What to expect from care planning and support

Making a referral

Referrals come to us from a wide variety of sources, including placement transfers, Special Education Needs schools, residential colleges, community support units and individuals looking to leave the family home for the first time. A referral can be made by a social worker, care manager or an individual's parents, although the care manager acting on behalf of that individual must be consulted before an assessment can take place.

You can make a referral for either our residential or supported living services by getting in touch with our Referrals Team on 0203 195 0151 or at [email protected].

Assessments

When we receive an enquiry, we review the individual's care requirements to ensure we're able to provide appropriate support. If this is the case, one of our Referrals Managers will get in contact to introduce themselves and discuss how best to complete a detailed assessment of your relative's needs. Our person-centred assessment process is designed to ensure we can offer a placement where your loved one can achieve the most positive outcomes. We look at the whole person to determine their suitability for a particular home or service: their needs, abilities and personality, where they'd like to live, who they'd like to live with and what things are important in their lives. The process is designed to ensure your relative feels as confident as possible that their placement will be a success.

Commissioners will often ask for three separate assessments, so they can compare value and suitability. This also helps give you options.

Visiting our services

If we have a suitable placement available, we'll arrange for you to visit the home or service to give you and your relative a chance to look round, meet the manager, staff and other residents, and get a sense if it feels right. If there are vacancies, this can sometimes mean multiple visits to different services.

Confirming a placement

If everyone agrees a placement is right, we provide a costing to the funding authority for approval. The cost proposal is reviewed by a commissioning panel to get funding confirmed. Local authorities each have their own eligibility criteria, based on the national criteria outlined in the Care Act. They complete a Care Needs Assessment (CNA) and base their funding on its results.

The local authority confirms how it will meet your relative's needs in a Care and Support Plan, which sets out what services will be provided, when they will be provided, and who will provide them. You are entitled to see a copy of your plan, and the authority should ensure that your relative, and in complex needs cases their immediate family, are happy before it's finalised. The plan is reviewed annually, or if circumstances change.

Challenging a decision

Individual authorities have their own specific complaints procedures, but if you want to challenge a funding decision, you should start by raising the issue in writing with the Director of Adult Services at the funding authority, requesting a Mandatory Reconsideration - a review of the decision. If you're not happy with the response you receive, you can then complain to the Local Government Ombudsman. They can also recommend a review. A solicitor can tell you if a judicial review may be possible. A judicial review is the way that people can challenge the lawfulness of a decision made by a public body. It's about questioning the way in which a decision has been made, rather than the rights and wrongs of the conclusion reached. This may mean that the public body will be able to make the same decision again, so long as it does so in a lawful way. If you want to argue that a decision was incorrect there are alternative approaches, such as appealing against the decision to a higher court.

Transition planning

If all parties agree that a placement in one of our homes is the best choice for your relative, and funding is approved, we develop a tailored Transition Plan. We understand that moving into a new home is not only an anxious time for your relative, but also for you, and we do everything we can to make the move as smooth and welcoming as possible.

Your Referrals Manager is responsible for overseeing the process, and you can contact them at any time with any concerns or questions you have. First, they'll organise a Transition Meeting, including the Home or Service Manager, where everyone can plan the move together, including agreeing how many visits your relative may need to get to know and feel comfortable with staff and housemates, whether they'd like an overnight stay or two before moving in, whether any adaptations need to be made to the home environment and if staff need any new training to support them.

The resulting plan is flexible and dynamic, offering a variety of opportunities for individuals to get to know their new support team, home, peers and community. As well as visits, this may include social stories and sharing pictures and details of what life will be like. Some people find they need extra support and time to adjust, others just want to move in as soon as possible.

Your keyworker

Everyone in our homes has a keyworker - a member of staff with particular responsibility for their welfare. Your relative's keyworker will take extra time to get to know you and them, visiting their current placement, shadowing staff and working to ensure a successful transition. A dedicated practitioner from our Positive Behaviour Support Team will also work with the home during and after your relative's transition period to monitor their emotional and mental wellbeing.

Settling in

It can take time for people (particularly those with autism) to settle in to a new environment, and for the people already living there to adjust to a new housemate. We will do all we can to support your relative to cope with these changes, but it's important to recognise that it may take a little time before they feel completely at ease. Typically there will be weekly reviews to discuss progress and highlight any learnings to be added to your relative's Care Plan.

Your Referrals Manager will officially hand over at the six week review. Going forward, the Home Manager and their team - and in particular, your relative's key worker - will become your first point of contact.

Transition to supported living

For those moving into supported living services, we also develop a plan. Often this is more practical, focusing around support and advice on aspects such as applying for grants or benefits to assist with the cost of moving, deposits, rents and sourcing furniture or specialist equipment. Again, we take time to ensure your relative is totally comfortable with the staff supporting them and any concerns are allayed.

Family Welcome Pack

Our Family Welcome Pack, provided for all new placements and available in accessible formats, outlines exactly how we will work together to achieve the best possible outcome for your relative.

Personal Care Plan

Everyone we support has their own personal Care Plan, developed with their input and tailored to their specific needs. Care Plans are designed so that key objectives for each individual can be met. The plan documents, in an easy and accessible way, the support your relative requires, any additional healthcare needs, their likes and dislikes, learning goals and any specific challenges. Everything we need to know to support them consistently and effectively. The Care Plan is the most important document we, care professionals, the people we support and, with the individual's permission, their family, share.

Developing the plan

To create a Care Plan, we gather information from your relative's initial assessment, from care staff at any previous placements, from you and others in their close network, their care worker and any other care professionals involved. If they have capacity, sections of the plan are co-written by your relative in the first person. It's important they're given choices and understand what the plan contains. If your relative is not capable in this way, you will usually be asked to help complete these details for them. Our Home or Service Manager finalises the plan, outlining any potential risks and providing specific guidance for support, so all staff are quickly familiar with your relative's needs. You should check the plan is accurate and covers everything that's important. If you have any concerns, raise them with the manager responsible.

Updating the plan

Once someone has moved into one of our homes or supported living services, their Care Plan is expanded as our staff get to know them better. Individual care requirements are reviewed on an ongoing basis, with any changes discussed at team meetings. The formal plan is reviewed annually with the individual, as well as being updated following any change in circumstances or medical requirements.

In almost every case, care planning involves family members, but it's important to note that where possible care plans are agreed directly with those we support, and some people may not want others, even close relatives, involved in that process.

Activity programmes

In every Choice Care home, we provide a wide range of engaging and meaningful activities, tailored to individual capabilities, to promote social, vocational and life skills, helping to build confidence and self-esteem.

All our homes have a Day Activity Coordinator who develops personalised activity programmes. The emphasis is always on getting involved and having fun. In a recent survey 100% of those we support said they enjoy their activity programme, participating in an average of 12 separate activities every week, from literacy and numeracy skills to cooking, swimming and horse riding.

Leisure time

During down time, homes have communal lounges (usually including a designated "˜quiet' lounge) with sofas, TVs, games consoles, computers and internet access. There are games and hobby and sports equipment for everyone to use.

Everybody in our homes has access to a variety of community-based leisure and entertainment facilities, including local shops, sports and leisure centres, cinema, community organisations and volunteering groups, pubs, clubs and restaurants, as well as the opportunity for religious worship.

Education

Many of our homes and services also work closely with local education facilities. Around a quarter of those we support attend school or college courses. In some cases external educational teams come into our homes to offer specialist support.

Special events and holidays

In addition to weekly activities, we organise regular special events throughout the year that everyone looks forward to. And last year, over two-thirds of the people we support enjoyed a holiday, by themselves or as part of a group, in the UK or abroad.

Managing your own money

The people we support use and manage their own money as and when they choose. Of course, some people need help managing their financial interests, but this support never overrides their right to access their money or to decide how and when they wish to spend it.

Everyone has a financial profile as part of their overall Care Plan, which includes details of what that person needs to pay for, a risk assessment of their money management skills and a money management action plan. The action plan suggests activities to help build confidence in managing finances, including budgeting, saving and making purchases.

Weekly allowances

If your relative is moving to one of our residential homes, they will receive a weekly allowance to cover the cost of personal expenses, including food, clothing, social and leisure activities and a contribution towards an annual holiday. You can supplement this if you wish, but all essentials are taken care of. Staff are there to help as necessary, and when required to support people outside the home - going to the cinema for instance, or eating out - those they're supporting are expected to cover their costs.

Note that this allowance shouldn't be confused with a Personal Budget. A Personal Budget is the total amount of money provided by a local authority to pay for your relatives care and support needs.

Complex needs

Where someone lacks capacity to express their needs, we will work with you to ensure that personal funds are always used to enhance your loved one's quality of life. Even if someone is unable to understand certain aspects of their finances, they're still involved as much as possible in choosing how their money is spent.

Supported living

In a supported living arrangement, personal care and accommodation are provided under separate contracts. The local authority meets the cost of care direct, but the individual must pay for accommodation, food, household and personal expenses, some activities and transport, through personal benefits - like the Personal Independence Payment and Employment and Support Allowance - or earnings.

Health Action Plan

As part of your relative's overall Care Plan, we will develop an individually tailored Health Action Plan covering all aspects of their general healthcare. Everyone has their own plan, and staff ensure that all appropriate appointments and check-ups are maintained. We work closely with local healthcare authorities and a variety of healthcare professionals, including GPs and dentists, speech and language therapists, professional physios, psychiatrists as well as our own internal Positive Behaviour Support Team to ensure the needs of all those we support are met. Where appropriate, our service managers can provide support with making referrals to other health services. Our staff will help administer medication or support individuals to self-medicate.

Healthy living

Personal Care Plans also provide guidance on exercise and diet. Where appropriate, individuals are encouraged to get involved in preparing meals to help build knowledge of nutrition and healthy eating.

Our relationship with you

Involving families in the referral, assessment and care planning process is a critical part of ensuring that the people we support get the care they need. Your views will be listened to carefully at each stage of the process by all those involved in your relative's care, and thereafter, each time their needs are reviewed. We will never replace you, but we aim to build a strong bond with them, and a positive relationship with you, so your loved one can lead the happy, safe and fulfilled life you want for them.

Keeping in touch

As part of the transition process, we will discuss with you exactly how you would like to be communicated with and how often. Managers and staff in individual homes and services communicate regularly with families and are available by phone and email. Many people we support have their own mobile phones and you can generally contact your relative at any time, as long as they are happy to receive the call.

Relatives can also keep in touch with news from Choice Care by registering for our email newsletters, via the Our Stories page on this website and by joining our Facebook and Twitter communities.

Family visits

Families are able to visit our homes at any time. We do, however, ask that staff are informed in advance. Many of those we support (particularly those with autism) prefer a set routine and can find sudden changes to their schedule, or missing out on a favourite activity, upsetting. So if we do need to make changes, we need to people appropriately. Arrangements can also be made at any time for you to take your relative for a home visit. By letting us know beforehand, we can make sure they are fully prepared.

Differences of opinion

Respect is one of our core values, and this applies to families as well as their relatives we support. In our most recent annual Quality Assurance Review, 93% of families confirmed that staff were welcoming, kind and respectful to them at all times.

Nonetheless, there may be times when a difference of opinion may arise. We hope that by creating open and honest channels of communication, we can resolve any issues quickly and efficiently. Differences of opinion are often helpful, as they make us continually evaluate the support we are providing and how we can enhance people's lives.

If you do have any concerns about your relative or their care, you should always raise them with the Home or Service Manager. We also have a very clear complaints procedure that is available for anyone to use. We will always take concerns seriously as, ultimately, our mutual priority is the happiness, safety and wellbeing of your loved one.

Respecting privacy

We believe sharing information is very important, but we also have to respect the wishes of the people we support. Where someone specifies we can't share certain personal information, we are bound to respect this unless to do so would not be in their best interests and/or they have been assessed as lacking capacity themselves. However, on a day-to-day basis, we would expect to inform you about all significant events in your loved one's life.