Contents

1. Purpose
2. Context
3. Policy principles
4. Policy inclusions
5. Support planning

• Approved: 13/12/2017
• Active from:13/12/2017
• Reviewed: 06/02/2023
• Next review: 06/02/2025

Purpose

1. This policy outlines what adults and carers with eligible care and support needs can expect from the council, to enable them to access the right care and support to promote their wellbeing and live their lives as independently, safely and successfully as possible.

2. It applies to both people with eligible care and support needs and carers with eligible support needs, as determined by the National Eligibility Criteria introduced by the Care Act 2014. Eligibility is covered by the council’s Assessment and Review Policy and associated guidance.

3. It is based on relevant Government legislation and Government guidance, including:

• the Care Act 2014;
• the Mental Capacity Act 2005;
• the Mental Health Acts 1983 and 2007;
• the Children and Families Act 2014;
• the Housing and Regeneration Act 2008.

4. It should be read in conjunction with the council’s Adult Social Care policies on Assessment and Review, Comments and Complaints, Safeguarding and Contributions, and associated operational procedures and guidance

5. It should also be read in conjunction with partners’ policies where applicable. Examples include the Oxfordshire Clinical Commissioning Group, NHS Continuing Healthcare and mental health services.

Context

6. Oxfordshire County Council aims to support and promote strong communities so that people live their lives as successfully, independently and safely as possible. It aims to encourage independence and choice, be fair and equitable and give service users more power and control over their lives.

7. The Care Act 2014 sets out that people whose eligible needs for care and support are being met by the council will have a Support Plan, and where applicable a Personal Budget. The Support Plan details the needs to be met and how, linking back to the agreed outcomes the person wishes to achieve in day-to- day life as identified in the assessment process.  The Personal Budget sets out the cost of the person’s care and support, and the amount the council will make available.

Policy principles

8. Where a person has eligible needs for care and support, or in the case of a carer for support, the following principles shall be applied, and the council will:

• Provide the person with clear information about the support they are eligible to receive from the council and how this has been determined.
• Ensure people have access to the information, advice and support they need to plan their care and support.
• Make clear that everyone with eligible needs is entitled to support from the council, whilst encouraging and supporting people to take as much control as they are able and willing to.
• Enable people to develop coordinated support plans which best address their needs and promote their wellbeing.
• Ensure the care and support planned meets eligible needs and as far as possible, maintains independence and prevents further needs from developing.
• Support people to stay safe from harm whilst living an active life, through taking a balanced and collaborative approach to managing risk.

Transparency

9. The council will make it clear to the person (and others involved) how the support planning process works, what their options are at each stage, and what they can expect to happen next.

10. The way in which the council determines what support the person is eligible to receive will be as simple and transparent as possible.

11. The council will work with the person (and others involved) to develop a Support Plan setting out how their eligible needs will be met. It will provide appropriate support throughout this process, in accordance with the person’s needs and circumstances.

12. The council will make clear how Personal Budget amounts will be agreed, through a support planning process centred on the person’s agreed outcomes and taking into account available resources.

13. The council will make clear whether a person needs to make a financial contribution towards meeting their needs, via a financial assessment. This is covered in the Adult Social Care Contributions Policy and associated guidance.

14. The council will make clear the process for complaining or appealing a decision. This is covered by the Adult Social Care Comments, Complaints and Compliments Policy and associated guidance.

Information and Advice

15. The council will ensure clear, comprehensive and wide-ranging information and advice is available about support and care choices and opportunities which promote wellbeing, prevention and recovery. The information will be accessible and in a range of formats and will include information from independent sources. The council will make sure people are informed of organisations and networks which can offer independent financial advice and/or support planning assistance.

Fairness and Equity

16. A single policy for support planning for those with eligible needs ensures people are treated fairly and equitably. This policy covers people who have been assessed as having eligible care and support needs, regardless of their circumstances.

17. This policy applies irrespective of a person’s ability to pay. For example, those whose financial resources mean that they will pay for their own care are nonetheless entitled to request other types of support from the council.

18. The council will support people who may require support to be involved in the support planning process and have no other means of accessing appropriate support through relatives, friends or others.

Choice and Control

19. The council will enable people to access what they need as directly, simply and quickly as possible, including high quality information and advice.

20. Together with its partners, the council will promote the availability of a wide range of high-quality care and support options in Oxfordshire.

21. People can choose how to meet their agreed outcomes, so long as the plan they put together meets their eligible needs and is lawful, effective and affordable.

22. The council will support people to consider their needs and the outcomes they wish to achieve, taking into account all aspects of their life. It will enable them to develop coordinated plans, where this most effectively meets their needs and promotes their wellbeing.

23. The council will work closely with its various partners to reduce duplication, for example through streamlined processes and sharing information where the person consents to this.  Examples include health and care provider partners.

Promoting prevention, early intervention and independence

24. Where possible the council will seek to enable people to stay in their own homes and communities. However, the council also has a duty to make best value decisions to ensure it operates within its financial means and maximises available resources so that meeting the needs and preferences of individuals is fairly balanced against meeting those of the entire local population.

25. The council will ensure there are a range of universal, preventative services available in Oxfordshire for adults and carers which are accessible to all.

26. A person’s needs for care and support can be met in various ways. The council will encourage people to think creatively about what resources they have already or can develop which they can draw upon, as well as which options will best promote their independence.

27. Where people are eligible for longer-term support, the same principles of encouraging and enabling independence will apply. People’s care and support will be kept under review to ensure it is meeting their assessed needs and enabling them to work towards their outcomes and maximising their independence.

Staying safe from harm whilst living an active life

28. In terms of Support Planning the council will enable, encourage and support people to make their own decisions about their lives. It will take a positive approach to managing risk, supporting people to balance living an active life with protecting themselves from harm.

29. The council will seek to stop abuse and neglect wherever possible, whilst safeguarding people in a way that supports them in making choices and having control about how they want to live. This is covered in more detail in the Safeguarding Adults Policy and associated guidance.

Policy inclusions

People with eligible needs

30. This policy applies to people with eligible care and support needs, as determined by the National Eligibility Criteria. Eligibility is determined following a needs assessment, covered in the Assessment and Review Policy and associated guidance.

31. It also applies to young people who are likely to have eligible needs for care and support after turning 18, to adult carers who are likely to have eligible needs for support after the person they care for turns 18, and to young carers who are likely to have eligible needs for support after they turn 18 (as determined following a transitions assessment referred to in the Assessment and Review Policy).

Carers with eligible needs

32. This policy applies to carers who have been assessed as having eligible support needs in line with the National Eligibility Criteria regardless of their circumstances, including whether or not the person they care for has eligible needs.

Ordinarily resident in Oxfordshire

33. This policy applies to people with eligible care and support needs who are considered to be ‘ordinarily resident’ in Oxfordshire.

34. It also applies to carers with eligible support needs caring for someone considered to be ordinarily resident in Oxfordshire, regardless of where they themselves live.

People who choose to access support from the council

35. This policy applies to people and carers with eligible needs who choose to access support from the council, irrespective of their financial resources. Whether or not and the extent to which they will pay towards the cost meeting these needs is covered in the Contributions Policy for Adult Social Care.

People who lack capacity to decide whether to access support

36. Following a mental capacity assessment, if it is determined that a person does not have capacity to decide whether to access care and support from the Council, a best interests process in line with the Mental Capacity Act will take place. If it is decided that it is in the person’s best interests for the council to arrange to meet their needs, this policy will apply.

37. If, following a ‘best-interests’ assessment, at-home provision is recommended as the least-restrictive option, the Council will not routinely insist upon a care-home placement. The decision will be made on a case-by-case basis having taken into account all relevant factors.

Support planning

38. Following a needs assessment and a determination that a person has eligible needs for care and support, the council will consider how the needs will be met.

39. Where the council is meeting a person’s needs, it will enable the person to be actively involved in planning how to meet them. This support planning process will be proportionate and flexible, guided by the individual’s needs, preferences and circumstances.

Independent advocacy

40. If a person has substantial difficulty in engaging in the support planning process and has no other means of accessing appropriate support through relatives, friends or others involved, the council will arrange an independent advocate to facilitate their involvement. Where applicable, this will be an advocate who meets the requirements of the Mental Capacity Act.

Mental Capacity and Deprivation of Liberty

41. In line with the principles set out in the Mental Capacity Act, the council will assume that people have mental capacity and can make decisions for themselves unless it is established otherwise.
42. If the council thinks a person may lack capacity to make a support planning decision, it will carry out a capacity assessment in relation to the specific decision to be made. This and the following steps are covered in the associated mental capacity guidance.

43. Where a plan for a person lacking capacity will unavoidably result in a deprivation of liberty (DOLS), the council will ensure it is authorised in the appropriate way.

If a person decides not to take part in the Support Planning process

44. The council considers that people themselves are best placed to make decisions about their care and support needs, including whether or not to accept help from the council in planning to meet their needs.
45. Where a mental capacity assessment concludes that the person lacks capacity to make the decision not to take part and there is no substitute decision maker, a best interests process will be carried out in accordance with the Mental Capacity Act and the associated guidance.
46. If the person has mental capacity but they appear to have care and support needs which if not met will leave them or others exposed to high levels of risk, a multi-agency risk assessment will be carried out to determine the level of risk and to decide what action (if any) should be taken to reduce this.

Meeting urgent needs

47. Where a person has urgent needs for care and support, the council will work with them and anyone else involved to put interim arrangements in place quickly. The same support planning aims and approach will apply.

48. The person’s situation will be kept under review. Once it becomes appropriate to do so, the council will support the person to consider next steps. This will be done on a case-by-case basis, in consultation with the person and others involved such as family, friends and other professionals.

Continuity of care

49. When a person chooses to move to Oxfordshire or from Oxfordshire to another area, the council will work closely with the other local authority to ensure there is no interruption to the person’s care and support.

50. When a person chooses to move to Oxfordshire, wherever possible the council will carry out a needs assessment and aim to begin the support planning process prior to the day of the move.

51. In cases where this is not possible, the council will continue to meet the person’s needs in accordance with the support plan from their previous local authority in line with the continuity of care principles.
52. Where a person chooses to move from Oxfordshire to another area and the council has been made aware of this, it will notify the other local authority and provide the relevant information to allow for care and support to continue without interruption.

Transition into adulthood

53. The council will ensure that children’s and adult’s services work together to enable young carers, young people with care and support needs, and those who support them to prepare for adulthood.
54. This will involve supporting the young person to identify the outcomes they wish to achieve, as they take steps towards greater independence. This will include preparing for the opportunities of adult life, such as: further education, paid employment, independent living, and leading an active life within the community (see Assessment and Review Policy). This applies to both young people with care and support needs and to young carers.
55. It will also involve supporting carers to identify the outcomes they wish to achieve to promote their wellbeing. This applies to adult carers preparing for the person they care for turning 18, and to young carers as they prepare for turning 18 themselves (or 25 if they are in education).
56. Where following a transitions assessment it has been determined that a person is likely to have eligible needs for care and support once they turn 18 or for support once the person they care for turns 18, the council will consider with the person (and others involved) when to begin planning to meet these needs.
57. As far as possible, the council will ensure this support planning process is completed before the young person turns 18.
58. In cases where this has not been possible, the person will continue to receive care and support in accordance with any plan from children’s services until a needs assessment has been carried out and where applicable, the support planning process is complete.
59. For young adults aged 18 to 25 with an Education, Health and Care Plan, the ‘Care’ element will be developed in accordance with this policy.

Mental health

60. Where applicable, the support planning process will also follow the Care Programme Approach.  This is covered by the associated guidance.

Developing the Support Plan

61. The Support Plan will be developed through a collaborative support planning process, in which the person will be encouraged to take as much control as they are willing and able to.

62. Where applicable, the Support Plan will also include the person’s Personal Budget. This is a statement which clearly sets out the cost of meeting the person’s eligible needs, breaking it down into the amount the council will pay and where applicable, the amount the person is required to contribute.

63. There will be a range of resources available to ensure people are actively involved and influential throughout the process of developing their plan, and are empowered to take as much control as they are able to. This will range from high-quality information and advice in various formats through to comprehensive

support from an independent advocate, depending on the person’s needs, preferences and circumstances.

64. Where a carer has eligible needs and is caring for someone who does not have eligible needs, the council will ensure the person being cared for is nonetheless involved in the decision-making process.

65. The council will aim to work with relevant partners to enable people to develop a single or coordinated plan, for example covering their health and social care needs. This may involve one organisation carrying out support planning on behalf of both organisations.

66. Where a carer has eligible needs for support and is caring for someone who is also eligible for care and support, the council will support them to develop a combined Support Plan whenever this is appropriate and both people agree.

67. Combined plans will clearly show the needs and agreed outcomes of each person involved, and how they will be met through the joint approach as well as any other elements specific to the person.

Options for meeting needs for care and support

68. Support to meet a person’s needs can be provided by the council in various ways, including: information and advice about options available within their communities; universal services; a range of preventative services; referrals to other organisations which can meet the person’s needs; equipment and assistive technology; and providing a Personal Budget for various care and support options.

69. Oxfordshire County Council wants to ensure that home care visits are long enough to enable people to maintain their dignity. Therefore, the council will not commission 15-minute home care visits for personal care tasks unless the person themselves requests this and/or it is agreed by managers that this is a suitable timeframe for the task involved.

70. Where a person’s eligible needs for care and support are being met by a carer, this will be recorded in their Support Plan. A decision about eligibility will have been taken before considering whether the eligible needs are met by their carer (see Assessment and Review Policy). The carer will be involved throughout the process and will be offered an assessment of their own needs. This is set out in the Assessment and Review Policy and associated guidance.

71. The council may meet a carer’s eligible needs in a number of ways, which could include through meeting the needs of the person they care for.

72. Where needs are identified which are not eligible for support from the council, the person will be supported to consider alternative ways of meeting these needs and how to prevent them from developing further.   This will be included in the person’s Support Plan. The council may signpost or refer the person to these sources, however it will not be responsible for meeting these needs.

73. The council will make clear whether people need to make a financial contribution towards the cost of meeting their needs and this will be calculated via a financial assessment. This is covered in the Contributions Policy.

74. The council will always offer at least one option (and where possible more than one option) which meets the person's eligible needs and falls within their Personal Budget.

75. A person can choose to access care that is more expensive than is required to meet their eligible needs by paying a top-up. They can pay this themselves (in certain circumstances) or family, friends or others can pay it on their behalf. This is covered in the Contributions Policy.

76. Throughout the process of planning how to meet their needs for care and support, people will be supported to consider the risks involved. Where a person decides to meet their needs in a way which involves significant risks, the council will work with the person and others involved to develop a proportionate approach to managing them.

77. There may be restrictions, for example there will be more limited options available to those in prison, approved premises or bail accommodation. However, where possible, the same principles of maximising choice and control will nonetheless apply.

Meeting needs with a Personal Budget

78. Where it has been determined that a person is likely to require a personal budget to access care and support options to meet their eligible needs, the following will apply.

79. This process will start with an estimated (indicative) budget. This is the amount the council anticipates it will cost to meet the person’s eligible needs, and which they (and others involved) can use to begin planning their care and support. It is an approximate figure which may increase or decrease throughout the support planning process, in discussion with the person (and others involved).

80. This estimated (indicative) budget is calculated using a Resource Allocation System (RAS) which determines the cost of meeting the assessed needs.

81. The final budget amount will be determined at the end of this collaborative support planning process, once it has been agreed how the needs for care and support will be met.

82. The council will ensure the final amount is sufficient to meet the person’s eligible needs, taking into account the type of care and support the person chooses and the options available.

83. The council will work with its partners to enable people to combine their budgets where applicable. For example, where people are eligible for both a Personal Health Budget from the NHS and a budget from adult social care.

84. People can decide how to manage their budget, with options including receiving it as Direct Payment, having it managed by either the council or a third party, or a mixture of the three.

Direct Payments

85. People wishing to have maximum control over their budget can opt to receive Direct Payments, so they can directly purchase care and support to meet their needs and agreed outcomes. In line with its aim of enabling people to have more power and control over their lives, the council will encourage people to consider this option. As part of this, it aims to make the process of accessing and using Direct Payments as straightforward as possible.

86. The council will ensure there is comprehensive information and advice available about the process of accessing a Direct Payment, the responsibilities involved and the support available.

87. People with care and support needs can request a Direct Payment. In cases where the person in need of care and support has been assessed as lacking capacity to request a Direct Payment, an authorised person can request the Direct Payment on the person’s behalf.

88. If the council decides that a Direct Payment is not appropriate, it will explain the reasons for this decision and offer support to explore alternative options. It will also inform the person (and others involved) how to appeal the decision.

89. Direct Payments cannot be used to pay a close family member living in the same household to provide care and support, except in exceptional circumstances and when authorised by an Adult Social Care Service Manager.

90. In exceptional circumstances and where the council determines this to be necessary, a close family member living in the same household may be paid to manage and/or administer the Direct Payment on behalf of the person with care and support needs.

91. In accordance with national legislation Direct Payments cannot be used to pay for long-term residential care.

92. The council will ensure that people who choose to use their Direct Payment to directly employ Personal Assistants are able to access appropriate support. This will include information and advice on their duties as employers, and support to put a plan in place in the event that the Personal Assistant(s) is absent.

93. The person or their representative will be expected to sign an agreement which sets out the terms and conditions they must comply with when opting for a Direct Payment.
94. The council will check to ensure that the Direct Payment is being used to meet eligible care and support needs in accordance with the Direct Payment agreement.

95. In some circumstances, the council may decide to suspend payments and/or to recover unspent funds.

96. This section does not apply to people with care and support needs in prison, approved premises and bail accommodation, except where they have yet to be convicted; and people subject to a court order for a drug or alcohol treatment programme or similar schemes.

Agreeing the Support Plan

97. The council will ensure the plan sufficiently meets needs, is appropriate and represents the best balance between value for money and maximisation of outcomes for the person.

98. The final plan will be agreed once the person, any third party involved and the council agree on the factors within the plan, including the final Personal Budget amount where applicable.

99. Where the council reasonably believes a person may lack capacity to agree a plan, it will carry out a capacity assessment to determine if this is the case. The council will follow the associated mental capacity guidance.

100. Where a plan cannot be agreed the council will make clear to the person how they can appeal or complain against this decision. Further information is available in the Adult Social Care Comments, Complaints and Compliments Policy and associated guidance.

Next steps

101. The council will provide a copy of the final Support Plan in a format accessible to the person, as well as to any other person they request receives one.

102. With the person’s permission and where appropriate, relevant information may also be shared with other professionals and people involved in the person’s care and support.

103. Where a person does not have capacity to decide whether to share their plan, the council will follow the guidance set out in the Mental Capacity Act.

104. The Support Plan will be kept under review, as set out within the Assessment and Review Policy and associated guidance.

Monitoring and review

105. The council will have procedures in place for monitoring support planning processes, to ensure they are consistent with this policy and associated guidance.

106. This policy will be reviewed every two years unless changes to statutory guidelines indicate this should take place sooner.