Actions and Next Steps (Social Care Direct)

You will often receive telephone contacts requesting to speak to a named worker or a particular service. However, this may or may not be the best person for them to speak to.

When the person/carer making the contact requests specifically to speak to or be contacted by a particular team or practitioner you should establish as quickly as possible whether the contact should be forwarded to that practitioner/team.

You should check available systems to establish whether:

1. The person/carer is allocated to the practitioner they have requested to speak to; or
2. The service/team is responsible for either the assessment or review of the person/carers needs.

You should not transfer a telephone call to a named worker if it is clear that the worker is not allocated to the person/carer. This will not be helpful to the worker or to the person/carer as they will not be speaking to the right person to resolve the contact.

If the practitioner is not available

If the practitioner is not available you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a member of the service/team they are based in.

If you know when the practitioner is likely to become available you should:

1. Inform the person/carer of this;
2. Leave the practitioner a message alerting them to the contact, any action undertaken and confirming the information given to the person about when to expect a call back;
3. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required should the practitioner be unavailable for more than a few hours;
4. Agree with the person/carer what they should do if the practitioner does not make contact at the expected time; and
5. Make a proportionate record of all the above.

If it is not clear when the practitioner will become available you should:

1. Inform the person/carer of this;
2. Leave the practitioner a message alerting them to the contact, any action undertaken and what information has been given to the person/carer;
3. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required; and
4. Agree with the person/carer what they should do if the practitioner does not make contact within an agreed timeframe; and
5. Make a proportionate record of all the above.

When a written contact is addressed to a named worker you should establish as quickly as possible whether the contact should be forwarded to that practitioner.

You should check available systems to establish whether the person/carer is allocated to the practitioner that the written contact is addressed to.

You should not transfer a written contact to a named worker if it is clear that the worker is not allocated to the person/carer. This will not be helpful to the worker or to the person/carer as they will not be dealing with the right person to resolve the contact.

Before transferring the contact you should:

1. Confirm that the practitioner the written communication is being transferred to is available within a reasonable timeframe for the action indicated by the contact, or that there is a mechanism in place for the written contact to be received and managed by the service in which they work;
2. Where the communication is a letter or an e-mail, whether the practitioner wishes to receive the original contact (if not this should be filed securely); and
3. Where a written response confirming the contact has been received is required or requested, agree who will provide this.

The most secure way to transfer a written contact is to send a message to the practitioner alerting them to the contact and where it can be found on the recording system.

Any original copies of e-mails must be sent via internal secure e-mail systems only and any original letters must be sent via internal postal services or secure delivery only.

If the practitioner is not available

If the practitioner is not available you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a member of the service/team they are based in.

If the practitioner is not available within a reasonable timeframe for the action indicated by the contact you should:

1. Leave the practitioner a message alerting them to the contact, where it can be found on the recording system and any action undertaken, including what has been agreed with the person/carer if contact has been made with them;
2. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required and writing any acknowledgement letter to confirm arrival of the contact;
3. When the practitioner is not available within any timeframes indicted in the written contact or for more than a few days inform the person/carer making the contact of this;
4. Agree with the person/carer what they should do if the practitioner does not make contact within an agreed timeframe; and
5. Make a proportionate record of all the above.

If the information gathered during a telephone contact suggests the person/carer would benefit from further assessment or intervention a referral should be taken so long as:

1. The person/carer the referral relates to is making the referral;
2. The person/carer the referral relates to has given their consent to the referral; or
3. The person/carer that the referral relates to lacks mental capacity to make a referral and a decision has been made under Best Interests that a referral should be made; or
4. The person that the referral relates to is at risk of harm from abuse or neglect.

The following information should be included in a referral:

1. All personal details, including the persons/carers full name (and also preferred name or previous surname), address and preferred contact details, date of birth, national insurance number and NHS number;
2. The name, relationship and contact details of the person making the referral (if not the person/carer themselves);
3. When and how the person/carer consented to the referral;
4. If the person has not consented to the referral, was a mental capacity assessment carried out and is the referral being made under Best Interests;
5. What the presenting issue is from the person's/carer's perspective and what they would like to happen;
6. What the presenting issue is from the referrer's point of view (if the referrer is not the person/carer) and what action they may recommend;
7. What options have been considered with the person/carer to resolve the issue so far, including what support the person/carer has had from family and community networks;
8. What information and advice has been provided to the person or what information and advice may be required;
9. What prevention services have been used, considered or may be of benefit;
10. Any specific communication needs of the person/carer that need to be considered so they can understand and be involved in any adult Care and Support process;
11. Whether the person/carer is likely to have substantial difficulty in any adult Care and Support process, and if so whether an independent advocate has been considered;
12. Details of any previous or current Care and Support/Support services (whether the Local Authority is providing them or not);
13. With the person's/carer's consent the name and contact details of anyone involved in their life who should be involved in any assessment (family member, friend or professional); and
14. Any other information deemed relevant by the person/carer or referrer (if the referrer is not the person/carer).

Sometimes it is clear which service in the Local Authority should receive the referral that has been made. Where this is clear local processes should be followed to transfer the referral to that service.

Sometimes it is less clear which service should receive a referral. For example, if the person/carer's needs could potentially be met by more than one team.

Decision making in this instance should be as simple and consistent as possible. It should involve the person/carer and the potential services with the aim of reaching a shared agreement. Any delays should not negatively impact the person/carer or put them at risk through the delay of any Care and Support/Support needs being met.

Though not a requirement, it would be prudent to apply the same criteria that the Care Act requires to be applied when deciding the most appropriate worker:

1. The views and wishes of the person/carer about which service/team would best support them must be regarded;
2. The service/team must possess the skills, knowledge and competence to carry out the anticipated Care and Support functions; and
3. The service/team must possess the skills, knowledge and competence required to work with the particular person/carer in question.

tri.x as developed a tool that can be used a required to support consistent decision making about team suitability.

See: Team Suitability Decision Support Tool.

The service area or team receiving the referral should make effective use of the information gathered thus far and not make the person/ carer (or anyone else previously consulted) repeat information unnecessarily.

Whenever the outcome of a contact or referral is that the person/carer will be involved in any adult Care and Support process (including any assessment, review, reassessment or safeguarding) the Local Authority has a duty under the Care Act to make an independent advocate available to the person/carer when:

1. There is no appropriate other person to support and represent them; and
2. They feel that the person/carer would experience substantial difficulty being fully involved in the Care and Support process without support.

Decisions about the need for advocacy should be made as early as possible because advocacy must be provided before the Care and Support function to be carried out can begin. As such if you know that advocacy will be likely you should discuss this with the person and make a referral at the same time as you transfer the request for a review or reassessment.

See Using Independent Advocacy, which includes guidance on how to establish whether a person needs an advocate, the different advocates that are available and how to make a referral.

The Local Authority has a duty to provide good information around finances at an early stage. This provides people with an understanding from the beginning about how they may be expected to contribute financially towards the cost of any Care and Support/Support they receive so that they can start thinking about and planning how they could use their financial resources flexibly to fund a range of potential care options. You should take any opportunity to provide this information, and should particularly make sure that it has been provided whenever a transfer is made to another service that may result in an assessment, review or reassessment.

See: Specific Requirements on the Provision of the Information and Advice around Finances for guidance on the requirements of the Care Act.

See the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment.

Whenever the outcome of a contact or referral is that the person/carer will be involved in any adult Care and Support process (including any assessment, review, reassessment or safeguarding) the Local Authority has a duty under the Care Act to make an independent advocate available to the person/carer when:

1. There is no appropriate other person to support and represent them; and
2. They feel that the person/carer would experience substantial difficulty being fully involved in the Care and Support process without support.

Decisions about the need for advocacy should be made as early as possible because advocacy must be provided before the Care and Support function to be carried out can begin. As such if you know that advocacy will be likely you should discuss this with the person and make a referral at the same time as you transfer the request for a review or reassessment.

See Using Independent Advocacy, which includes guidance on how to establish whether a person needs an advocate, the different advocates that are available and how to make a referral.

The Local Authority has a duty to provide good information around finances at an early stage. This provides people with an understanding from the beginning about how they may be expected to contribute financially towards the cost of any Care and Support/Support they receive so that they can start thinking about and planning how they could use their financial resources flexibly to fund a range of potential care options. You should take any opportunity to provide this information, and should particularly make sure that it has been provided whenever a transfer is made to another service that may result in an assessment, review or reassessment.

See: Specific Requirements on the Provision of the Information and Advice around Finances for guidance on the requirements of the Care Act.

See the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment.

Support for Older People

Age UK

Age UK Wakefield District provide a wide range of services for people over 50 including an Advocacy Service, Home Shopping service, Bereavement Advice, and Befriending. Their Information and Advice service provides a range of information on a wide range of issues including housing, mobility aids, social care e.g. care packages, residential care and maintaining independence. If someone is interested in local lunch clubs or delivered meals, Age UK can advise.

Tel: 01977 552 476
Website: https://www.ageuk.org.uk/wakefielddistrict/.

Alzheimer’s Society

The Alzheimer’s Society provides a wide range of information, advice and support for individuals suffering from dementia and their families/carers. Dementia support workers offer information and practical guidance to help people understand dementia, cope with day-to-day challenges of the condition and prepare for the future. They offer support face to face, over the phone or in writing.

Tel: 01924 373 264 (Office opening times: Monday to Friday 9am - 5pm)
Email:  wakefield@alzheimers.org.uk

Support for Carers

Carers Wakefield and District

Carers Wakefield and District provides advice and support for carers. They give advice and information about services available for the carer and/or the person they care for and advice about relevant benefits.

Tel: 01924 305 544
Website: carerswakefield.org.uk

Health and Housing Support

Live Well Service – (South West Yorkshire NHS Partnership Foundation Trust)

This service provides advice and support around accessing healthcare, managing long term conditions, housing, social groups and activities and support for carers. Live Well Advisors are able to meet people at home or at a location they choose.

Tel: 01924 255 363
Website: www.livewellwakefield.nhs.uk/

Wakefield and District Housing (WDH)

WDH runs Care Link which can provide sensors, alarms, home visiting and a 24-hour responder service, in a range of packages (for anyone in the Wakefield District). There is a charge for this service.

Tel: 01977 788 000

Please note: a person who lives in WDH property, can also contact 0345 8 507 507 for additional advice about adaptations and specific support such as Wellbeing Case Workers.

Housing Options

Housing Options is part of Wakefield Council and can provide advice about housing, including when someone is homeless, or at risk of homelessness.

Tel: 01924 304 354
Email: housingneedsservice@wakefield.gov.uk.

Mental Health Support

Turning Point Talking Therapies

Turning Point Talking Therapies provides advice and support for people feeling anxious, low or stressed. They provide 1-1 support and offer groups and workshops.

Tel: 01924 234 860 
Website: www.talking.turning-point.co.uk

Support with Household Tasks

Care & Repair

The Handyperson Service is provided by HRS Homecare. It is available to all older and vulnerable households in the district. The service is aimed at promoting people's independence and enabling them to stay in their homes

Tel: 07960 055 733
Email: Hrshomecare22@gmail.com

Sometimes it is helpful to contact a well known national organisation with a dedicated information and advice service or help-line. See: National Organisations with Information and Advice Helplines for details of some national organisations offering this service.

Some national organisations do not have dedicated information and advice services but can still provide such support upon request. See: National Contacts for Adult Care and Support for a wider range of useful national contacts for adult Care and Support.

You can also see the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment, including questions relating to Disabled Facilities Grants.

Information and advice must be provided in an accessible way so that the person/carer for whom it is intended can best understand and make use of it.

If you feel the person/carer for whom the information and advice is intended will need support to understand it then you should:

1. Consider whether the person/carer has anyone appropriate who can help them to understand it;
2. Consider any steps that you can take to support them to understand it (for example talking through the information over the telephone or summarising it in a simpler format); and
3. Consider the benefit of independent advocacy.

Not everyone contacts the Local Authority in a timely way so as to allow for an assessment and exploration of options to take place prior to any initial decisions being made about the need for Care and Support.

For example, some people only approach the Local Authority when they are in a time of crisis, high risk or when there is a sudden or unexpected change in their Wellbeing.

In these cases there may appear to be an urgent need for support that cannot wait for an assessment or review process to be carried out.

The Care Act recognises this occurrence and gives the Local Authority powers to meet such needs without having carried out a formal assessment process.

To see what the Care Act says about meeting urgent needs without an assessment or review, see: The Power to Meet Needs.

Having the power to meet needs without an assessment or review means that the Local Authority can decide whether or not to do so, based on the available information and specific circumstances of the person/carer and their situation.

Under the Care Act, the Local Authority can put any interim or urgent measures in place that it deems appropriate to meet the needs of the person/carer and manage the situation. This can range from a small number of domiciliary care visits to a stay in residential accommodation.

The same legal considerations apply when meeting urgent needs as they do when meeting non-urgent needs:

1. The impact on the person's/carer's individual wellbeing;
2. Whether any preventative service can be provided that will delay, reduce or prevent the need for Care and Support/Support;
3. Whether information and advice can be provided to support the person/carer to find their own solution, or to delay, reduce or prevent the need for Care and Support/Support.

It is vital that you understand your duties in relation to the above. Please use the links below to access further information as required.

• Promoting Individual Wellbeing for information about the duty to promote individual wellbeing;
• Preventing Needs for Care and Support for information about the duty to prevent, reduce or delay needs;
• Providing Information and Advice.

In addition, you should be mindful that nobody has yet assessed (or reassessed) the needs of the person/carer and you may be relying on historical information or information from sources currently under significant strain or pressure to act. As such the information presented may or may not be an accurate reflection of the person's/carer's needs following an assessment.

Interim support should therefore only be seen as a temporary measure to reduce risk of harm and support the person/carer to a place in time where a needs or carer's assessment can be carried out and long term options explored and agreed with them. As such, you should be cautious about providing interim Care and Support/Support that may be problematic to cease following assessment.

tri.x has developed a tool that can be used as required to support consistent decision making about the provision of urgent or interim support.

See: Urgent or Interim Support Decision Tool.

Wherever possible, every conversation with a person/carer should be from a strengths perspective. This means that before you talk about service solutions to the presenting issue you must support the person/carer to explore whether there is:

1. Anything within their own power that they can do to help themselves; or
2. Anything within the power of their family, friends or community that they can use to help themselves.

A strengths based approach is empowering for the person/carer and gives them more control over their situation and how best to resolve any issues in the best way for them. The end result may still be that the Local Authority intervenes with an assessment or other support, but this decision will have been reached knowing that it is the most proportionate response available.

Adopting a strengths based approach involves:

1. Taking a holistic view of the person or carers needs in the context of their wider support network;
2. Helping them to understand their strengths and capabilities within the context of their situation;
3. Helping them to understand and explore the support available to them in the community;
4. Helping them to understand and explore the support available to them through other networks or services (e.g. health);
5. Exploring some of the less intrusive/intensive ways the Local Authority may be able to help (such as through prevention services or signposting).

SCIE have produced clear and practical guidance around how to use a strengths based approach in practice. See: Care Act guidance on Strengths-based approaches. Note: SCIE requires a login to access resources, but any social care practitioner can create one quickly and easily.

All funding requests for urgent and interim support should be made in line with available local processes and requirements.

It can be difficult to make a decision about the level of funding required to meet the urgent or interim Care and Support/Support needs because:

1. There will be no personal budget allocated to the person/carer; or
2. There will be a personal budget but this will not be based on their current needs.

The Care Act does not discuss or set funding limitations in relation to the provision of any Care and Support/Support. This includes urgent and interim Care and Support/Support. Instead, the golden rule of the Care Act when making any funding decision is that 'the amount of funding agreed must be sufficient to meet the needs that are to be met at that time'. Decisions must also be made in a way to ensure that the person/carer will be satisfied the process was fair and robust.

Other than sufficiency, the factors that decision makers must consider are:

1. The views and wishes of the person/carer about how their needs should be met;
2. The availability of other potential options in the marketplace; and
3. The cost of available suitable services in the marketplace.

Other factors that should be considered are:

1. The complexity of the needs;
2. The level of risk/sense of urgency; and
3. Whether the practitioner requesting the funding has provided relevant information and advice, whether they have explored prevention services that may be appropriate and whether they have explored how the person's/carer's own networks of support could help; and
4. Where the person/carer is not ordinarily resident; if they receive Care and Support/Support already in another Authority the nature of the Care and Support/Support they receive.

Decision makers should also take into account that the Local Authority is also permitted under the Care Act to consider how to balance its legal requirement to maintain universal services to the entire local population with the power to meet urgent needs. In doing so it must:

1. Not base it's decision on finances alone;
2. Consider things on a case-by-case basis; and
3. Not set arbitrary limits (fixed amounts for a particular type of need or service).

The outcome of the funding decision should be communicated to the person/carer at the earliest opportunity. The method of communication should reflect that requested by the person/carer and any specific communication needs they may have. For the purposes of the Care Act communication about the outcome of a funding decision is subject to the same requirements as the provision of information and advice, and the duty to make it accessible therefore applies equally.

Where communication is provided by telephone a follow up letter confirming the conversation and the funding decision should be sent to the person/carer as a formal record.

When communicating the outcome you should include the following information:

1. The funding decision itself;
2. The rationale for the decision;
3. Any information and advice relating to adult Care and Support, and the prevention, delay or reduction of needs;
4. What will happen next and the timeframes involved;
5. How to complain about any aspect of the decision or proposed outcome.

Any funding decision rationale should be clearly recorded in line with local recording requirements.

The Local Authority is not required to record urgent and interim support on a Care and Support/Support Plan because:

1. The support is being provided under the Local Authority's powers (as opposed to duties);
2. The person/carer has not yet been assessed (or reassessed); and
3. There has been no decision about eligible needs.

However, the following must be clearly recorded:

1. The urgent or interim support being provided;
2. The contribution to the cost of the support being made by the Local Authority;
3. The contribution being made by the person/carer;
4. The duration of the support;
5. How the support will be reviewed;
6. What outcomes the support aims to achieve; and
7. The next steps, including timeframes for any assessment.

Under the Care Act the process of arranging to meet urgent and interim Care and Support needs is the same as arranging to meet needs agreed through a non-urgent Care and Support Planning (or Support Planning) process.

The Local Authority is permitted under the Care Act to charge any person/carer for Care and Support/Support (including Care and Support/Support provided on an urgent basis) unless:

1. It chooses not to; or
2. The person/carer has been financially assessed as having insufficient funds to contribute; or
3. The support being provided is reablement (up to 6 weeks is non-chargeable); or
4. The support being provided is equipment (up to the cost of £1000 is non-chargeable).

For further information about charging for all services under the Care Act, see: Power of the Local Authority to Charge.

It is your responsibility to understand the position of the Local Authority in regards to the financial assessment of carers.

See the Financial Assessment Procedure for further guidance.

Where urgent support is provided to a person/carer who is not ordinarily resident contact should be made at the earliest opportunity to the Local Authority in which they live to inform them of the intention to meet an urgent need.

Where the person/carer is already in support of a service from the other Local Authority information should be gathered to support any decisions made about which support should be provided.

Agreement should be reached with the other Local Authority about how any urgent Care and Support/Support services will be monitored, when they intend to assess for eligible needs and how reimbursement of costs incurred can be sought.

tri.x has developed a tool to support decision making around ordinary residence.

See: Ordinary Residence Decision Support Tool.

Also see the Ordinary Residence Procedure for further information.