Adult Social Care Your Guide to Writing a Care and Support Plan

Transcription

1 Adult Social Care Your Guide to Writing a Care and Support Plan

2 About your Care and Support Plan What is a Care and Support Plan? A Care and Support Plan is a detailed plan to help you, professionals and people that you work with make the best use of your time together. It describes: your personal goals the services and support you require how these will be organised what these will achieve. Writing your own Care and Support Plan gives you a chance to: plan and arrange your own support choose services to suit you manage your own support have more control over the design and delivery of your services. Page 2 of 20

3 If you are eligible for Adult Social Care support we let you know how much money we will provide to meet your needs. We call this your personal budget. Your Care and Support Plan sets out how your personal budget will be used. The support that you arrange must safely meet your eligible needs, be within the law and costed within the agreed personal budget. Your Social Worker or Care Manager will check that the essential information is included. Creating your Care and Support Plan You can: produce the plan yourself. You may like your family, friends, Social Worker or Care Manager to help you with ideas and identify options. ask an advisor from Enham Independent Living Service to help. They can give you as much or as little help as you need to write your support plan. They can share examples of other plans. ask your Social Worker to complete the Care and Support Plan with you or on your behalf. Page 3 of 20

4 What should I put in my Care and Support Plan? You can use any format and set your plan out in the way that makes sense to you, or use the blank Care and Support Plan that we supply. If you are not using the form we supply please make sure you have covered all the headings in this guide. Front Page The front page of your support plan asks for personal information, such as your name, date the plan was completed, your address, Carer s RAISE number (this is an internal system at Bournemouth Borough Council, so don t worry about filling in this box), and your phone number. The form then asks for your estimated or actual and frequency of your Personal Budget agreed by the Council. Again, don t worry if you don t know these amounts yet. The last pieces of information on the front page ask about the name of anyone helping you to write your Care and Support Plan and ask for their address, contact details, and relationship to you. The rest of this guide goes through each section of the Care and Support Plan template, with some ideas about what to put under each heading. Page 4 of 20

5 About Me People reading your plan may not have met you before, so introduce yourself and set the scene. This helps them when they are working with you. For example, you might want to mention: the important people, places and routines in your life what are the three most important things in your life? your interests and any work or leisure activities any disabilities or medical conditions anything important to you now and in the future. You can add pictures or photos if you want. Page 5 of 20

6 Things other people need to know Make sure you tell us about anything important that will assist other people working with you, such as: any likes or dislikes (maybe food related), what works well or not so well for you allergies, phobias, signs that may show when you are becoming unwell or need more support, how you like to be addressed, or how culture or religion may affect the way you prefer people work with you. The Aims of Your Plan and how these will contribute to Your Wellbeing As a starting point you could look at the assessment that you completed (either online, with a Social Worker or Enham Trust Advisor). How can any of the outcomes you would like be met from your local community or your existing circle of friends or family? What can you do to help your wellbeing? Page 6 of 20

7 What do you want this plan to achieve? What difference will it make? We call this the aims or outcomes of the plan. These may be as simple as: to stay living in my own home as long as possible to feel safe and be healthy to maintain my independence to see more of my family and friends to get a job You may have a longer term aim such as to learn how to look after myself so that one day I can live independently. One way of thinking about outcomes is to ask How will I know my plan has made a difference for me? Think about the whole of your life. What works well? What can be done to help make your situation better? What can be done to prevent or delay the increase of needs in my future? When thinking about your plan, remember to consider: What you do in the day time Do you work? Access training/classes? Volunteer, join in with community activities? Page 7 of 20

8 How do you keep healthy? Do you access health and leisure activities? If so what? Do you need personal care/toileting support? Do you have complex health needs? How do you keep safe? Things you do to reduce the chance of hurting yourself or others. What helps you best get your point of view across? Do you need someone or some equipment to help you? Staying in control: Explain to help the reader get to know you better. You can add to your plan any particular actions you want others to take to help you be in control in the way you want. For example: How My Needs Will Be Met Your home: please make sure all my heating is adjusted as I want it, before you leave People: I get really anxious if the shops are crowded, please stay with me when we are out and about Choices: I ve chosen not to move my bed downstairs. I know I might fall on the stairs but sleeping upstairs is important to me and I want people to respect this choice On the template, this section is written as a table this guide has suggestions for what could be included in each section of the table, below. Page 8 of 20

9 My Personalised Outcomes Once you have worked out the aims of your plan, put each outcome goal into a sentence. Your assessment will have some clear aims within them that you can use as a starting point to help you work out the goals that will work the best for you. You can use this section for any goals you have, not just ones that meet your eligible needs. (These are the needs that a Personal Budget can pay for). Support required to meet these outcomes: When working out your goal ask yourself the following questions: What exactly needs to be done? How will it meet the need/ What will be the outcome? Is there anything else about the goal? How will we know it has succeeded? How many actions will it take? Is this goal a good stretch for me? not too easy but not too difficult? What happens next? Is this goal meaningful for you, or just something others want you to do? Is this a worthwhile goal for you at this time? Will this goal delay or stop you achieving another goal? Are you committed and motivated towards achieving this goal? In what ways? How the support will be provided This might be from a friend or family member, some equipment, an organisation or a personal assistant. The support could be at home or out and about. Page 9 of 20

10 Ask yourself: Who is going to do it? Who else will be involved? Where will this take place? Describe here the actions you are expecting from others, such as: Help with...; Reminding me to..; Advising me about..; showing me how to... Be clear so that the helper knows what is expected. For example: I can wash the top part of my body but need help reaching the bottom half I am able to take a shower by myself, but need to be reminded that I have to do this I am able to get to the shops but get very anxious. I need help to stay calm if this happens How it will be arranged: Ask yourself: How much does it cost? Who will pay for it? Do we have, or can we get, the resources needed to achieve this goal? Page 10 of 20

11 What is the date/deadline for these goals/actions? When do the people involved need to take action? What can be done today? Is there another option that is available already in my local community? How much might I have to pay towards the cost of my service? Support to meet your eligible needs (needs which are eligible for funding by the Council) should be arranged using your personal budget. You can manage your personal budget yourself using a Direct Payment or you can ask the Council to manage it for you. You can have a combination of the two. A Direct Payment means that we will pay into a special bank account the amount of money we have worked out you can have towards paying for the services we have agreed you need. We will give you a card to get to this money. You may have to pay towards the cost of your services, depending on how much money or property you have. This is worked out from a Financial Assessment. If you want to include needs which are not eligible for Council support in your plan you have to make sure you can fund this yourself or with help from others. For example you may be paying through your own resources, using benefits such as Personal Independence Payment, or the service may be supplied by somebody else e.g. the NHS. Expected outcomes and time frame: Describe here what difference this activity or help will make (such as I will feel confident going to the shops ). Page 11 of 20

12 You may aim to achieve this in a certain time ( and I hope to achieve this in six months ). This will help you later when we review the plan with you and think about whether this bit of the plan has achieved what you wanted. Care Diary: Some people set out a weekly care diary showing how the support fits together. We can show you examples to help you set out your plan for other people. This template can be found at the end of this document. How the Personal Budget will be spent The total Personal Budget is made up of the amount you need to contribute (if any) plus the amount that the Council is paying. Your plan must explain how your personal budget will be used. It should split your overall budget into the main areas of support you are planning. Give a brief description, for example personal assistant costs, care agency costs, costs attending activities or groups, and the amount you are allocating to that area in your plan. Your plan should show how this adds up to equal your personal budget. It must not exceed it. If you can make a plan which meets all your needs effectively without using the whole budget you must let us know so that the budget can be adjusted. Council Managed Support: If some or all of your plan will be managed by the council, without Direct Payments, this budget information will be supplied by your Social Worker/Care Manager. If you have been assessed to make a financial contribution we will send you a bill each month to pay. Page 12 of 20

13 Direct Payments: You will need to make sure you spend your Direct Payments as agreed on your Care and Support Plan. When you start, you need to give us a breakdown of what you expect to spend each month. if you use Direct Payments. A Social Worker or advisor from Enham can help you with this. Direct Payments Assistance Costs: If you have Direct Payments you may also receive money towards any additional administrative costs you incur. We call these payments assistance costs. They are not part of your personal budget, so list them separately. We will tell you about any entitlement to these allowances when Direct Payments are being discussed, and Enham can provide a list of managed account and payroll providers. Managing your Direct Payments account Many people manage their Direct Payments independently, but sometimes advice or support to do this can be helpful. For example, remembering to pay bills to care providers, working out wages for personal assistants, or keeping track of your expenditure. Enham can give you a list of managed account and payroll providers who you can pay to run your Direct Payment account. If you manage the account yourself, you can do this using on-line or telephone banking with the account provider APS, or just use the bank card provided. Using the Direct Payment account means that both you and the Council can keep track of what you have spent. We will let you know if it looks as if you are spending too much or too little. Example: I have a direct payment card for my direct payments. I understand that each month the Council pay in to this account the amount of money they pay towards my Care and Support costs and I will pay in any contributions I have to make I will keep invoices and paperwork in a folder ready for any check of what I have spent. Page 13 of 20

14 If you do need help, tell us who you would like to help you and in what capacity (e.g. friend, relative, power of attorney etc). If you are not sure, advisors at Enham can talk this through with you and provide ongoing help. Example: I will receive my direct payments as a Managed Account operated by a payroll management service. They will make all payments on my behalf and complete any financial returns asked for by the Council. Should I require any help with regards to this Care and/or my Care and Support Plan, I can contact Enham Independent Living Service or Adult Social Care Decision making and how your support arrangements will be managed Tell us if you sometimes need help making decisions about your support, and say how this should happen. For example you may want personal assistants or support workers to help plan the week ahead. There may be someone you trust a friend or family member who you would like involved in bigger or more important decisions. Example: I am able to make day to day decisions myself. If I have any important decisions to make, I am able to discuss them with my children who help me pull together the important facts when decision making. Page 14 of 20

15 You may want to change your plan, for example because you require more help, or you are now able to do more for yourself. If this is the case, you must let us know so that we can review your needs and adjust the personal budget to fit your new plan. Back up Plans Do you have any standby arrangements e.g. for when a personal assistant is away on holiday or not well? Who will you contact if something doesn t go to plan? Who should be contacted in an emergency if you are unable to do so yourself? Risks - Keeping Safe Life is full of risks. Risk is often thought of in terms of what could go wrong, but it can also have positive benefits ( nothing ventured, nothing gained ). This section of your support plan is to help you and your Advisor/family/friends, to agree a level of risk that is acceptable to both of you. If there are particular things that concern you such as your living environment, activities in the plan or choices you have made please let us know. We will help you weigh up the risks you have identified and suggest ways of dealing with them. It is important to us that you feel safe and secure. If you have a concern about other people please tell us. This can be built into your plan or kept separately if that is better for you. Page 15 of 20

16 Signing Off Your Signature: please sign and date the plan to show it is your plan and you have agreed it. If you are unable to physically sign, a mark is fine. Other People involved: If anyone else assisted you in making your plan they should also sign it and state their capacity e.g. family member, carer, advocate, independent advisor (Enham). When the person the plan is about lacks the capacity to participate: If the plan has been devised on behalf of someone who lacks the capacity to contribute or participate then this should be noted explaining the reason and the steps taken to involve them. If they are unable to sign the plan then the main signatory will be the person that led the plan development.. If a Best Interests Decision has been made under the Mental Capacity Act 2005 please state where this has been recorded. Getting your plan agreed Your Social Worker or Care Manager will need to check that your plan covers all it needs to. Please do not start arranging your support until we have told you the plan has been agreed. FURTHER INFORMATION For more information on personal budgets in Bournemouth and help with Care and Support Planning or Direct Payments contact our independent support service: Enham Independent Living Service Telephone: Text phone: directpayments.bmth@enham.org.uk Payments--Personal-Budget-Support/ Page 16 of 20

17 For general enquiries speak to one of our advisors at: Bournemouth Care Direct, Customer Services Centre, St. Stephen s Road, Bournemouth BH2 6EB (for deaf and hard of hearing): caredirect@bournemouth.gov.uk This is one of a number of fact sheets and leaflets available about Adult Social Care Services at Information in other formats You can ask for this information in large print, Braille, audio or other languages. Glossary Some of the difficult to explain terms used in this document are defined below: Community Your local area and the people, activities and facilities within it. Contributions Adult Social Care is not a free service like the NHS. You may have to pay part of the cost of your service depending on your income. We will work this out using a Financial Assessment. Council Managed Budgets Money that is allocated to you by your local council to pay for care or support to meet your assessed needs that you choose to leave with the Council, who arrange the services you would like for you. Page 17 of 20

18 Direct Payment Money that is paid to you (or someone acting on your behalf) on a regular basis by your local council so you can arrange your own support, instead of receiving social care services arranged by the council. Direct payments are available to people who have been assessed as being eligible for council-funded social care. They are not yet available for residential care. This is one type of personal budget Mental Capacity The ability to make decisions for yourself. The law says that people may lose the right to make decisions if this is in their best interests. The Mental Capacity Act is a law that is designed to protect people who are unable to make decisions about their own care and support, property or finances, because of a mental health condition, learning disability, brain injury or illness. Personal Budget Money that is allocated to you by your local council to pay for care or support to meet your assessed needs. The money comes solely from adult social care. You can take your personal budget as a direct payment, or choose to leave the council to arrange services (sometimes known as a managed budget) - or a combination of the two. Review When you receive a re-assessment of your needs and you and the people in your life look at whether the services you are receiving are meeting your needs and helping you achieve your chosen outcomes. Changes can then be made if necessary. Wellbeing Being in a position where you have good physical and mental health, control over your day-to-day life, good relationships, enough money, and the opportunity to take part in the activities that interest you. Think Local Act Personal have written a jargon buster, which explains some of the commonly used terms in Adult Social Care documents Think Local Act Personal Jargon Buster Page 18 of 20

19 Care Diary Template Adult Social Care Care Diary Full Name Computer Ref. No Please provide below the name(s) and address(es) of the person(s) / organisation(s) that provides the care, as detailed overleaf, along with a contact telephone number, and the total numbers of hours of care that they provide. Total nº of Name of person / organisation Address Contact telephone nº Start date hours of care provided Page 19 of 20

20 Full Name Computer Ref. No 6.00 am am am pm 7.00 pm am Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 20 of 20