Actions and Next Steps (Complex Care and Review Team)
Amendment
In November 2023, information about the Caldicott Principles was added into the 'Providing Information about a Person' section.
This procedure should be used to action the outcome of a contact or referral regarding a person with Care and Support needs. It should not be used when the contact was in regard to a carer.
If the contact relates to a carer, see Actions and Next Steps (Carers).
The Local Authority (and anyone representing the Local Authority) has a duty under Section 4 of the Care Act to either provide directly, or provide access to a range of information and advice relating to adult Care and Support, including financial advice. This duty applies equally in respect of all local residents regardless of whether the person with Care and Support needs is known to, lives in, or is already receiving services from the Local Authority.
See: Providing Information and Advice to read more about what the Care Act says about the duty to provide information and advice, including how information and advice should be provided and the specific information and advice requirements around finances.
Online
To access the adult social care pages of our website see: Adult Social Care.
The council operates a shared Live Well website with Cheshire West Place where practitioners and residents can search for local information and services. See: Live Well Cheshire West.
A care and support directory can also be found on the Live Well website. See: Care and Support Directory.
Let’s Talk
As part of the ongoing Community Led Support development programme the council has introduced Let’s Talk sites across the borough with further site developments planned over the next 6 months.
There are currently four Let’s Talk sites across the borough, which have been developed along with a range of partners and community organisations. Each site provides a warm welcome for residents who are facing challenging issues that are affecting their health and wellbeing. At Let’s Talk everyone is welcome to drop-in for face to face advice about wellbeing support that is available in the local area, as well as for practical advice and guidance. People’s health and wellbeing can be affected by lots of different issues including housing and financial challenges and a visit to Let’s Talk can start the conversation.
For the most up to date information see: Let’s talk health and wellbeing.
Citizen’s Advice
There are a number Citizen Advice face to face meeting sites across the Cheshire West and Chester Borough, some are drop in and some are bookable only sites.
For further information see: In-person support.
There is also an adviceline that can be called on 0808 2787 806.
Carers
Cheshire and Warrington Carers Trust provides support and services across the borough.
See: Cheshire and Warrington Carers Trust
Helpline: 0300 102 0008
Email: advice@cheshireandwarringtoncarers.org
We have an all Age Carers Strategy in Cheshire West and further information can be found here: All age carers strategy 2021-2026.
If you would like to be involved in the carer groups discussed in the strategy, then get in touch:
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 for whom it is intended can best understand and make use of it.
If you feel the person for whom the information and advice is intended will need support to understand it then you should:
- Consider whether the person has anyone appropriate who can help them to understand it;
- 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
- Consider the benefit of independent advocacy.
Under the Care Act the Local Authority has a duty to not only provide information and advice where it is needed, but to ensure that the information and advice it provides has been effective.
Therefore, when information and advice has been provided you should agree appropriate arrangements to follow up with the person to whom it was given in order to review how effective it has been.
The timescales for this follow up should reflect the individual circumstances and level of risk.
Where you are making arrangements for someone else to follow up on the information and advice you have given (rather than following up on it yourself) you must make sure that you have recorded this in a way that will ensure the person follows up on it at the agreed time.
The Local Authority has a common law and legal duty to safeguard the confidentiality of all personal information. As an employee of the Local Authority you are bound contractually to respect the confidentiality of any information that you may come into contact with. Under no circumstances should such information be divulged or passed to any persons or organisation in any form unless you have authorisation to do so.
All information sharing that takes place must be in line with data protection legislation (namely the UK General Data Protection Regulation and the Data Protection Act 2018) and local policy.
The Caldicott Principles must also be regarded. The Caldicott Principles are a set of principles that apply to the use of confidential information within health and social care organisations and when such information is shared with other organisations and between individuals, both for individual care and for other purposes. For further information, see: The Caldicott Principles.
Any unauthorised disclosure of confidential information may result in disciplinary action of individual prosecution under the Data Protection Act 2018.
For further information and guidance see: Providing Information about a Person or Carer
It is important that the person making contact speaks to the right practitioner at the right time. Sometimes you may find that you are not the most appropriate practitioner to manage the contact.
When the person making the contact requests specifically to speak to or be contacted by a particular person 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 is allocated to the practitioner they have requested to speak to.
You should not transfer a telephone call to a named worker if it is clear that the worker is not allocated to the person. This will not be helpful to the worker or to the person 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 colleague or manager who may know.
If you know when the practitioner is likely to become available you should:
- Inform the person of this;
- 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;
- 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;
- Agree with the person what they should do if the practitioner does not make contact at the expected time; and
- Make a proportionate record of all the above.
If it is not clear when the practitioner will become available you should:
- Inform the person of this;
- Leave the practitioner a message alerting them to the contact, any action undertaken and what information has been given to the person;
- 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
- Agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
- 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 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. This will not be helpful to the worker or to the person as they will not be dealing with the right person to resolve the contact.
Before transferring the contact you should:
- 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 you have agreed with a manager how the contact will be managed;
- 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
- 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 colleague or manager who may know.
If the practitioner is not available within a reasonable timeframe for the action indicated by the contact you should:
- 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 if contact has been made with them;
- 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;
- When the practitioner is not available within any timeframes indicted in the written contact or for more than a few days inform the person making the contact of this;
- Agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
- Make a proportionate record of all the above.
If, as part of any conversation or information gathering you become concerned that a vulnerable adult or child is experiencing, or at risk of abuse or neglect you must respond appropriately by raising a concern.
See Safeguarding Adults, which also includes information about how to raise a children's safeguarding concern.
If you are concerned that an adult or child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialing 999.
Whenever the outcome of a contact or referral is that the person will be involved in any adult Care and Support process (including a review or reassessment) the Local Authority has a duty under the Care Act to make an independent advocate available to the person when:
- There is no appropriate other person to support and represent them; and
- They feel that the person would experience substantial difficulty being fully involved in the Care and Support process without support.
tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.
See: Advocacy Decision Support Tool.
The Local Authority also has a power (but not a duty) to make advocacy available in other situations on a case by case basis if it deems this appropriate and is able to do so. This could include advocacy to support a person to understand information and advice, or advocacy to support a person to explore possible options available to them.
Having substantial difficulty is not the same as lacking mental capacity.
See: Determining Substantial Difficulty for information about how to determine substantial difficulty.
See the Mental Capacity Act 2005 Resource and Practice Toolkit, with guidance about assessing capacity and making best interest decisions.
An appropriate person for general representation purposes is not the same as an appropriate person for independent advocacy under the Care Act.
See: An Appropriate Other Person for information about the difference and how to establish whether there is already an appropriate person.
The role of an independent advocate appointed under the Care Act is not the same as the role of a general advocate or any other type of advocate (for example an Independent Mental Capacity Advocate or an Independent Mental Health Advocate).
An independent advocate appointed under the Care Act must both facilitate and ensure the involvement of the person with substantial difficulty in the Care and Support process that is taking place.
For information about the ways in which an independent advocate should fulfil their role, see: The Role of an Independent Advocate.
People who lack capacity will likely be legally entitled to advocacy under both the Care Act and the Mental Capacity Act 2005.
The Care Act statutory guidance recognises that it would not normally be appropriate or practical for a person to have 2 advocates and gives the Local Authority the responsibility to make a decision about the best type of advocacy support.
There are various factors that should influence this decision (such as existing rapport with an advocate or whether any important decisions are likely to be the outcome of the Care and Support process) and the Local Authority must ensure that whatever it decides, it does not deny the person any of the specialist advocacy skills they need or are entitled to.
tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.
People eligible for an Independent Mental Health Advocate (IMHA) under the Mental Health Act 1983 will likely be entitled to advocacy under the Care Act.
The Care Act statutory guidance recognises that it would not normally be appropriate or practical for a person to have 2 advocates and gives the Local Authority the responsibility to make a decision about the best type of advocacy support.
There are various factors that should influence this decision (such as existing rapport with an advocate or the likely outcome of the Care and Support process) and the Local Authority must ensure that whatever it decides, it does not deny the person any of the specialist advocacy skills they need or are entitled to.
tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.
Voiceability provides the advocacy service in Cheshire West and Chester.
To make a referral or general enquiry:
Tel: 0300 303 1660
Email: helpline@voiceability.org
Note: The advocacy referral can be made at any time and should be made without delay as soon as the duty applies.
Regardless of whether or not independent advocacy is available in the local area the duty to provide it still applies. A failure to do so is a breach of this duty and of the law. It is the role of commissioners to ensure that advocacy services are in place and available when required, and it is the role of practitioners to make timely referrals to advocates to prevent unnecessary delays in the meeting of its duty.
If you are aware that advocacy support is required and is not yet available you must not proceed to carry out any Care and Support process until it is in place.
In some circumstances urgent interim measures may need to be agreed without an advocate in place in order to reduce immediate risk to the person from inaction. However, Care and Support processes that will decide long term and important decisions must not be carried out without advocacy support.
The duty upon the Local Authority is to make independent advocacy support available to any person who requires it. Once made available the duty is met.
If a person decides that they do not wish to engage in the advocacy support that has been made available to them they do not have to do so, but the Local Authority must still provide it.
The Local Authority is expected under the Care Act to support the person to understand the role of an advocate and promote its benefit to them so as to reduce the likelihood that they will not engage.
The multidisciplinary nature of many of our teams enables and encourages joint working at all times.
However, sometimes there may be a clear benefit to a joint review or intervention with another service area, team or professional. The Care Act recognises this and permits the Local Authority to make any arrangements it deems appropriate in order to facilitate joint working with others.
Where the Local Authority requests another party work jointly in some way to benefit the person with Care and Support needs that party has a duty to co-operate with the request (unless by doing so they will be prevented from carrying out their own duties under the Care Act or other legislation).
For further information about the duty to co-operate under the Care Act, see: Co-Operation.
Any decision to request joint work should be made with the person (or their representative). Where the person is unable to provide consent to joint work decisions should be made in their best interests.
A manager to manager discussion should take place to consider if this is a suitable support mechanism for a case.
A complex case discussion can be requested to the Principal Social Worker to oversee discussions where the decision process lacks clarity or the complexity of the case requires consideration of a wider practitioner group.
Once agreed as appropriate, joint work requests should be made in the manner preferred by the service, team or professional to which the request is being made. This may or may not take the form of a referral.
The request should explain clearly the nature of the joint work required and any specific skills, knowledge and competence requirements to support allocation.
When you have been asked to work jointly with another service, team or professional you should contact them to confirm your involvement and discuss the most effective way to work together. The things you should establish include:
- The work they are doing/will be doing/have done and whether they have any information that you need to know or can use to avoid duplication;
- Whether there are opportunities to co-ordinate systems and processes and, if so how this will be managed;
- What the expectations are in terms of joint-working (for example will you be expected to carry out a joint review, meet with the person together, produce joint records or just consult and share information);
- What the anticipated outcome of the joint work is (for example joint funding of support, on-going joint-work to monitor);
- What does the person with care and support needs know about the joint-work to be carried out (and if they don't know who and how should this be explained);
- Who will be the primary contact for the person (or their representative) to go to with any queries; and
- Who will be responsible for communicating progress and decisions to the person.
See: Joint Work for further practice guidance about effective joint working.
If there are likely to be delays in your commencement of joint work the person who requested the joint work will need to:
- Consider whether to proceed with their intervention; or
- Await your availability.
It is the responsibility of the person requesting joint work to make this decision (in agreement with the person and any carer) and to take steps to ensure that any urgent needs for Care and Support are met.
Some areas of joint work are specialist in nature. The procedures for these pieces of work can be found in the Specialist Procedures section. The following are examples of the procedures that can be found there:
- NHS Continuing Healthcare;
- Continuity of Care;
- Cross Border Placements.
Under the Care Act, when a person is already receiving Care and Support from the Local Authority they may request a change to their Care and Support Plan at any time and the Local Authority must consider the request. Where the request is deemed reasonable the Local Authority has a duty to review the plan.
The review is the mechanism by which the need for a revision is determined. As such, under the Care Act a Care and Support Plan can only be revised following a review.
Where a change is requested to a plan and there is no planned review scheduled consideration should be given to arranging an unplanned review. Any review must be proportionate to the needs of the person and undertaken in a timely way so as to reduce the risk of a crisis developing and needs not being met.
If the person has an allocated worker this person should carry out the review, unless the review is urgent and the worker is unavailable.
Before transferring the review request you should confirm that the practitioner the review request is being transferred to is available.
If the practitioner is not available you should speak with a manager to establish whether:
- The request should still be transferred to the allocated worker to action when they become available;
- Alternative arrangements should be made to carry out the review.
Where the information gathered at contact suggests there has been no change in the person's needs, and that a change to the personal budget amount is not required it may be possible to complete a 'light touch' review without further allocation.
John has support from a domiciliary care agency on a Monday, Wednesday and Friday before he goes to work. His employer is going to change his days of work and John needs to change his Care and Support Plan to reflect the new days that he is going to be supported.
When the information gathered at contact suggests there has been a change in need or circumstance, and that a change in the personal budget amount is required any review carried out is likely to lead to a proportionate reassessment of need. Because this is a longer term intervention allocation for this should be considered.
John has support from a domiciliary care agency on a Monday, Wednesday and Friday before he goes to work. He has sought reduced hours at work because his health condition has deteriorated and he often feels too tired to work. He no longer requires support in the morning as often, but feels he now requires additional support in the evenings and to prepare his meals.
Where the outcome decision is for the person's case to be allocated to an individual worker to carry out a review or further intervention this allocation should take place in a timely way so as to:
- Avoid any unnecessary delays to the person;
- Reduce the risk of a deterioration in the situation; and
- Maximise the use of measures that will prevent, delay or reduce needs.
Where there are a significant number of people awaiting allocation there should be a fair and consistent prioritisation process in place that takes into account:
- The level of risk;
- The level of need;
- Current support in place and the sustainability/effectiveness of this;
- The urgency;
- The likelihood of deterioration; and
- The potential for fluctuation.
An element of monitoring should be incorporated into any allocation process to ensure that you remain aware of every person's situation and are able to respond appropriately to any changes or need to re-prioritise allocation.
The Care Act recognises that each worker (regardless of whether or not they have a professional qualification) will possess specific skills, knowledge and experience that will enable them to carry out different Care and Support functions or work with particular people well.
Because of this there is no expectation that a particular role should carry out a particular function; instead the Local Authority should allocate tasks to the most appropriate person for the job.
Allocation decisions should take into account:
- The skills, knowledge and experience of the worker in carrying out the function or process required;
- The skills, knowledge and experience of the worker in working with the particular needs of the person (for example health needs or communication needs); and
- The views and wishes of the person themselves in relation to the skills required of the worker and who they feel would best support them.
tri.x has developed a tool that can be used as required to support allocation decisions.
See: Allocation Support Tool.
Last Updated: May 23, 2024
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