the Act facilitate a move towards an outcomes focus – where the individual is central to the planning of their support. It enables a focus on an individual’s goals rather than on what services can provide.

Key issues

• planning for outcomes-focused support with a person requires creativity and imaginative thinking to ensure the wider resources available are recognised and valued.
• these resources should start with the individual’s own personal assets, which could be their experiences, their resilience and motivation, their circumstances and life history, their family and community supports – partnered with the professional’s experience, skills and knowledge of systems and potential sources of support.
• this can also involve other agencies using support planning to develop shared and joint plans with clear roles and responsibilities.
• planning activity also needs to take account of proportionality and of opportunities for time limited or time specific interventions based on the aims and objectives agreed.
• support planning also takes place in specific statutory contexts. As the new Act sits alongside other guidance and legislation – such as Adult Support and Protection – it gives practitioners an opportunity to enhance effectiveness and adapt practice in order to ensure the best possible outcomes for each person.
• good practice suggests a ‘one person – one plan’ approach. Practitioners should therefore aim to minimise duplicate planning and streamline existing processes.
• professional judgement needs to be applied when determining how to engage with people whose capacity is impaired. It is important to support the application of principles of participation and choice to promote the least restrictive option that is of most benefit to the person.

The safety of individuals remain the paramount concern when assessing risk. In circumstances where concerns or possible conflict of interests arise around roles within family or in other key relationships e.g. where a child or adult may be considered to be at risk, the self-directed support principles can still apply. There needs to be full consideration of the child and adult protection guidance and procedures when assessing risk and working with the supported person and their family.

There is some apprehension that the development of Self Directed Support approaches, processes and the transferring of power may increase risk for some of the more vulnerable people who engage with services. There is however increased recognition that practice based on sound relationships with the supported person, their families and wider support networks may, in fact, support greater safety and risk enablement opportunities. Helping to identify more creative solutions of support may in many circumstances, lead to reduced levels of risk and harm.

Children:

In relation to the Act, a child over 16 has the right to make decisions about their own support and the choice of the four options. Below the age of 16 the person with responsibility for a child, the ‘appropriate person’ should be involved in decisions about a child’s support and the choice of the ‘four options’. However a child’s age, stage and maturity needs to be considered. Children over the age of 12 years have the right to make decisions unless it is shown that they are unable to do so. Even in that event, all attempts should be made to seek the child’s view, include them in the process and keep them at the centre of decision making about any support arrangements.

An effective support plan should:

• demonstrate how the principles of the Act have underpinned the planning and guided practice throughout.
• demonstrate how identified outcomes can be achieved within available resources.
• demonstrate a shared understanding of the outcomes, objectives, tasks and decisions.
• outline clear timescales and date of review.
• explore and take account of a person’s existing strengths and supports and how these can be enhanced.
• outline the roles of each person and agency involved, the part they play in effective support, and their responsibility for supporting change.
• clearly identify how areas of risk will be managed or supported and by whom.
• be reflective and responsive to changing circumstances where possible.
• demonstrate how to link the individual’s eligible needs and their agreed outcomes and show how creativity and lateral thinking are effective in meeting need.
• demonstrate how the supported person has a good understanding of the process and the agreed priorities.
• outline information about any services provided.
• be written or communicated in a format that the supported person understands (considering – age, communication, language, ability etc).
• describe arrangements for what happens within a crisis situation – consider what may need to happen if things go wrong – a contingency/back-up plan.
• allow for a sufficient degree of flexibility, allowing for reasonable adjustment over time and in response to the ‘real world’.

The Act requires that, for people to make informed choice and be involved, the support planning and decision making processes must be clear and understandable to each person.

The Act requires that, for people to make informed choice and be involved, the support planning and decision making processes must be clear and understandable to each person.

There are a wide range of templates or formats used to guide and facilitate both the individual and practitioner through the support planning process. Whatever method is used, it must be accessible and reflect the needs of the individual, and it must encourage and support an outcomes-based rather than ‘tick box’ led approach. Consideration needs to be given to age, disability, culture, communication method, ethnicity, language etc.

Agreeing the support plan:

Local arrangements for agreeing level or type of resource should be followed. Local authorities’ duty of care means that it can refuse to agree to any element of a support plan where the support would:

• unreasonably endanger any person and put their safety at risk
• support an illegal act
• involve gambling or financial investments
• fund health care that should be met by the NHS unless budgetary arrangements have been put in place between agencies to permit this
• pay for anything that other sources of income should normally cover
• not contribute to the agreed outcomes within the support plan.

This applies to all of the options under the Act.

Tom’s story

Tom is a young man who, just after graduating from university, sustained a brain injury following an operation on a brain tumor which has left him totally blind with no light or shade. Following discharge from hospital he moved into his own accommodation.

He now lives alone in his own tenancy with support three times per week amounting to 15 hours. He had his own flat after university and wished to continue to live the life of a young man though had to give his flat up when in hospital. He has had to make huge adjustments; the career dreams he had, the plans he had for adventures with his friends and the aspirations of his family all had to be adjusted.

His one surviving parent, his mum who was widowed when Tom was a child, lives nearby. She has recently had a crisis in her own health which has long term implications and she suddenly is not able to support Tom physically. She still provides emotional and social support through email phone and of course when he visits her home. His mum is concerned that she’s not able to support her son as she’d expected and this has had profound impact on her own emotional wellbeing and her sense of being a parent and carer. She wanted the best for Tom and before her own health crisis, she ensured the support that Tom got was as good as it could be, using community and other resources to enrich Tom’s life and choices and to envision a future that was positive and safe and made the best of the circumstances. She was a powerful advocate but this role has been compromised through her own ill health.

It has taken time and effort for the family to get through each challenge step-by-step.

Tom’s support arrangements were set up before self-directed support and at the time, most of the arrangements were set up to enable discharge from hospital.

Tom is required to be offered the four options at his next review after 1st April.

He likes the arrangement he has, but this is still a new experience for him and circumstances have changed since it was set up. Tom’s carers are his life, and part of his routine, and he would not manage without them.

Now that he has had time to adjust to his new way of living, what would an outcomes- focused review enable him to say?

What matters most?

That his family feel he is managing so they can focus on his mum. One very visible sign of this is shaving. A seemingly small thing, he is by shaved by female carers most of the time – passable but not great. He is aware his mum feels he looks unkempt at times, and this becomes a source of argument, about the quality of his carers and if he defends them, then his personal priorities are questioned.

He can cope but if there is a special occasion like visiting his mum, or other relatives and friends a sign to them of him managing is to look groomed. The only way he feels properly clean shaven is on the rare occasions he is taken to a Turkish barber – (he is totally blind and has to rely on others to escort him).

He would feel more independent if some of his support was turned into escort to a Turkish barber, and flexible enough for shaving before family gatherings, not just on a particular weekday, but at weekends when parties happen and families gather. Then he knows and feels he is groomed.

The outcome for him, is he can trust that his appearance is how he would like to look if he could see, and secondly he feels this is one less worry for his mum, therefore, the time they spend together therefore has more quality.

Option 1 a direct payment for unpredictable escort to a Turkish barber

What else matters?

Tom likes most of his carers but wants them to remember it is his life and he wants to have friends round – for meals, coffee, film nights with carry out food and drink. He attempts to wash his dishes, but can’t see how clean the plates are, and he doesn’t mind anyway. He would prefer that one of his carers does not scold him for leaving plates used by others for her to wash. He wants to remind her this is his home. But he needs her support. His involvement in designing his support would enable him to make this clear at the outset, there are other tasks he would be happy to do without so that he could have friends round and live his life as normally as he can.

Outcomes: Tom feels just like any other young man learning to live as independently as he can, and to enjoy a normal life with friends.

SDS Duties confirmed. Involvement in designing support. Collaboration through more effective use of own resources and networks. Choice and control through support being designed around him with small adjustments.

Support planning: considerations for:

Practitioners

• the support plan must evidence the involvement and participation of the individual and highlight that collaborative approaches have been taken especially with the person, with other agencies and people who are important.
• the practitioner, where they consider it appropriate, should provide the individual with information about independent advocacy services provide a unique role in terms of helping people navigate and make their choices.
• the Mental Health (Care and Treatment) (Scotland) Act 2003, the Adults with Incapacity (Scotland) Act 2000 and the Adult Support and Protection (Scotland) Act 2007 require consideration of independent advocacy when people are subject to duties under these acts.
• when support planning for a child or young person, the GIRFEC approach must be adopted (this will be further supported within the new Children and Young People Bill).
• the individual should have an understanding about the choices they have made and what this means for their support arrangements, now and in the future, pending review.
• the person is clear about how the plan will be monitored and reviewed and how this will support their agreed outcomes.
• the plan should make use of natural networks and other community resources where possible.
• there should be clear evidence of the person’s full involvement within the process.
• capacity can be variable; this needs to be built into plan.
• clear timescales are identified and outcomes are broken down into manageable chunks. This helps make it measurable and easier to see progress if there are milestones identified along the way.
• the person should be clear about what supports are going to be provided to them, by whom, when, how and every other detail of the support plan arrangements along with how these will be managed and everyone’s role within this process.
• the support plan should focus on what the person wants to achieve as well as openly discussing and recording any risk factors to the person or from the person to others.
• the support plan should consider the importance of the principle of minimum intervention – as the least restrictive options should be used.
• use of assistive technology can deliver discreet support that enables people to retain independence and dignity and this should be considered.

Organisations

• decision making and budget setting processes should be transparent regardless as to what system is adopted to determine a person’s personal budget.
• practitioners need to be supported by supervisors and managers to ensure individuals are at the heart of all assessment, planning and decision making.
• the requirement to evidence involvement and choice will require coherent support plan recording methods.
• practitioners will require guidance and support in relation to a range of new procedures, structures, polices, and resources to allow them to feel clear and confident about this stage.
• these will vary across local authorities and partnership arrangements, but must be fit for purpose to ensure practitioners carry out their duties in relation to the Act.
• opportunities to contest decisions should be known to all parties (e.g. appeal or complaints processes).

Carers

There are two specific areas relating to carers in addition to those listed above:

1. they are to be fully involved in developing a support plan in their role as a key partner.
2. when support is to be provided to enable the carer to continue in role, the support plan is to be developed jointly and highlight which areas are for the supported person and which are for the carer in their own right.

A carer’s story

A carer looks after her father, who lives alone, is getting older and more frail and starting to need a bit of help around the house. The carer does the more heavy-duty housework such as vacuuming and mowing the lawn, as well as going to the supermarket and running errands.

Her father has a stroke and is taken into hospital. He is in hospital for three weeks and during this time his daughter has a carer’s assessment, organised by the hospital social worker. It establishes that although his daughter was able to support him before the hospitalisation, the care required when he leaves hospital will be more substantial than what has been done before, including some personal care, and it is not known how long the more substantial care will be needed for, as rehabilitation following a stroke can be variable.

The carer will not be able to cope with this level of caring as she works full-time and has two teenage children. In addition, she does not want to provide personal care for her father and he would prefer to receive it from paid care workers. She is still able to visit regularly, and helps with the housework when she visits, as well as picking up shopping, running errands and supporting him when the occupational therapist and physiotherapist visit. She is also referred to the local carers’ centre, and is able to meet with other carers who are in similar situations.

Her father is offered support from the local authority, and after talking with his daughter about how the support will fit in with the care she can provide, he decides to take an individual budget, and asks the Council to arrange care from a private care agency who can come and help him with showering, dressing and cooking at times that suit him. The care agency is very flexible and will come along in the mornings and evenings to provide personal care and help with making meals. The care workers have shorter visits at weekends and on days when his daughter is not at work, as she is able to help her father with meals then and so the care workers only have to help him wash and dress.

A key safe is installed to make it easier for the care workers to access the property. It also means that the eldest grandchild can visit if required when the carer is not available.

The flexibility of the agency care workers is very important as his daughter’s days off are not on a specific schedule. Likewise, if the carer needs a break, the agency uses the hours that have been ‘saved’ to provide extra support with shopping and household tasks.

Learning points:

The carer has been caring for a while but has only had a carer’s assessment after reaching crisis/emergency. It has been recognised that her caring limit had been reached and support must be provided for her to be able to continue to care.

The cared for person is provided with support due to his condition, but this support also benefits the carer. It will be detailed in both plans. He is able to choose support that suits him and also has the help and support of the carer when choosing.

The flexibility of support suits both the carer and the person receiving care, as it allows the carer to maintain their own life, remaining in employment and having a break from caring. Neither of them wanted a direct payment, but do want some choice over who provides care, so option 2 was the best choice for them as they can ‘bank’ the hours they don’t use for extra support when it’s needed.