I need to acknowledge the use of work produced by Professor Luke Clemens which was provided by Kate Whittaker, of Scott-Moncrieff to us. The full summary produced is here http://www.lukeclements.co.uk/wp-content/uploads/2015/01/0-Care-Act-notes-updated-2015-02.pdf
There are also 2 excellent youtube videos by Professor Clemens on Continuing Health Care and assessing social care needs.
Luke Clements lectures
https://www.youtube.com/watch?v=hEwBN873dYE assessing social care needs
Background to Care Act 2014
The Care Act 2014 repeals almost all of the principal adult social care statutes. The list of ‘repeals’ is extensive including the National Assistance Act 1948, as well as the Acts and regulations that govern such things as direct payments, charging for social care, assessments (ie the NHS & Community Care Act 1990) and all the Carers Acts. It also replaces FACS criteria with a list of eligible needs.
The implementation timetable for the Care Act 2014 has been the subject of significant criticism. The 506 page guidance and 17 sets of regulations weren’t approved until mid-October – leaving local authorities less than 5 months to make major) changes (including training their workforce) before the Act comes into force in April 2015. It is I think fair to sat that many local authority social workers and managers are unlikely to know just what the Care Act entails even once it has replaced existing social care legislation so as disabled people and carers it is probably more important than ever that we know what it says and what our rights are.
The Government say this is ‘the most significant reform of care and support in more than 60 years’ and it also provides a range of new rights for family carers.
The equivalent Welsh legislation (Social Services & Well-being (Wales) Act 2014) is not coming into force until 2016.
While the bulk of the Act will come into force in April 2015, the new appeals process and the ‘cap on costs’ provisions aren’t due to come into force until April 2016. A sum of £55.5m was ‘released’ which becomes the ‘Carers and Care Act Implementation Grant.’ aimed at meeting the expected increased potential demand from carers to access their ‘new rights’.
Luke Clemens says that “The speed with which the final guidance has been produced has resulted in it having a number of material errors and omissions. One is a section explaining the guidance’s status at law. The draft guidance contained a statement (page 3) that ‘local authorities are required to act under the guidance, which means that they must follow it, unless they can demonstrate sound legal reasons for not doing so’. This obligation stems from section 78 of the 2014 Act – which replicates the current duty (in section 7(1) Local Authority Social Services Act 1970) and means that existing case law concerning Department of Health ‘policy guidance’ will remain relevant under the new legal regime.”
The regulations detail specific obligations relating to market oversight / business failure (3 sets of regulations); the assessment of need; eligibility criteria; advocacy; charging; choice of accommodation; deferred payments; personal budgets; direct payments; the NHS interface; delayed hospital discharge; ordinary residence (2 sets of regulations); portability of care packages and cross-border placements; and registers for people with visual impairments. The longest set of regulations concern charging and there are none on some key questions – notably adult safeguarding.
The guidance contains a number of ‘examples’. While these had the potential to be of considerable value, they are disappointing: generally limp and have the predominant outcome that once the person had been pointed in the right direction, there was no need provide them with any local authority support.
The Act does not talk of disabled, elderly or of ill people: instead it uses the word ‘adult’ – but this is generally qualified as being an adult ‘in need’ of care and support. The regulations however stipulate that this is an adult who has ‘a physical or mental impairment or illness’. The current community care legislation generally requires that the impairment be both substantial and permanent.
Section 10 defines a carer as someone 18 or over who provides or intends to provide care for someone but is not contracted to provide the care or providing the care as formal ‘voluntary work’. All ‘carers’ are now eligible for an assessment. This means that many more carers will be eligible for an assessment – for example those who are providing little or no physical or practical care – but providing emotional support This change, coupled with: (a) the abolition of the requirement that carers’ ‘request’ an assessment; and (b) the new ‘duty’ to meet carers assessed needs has the potential to recast radically the legal regime for carers.
As with the pre-Care Act law, there is no duty to assess carers who provide their care by virtue of a contract, or as voluntary work (section 10(9)). The guidance addresses the not uncommon situation of a carer who is paid to provide care for the adult (possibly through the use of a direct payment) but is also providing unpaid care for that person. At para 6.17 it advises that in such circumstances ‘the local authority must consider whether to carry out a carer’s assessment for that part of the care they are not providing on a contractual or voluntary basis’.
The act also includes provisions for young carers and disabled children.
Local Authorities also have far greater duties to provide assessments to eligible persons even those who self-fund, they must provide transparent information to people including how their Resource Allocation System operates, they must provide access to information and to advocacy for those who need it.
RAS will be based on the 10 outcomes outlined below with each outcome having a maximum number of points based on how expensive that outcome is to meet. Questions asked about support levels and the need to meet these will produce points for people whereasquestions about informal support which may be in place to help meet needs will remove points but it is also stressed in the Act that any assessment of needs must ignore care provided by informal carers and that such input can only be considered if appropriate and the informal carers are willing to provide such support. (6.64)
Social Care Institute for Excellence (SCIE) says that the Care Act is based on a strengths based approach to improve wellbeing and independence and that it looks at what people can do rather than what they can’t do as well as what those around them can do and what the community can do to support them to put off the need for care and support.
Underpinning principles (section 1)
The consultation process leading to the drafting of the legislation resulted in demands that the Act be underpinned by a coherent set of guiding principles (rather like those that apply in relation to the Mental Capacity Act 2005, s1). The Act does not have such a set of principles – instead it contains a general duty to promote the ‘well-being’ of individuals (ie adults and carers). The duty applies to local authorities and their staff when exercising ‘any function’ under Part 1 of the Act (ie sections 1-80).
Well-being is so widely defined that there was a risk that it would prove to be of little practical application and is fairly meaningless. Clemens says however the guidance goes a considerable way to dispelling this fear.
‘Well-being’ includes personal dignity, physical and mental health and emotional well-being; protection from abuse and neglect; control over day-to-day life; participation in work, education, training or recreation; social and economic well-being; domestic, family and personal relationships; suitability of living accommodation; and ‘the individual’s contribution to society’.
The emphasis on the importance of ‘control’ has been seen as a cause for concern by some commentators: in many respects the inclusion of ‘control’ can be seen as a further manifestation of the ‘responsibilization’ agenda. Despite the Law Commission’s comments, ‘choice’ does not appear as a well-being principle.
When discharging any obligation under the Act, the local authority must ‘have regard to’—
the individual’s views, wishes, feelings and beliefs;
the need to prevent/ delay the development of needs for care and support;
the need to make decisions that are not based on stereotyping individuals;
the importance of individual’s participating as fully as possible in relevant decisions (including provision to them of necessary information and support);
the importance of achieving a ‘balance between the individual’s wellbeing and that of any friends or relatives who are involved in caring for the individual’;
the need to protect people from abuse and neglect;
the need to ensure that restrictions on individual rights /freedoms be kept to the minimum necessary.
A criticism made of the ‘well-being’ obligation and the above list in particular – concerns the failure to include an explicit reference to the right to ‘independent living’ – ie as protected by Article 19 UN Convention on the Rights of Persons with Disabilities (CRPD). The guidance, however, goes a good way to addressing this omission, stating that (para 1.19):
The wellbeing principle is intended to cover the key components of independent living, as expressed in the UN Convention on the Rights of People with Disabilities (in particular, Article 19 of the Convention). Supporting people to live as independently as possible, for as long as possible, is a guiding principle of the Care Act.
Such an express statement is of considerable value – not least because the courts and Ombudsmen have shown a surprising willingness to have regard to the Convention in recent judgments / reports.
Well-being is defined as including being protected from ‘abuse and neglect’ (s1(2)(c)) and the guidance gives emphasis to this stating that ‘it is not possible to promote wellbeing without establishing a basic foundation where people are safe and their care and support is on a secure footing’ (para 1.26). The problem, as is noted below, is that although the eligibility criteria lists ‘being able to make use of the adult’s home safely’ as an outcome – this in itself does not (on one interpretation) trigger the safeguarding duty as the adult would also have to demonstrate an inability in relation to another ‘outcome’: being an elderly ill person unable to keep herself safe – is not without more, sufficient to instigate the safeguarding duty.
Bits of particular interest to us
Services / care and support responses (section 8)
Under the current legal regime the object of a community care / carers assessment is to determine (among other things) whether there is a need for ‘services’. The community care statutes provide exhaustive lists of services that can be provided and the Carers and Disabled Children Act 2000 provides a generalised statement as to what a carer’s ‘service’ might be. The Care Act repeals these statutes and (in keeping with its ‘outcomes’ rhetoric) avoids referring to the word ‘service’ when describing what may be provided to meet a person’s needs. Instead, section 8(1) contains an illustrative list of what may be ‘provided’ to an adult in need or carer – namely:
- a) accommodation in a care home or in premises of some other type;
- b) care and support at home or in the community;
- c) counselling, advocacy and other types of social work;
- d) goods and facilities;
- e) information and advice.
The absence of such things as ‘adaptations’ ‘travel’; and ‘holidays’ (which are specifically cited in the current law) was considered problematical by the Select Committee and in response to a question it asked the Department of Health, received confirmation that the Department considered that these services did fall within the ambit of the list.The Committee expressed the hope that the subsequent guidance would ‘make clear that the list is not intended to limit the ways in which a local authority might meet any eligible needs or agreed outcomes, removing any possible ambiguity on that point’ (para 170). Unfortunately the guidance does not make this sufficiently clear.
Support such as home adaptations, equipment and transport is often vital to enable ‘adults in need’ to live independently in the community. The facilitation / provision of suitable adaptations / equipment requires explicit guidance, given that the overlap of responsibilities between housing and social services authorities will remain (with such support being capable of being delivered under both the Housing Grants, Construction and Regeneration Act 1996 and the Care Act 2014). The guidance fails to reiterate and build on the current guidance on this question.
Section 8(2) slips out of the ‘outcomes’ mode and gives examples of the ways need may be met which include the ‘service’ word – namely:
(a) by arranging for a person other than it to provide a service;
(b) by itself providing a service;
(c) by making direct payments.
Local authorities will be able to charge (under section 14) for the costs that they incur in providing care and support (under section 8) to meet the ‘needs’ of individuals – ie carers as well as elderly ill and disabled people. The question arises therefore as to whether local authorities will start charging for support such as advocacy, social work and information (and indeed how ‘social work’ is to be defined). The question is all the more pressing since local authorities will be able to delegate assessments (and most of their other functions) to independent sector organisations (section 79 – see below). In answer to a specific question on this point, the Minister (Norman Lamb) stated that these provisions do ‘not give a power to local authorities to charge for carrying out a needs or carer’s assessment in any circumstances’.
Assessment of adults in need (section 9)
The Act, the regulations and the guidance create important and welcome obligations on local authorities in relation to the advocacy and safeguarding needs of individuals
identified during the assessment and care planning processes.
The duty in the Care Act to assess adults in need is closely aligned to the existing duty (under s47 NHS and Community Care Act 1990). As with the current law, the duty is triggered by the appearance of need and arises regardless of the ‘level’ of those needs or the person’s financial resources (it applies, as now, to self-funders). The assessment must have specific regard to the well-being criteria (ie section 1(2) above) and must involve the adult and any carer. It is difficult to see how this can be achieved without a face to face assessment (unless the adult agrees this is not necessary) however para 6.28 of the guidance states that:
Where appropriate, an assessment may be carried out over the phone or online. In adopting such approaches, local authorities should consider whether the proposed means of carrying out the assessment poses any challenges or risks for certain groups, particularly when assuring itself that it has fulfilled its duties around safeguarding, independent advocacy, and assessing mental capacity.
There appears to be a downgrading (or at least a welcome acceptance of reality) of the value of ‘supported self-assessments’. Rhetorically they have promoted the unrealistic notion of disabled people identifying their own needs and mapping out their support – with a social worker giving gentle guidance and the benefit of her or his wisdom. In reality they have too often been the posting of a Self Assessment Questionnaire (SAQ) to the person in need and then running the ticked boxes through a Resource Allocation System (RAS): highly impersonalised and designed to reduce care costs: to ‘lower expectations’. The guidance requires individuals who are able and willing to undertake a supported self-assessment be offered one (para 6.44) but that: (a) the local authority must assure itself that it ‘is an accurate reflection of the person’s needs’ (para 6.3); and (b) that regardless of what the individual may think ‘the final decision regarding eligibility will rest with the local authority’ (para 6.53).
The guidance gives useful emphasis to the need for assessors to be ‘appropriately trained’, but also states that registered ‘social workers and occupational therapists can provide important support and may be involved in complex assessments which indicate a wide range of needs, risks and strengths that may require a coordinated response from a variety of statutory and community services’ (para 6.7). In so doing the implication is that for non-complex cases social workers may not be necessary. The general (and welcome) tenor of the guidance is, however, that assessors must be ‘appropriately trained’. Para 6.88, for example states that if an ‘assessor does not have the knowledge of a particular condition or circumstance, they must consult someone who has relevant expertise’ and at para 6.86 it requires that:
assessors undergo regular, up-to-date training on an ongoing basis. The training must be appropriate to the assessment, both the format of assessment and the condition(s) and circumstances of the person being assessed. They must also have the skills and knowledge to carry out an assessment of needs that relate to a specific condition or circumstances requiring expert insight, for example when assessing an individual who has autism, learning disabilities, mental health needs or dementia.
The guidance requires that assessments be ‘person-centred, involving the individual and any carer that the adult has, or any other person they might want involved ‘ (para 6.9) and that they must ‘establish the total extent of needs’ (para 6.10). Local authorities are also required to ‘provide in advance, and in accessible format, the list of questions to be covered in the assessment’ (para 6.38).
Carer support ignored
The ‘eligibility criteria’ regulations make explicit that the decision about whether an adult has eligible needs, is made on the basis that it does not take into account any support that is being provided by third parties (ie carers): ‘instead, where a person receives support from a carer, this will be taken into account during the development of the care and support plan.’ This important point is addressed in the guidance, which at chapter 6 (Assessment and eligibility) states:
6.15 During the assessment, local authorities must consider all of the adult’s care and support needs, regardless of any support being provided by a carer. Where the adult has a carer, information on the care that they are providing can be captured during assessment, but it must not influence the eligibility determination.
This approach is restated in the care and support planning section of the guidance (para 10.26) which requires that authorities ‘must identify, during the assessment process, those needs which are being met by a carer at that time, and determine whether those needs would be eligible’.
Section 10(5) requires that assessments must take into account the extent to which the carer is ‘willing, and is likely to continue to be willing’ to provide care. The guidance at para 2.48 that ‘authorities ‘should not assume that others are willing or able to take up caring roles’ echoes earlier guidance – for example the original 1990 policy guidance to the Community Care reforms61 and guidance to the Carers (Recognition & Services) Act 1995.62
The nature and setting of the assessment
The guidance advises that to enable individuals to prepare for their assessment, they should be provided in advance (in an accessible format) with the list of questions to be covered in the assessment (para 6.38). At the same time the authority must consider if the individual may have ‘substantial difficulty’ in being involved in the assessment process and if so consider the need for independent advocacy (para 6.23). At the conclusion of the assessment the local authority must ‘ensure that it is an accurate and complete reflection of the person’s needs’ (para 6.46) – which must presumably mean sharing a draft and getting it agreed (or details of what is not agreed) – since a copy of the assessment must then be given to the carer / adult in need (para 6.98).The duty to endeavour to reach agreement at this stage is not however explicit – unlike the requirement in para 10.83, that authorities ‘must take all reasonable steps to reach agreement with the person for whom the plan is being prepared’.
Individuals must be ‘at the heart’ of their assessments and in the case of an adult ‘in need’ the authority ‘must also involve any carer the person has (which may be more than one carer)’.
The Act, regulations and guidance make specific provision for advocates to be provided where a person has ‘substantial difficulty’ in being actively involved with the planning process. Less is said concerning the needs of those who don’t have such a difficulty – but nevertheless feel the need for support from friends or advocates.
Eligibility criteria (section 13)
Where an assessment identifies that an individual has needs for care / support then the authority must decide if these needs are sufficient to meet the eligibility criteria. The pre-Care Act legislation contains no reference to ‘eligibility criteria’: locating them instead in guidance (commonly referred to as FACS). The Care Act places eligibility criteria in a statutory footing (section 13) with the detail being spelled out in the regulations– which contain separate criteria for adults in need and for carers. Whether this change of status – or indeed the significant changes to the criteria themselves – will result in material change in practice is difficult to predict. Research suggests that for both carers and disabled / older people, the content of national criteria is less influential than ‘social work attitudes’ and local interpretations of the national criteria.
Adults in need eligibility criteria
For adults in need, the Care Act criteria have many similarities to the FACS guidance: the most obvious change is the absence of ‘bands’ (the ‘critical’, ‘substantial’, ‘moderate’ ‘low’ bands in FACS).
Under the new eligibility scheme, adults in need must satisfy three requirements:
(1) their needs must be the result of a physical or mental impairment or illness;
(2) as a result they must be unable to achieve two or more specified outcomes; and
(3) as a consequence, there is (or there is likely to be) a significant impact on their well-being.
In this process – a key word is ‘significant’ and it is one that also appears in the carers eligibility criteria. The guidance avoids a precise definition of what ‘significant’ means – para 6.110 stating that it is to have its ‘everyday meaning – but then adding that authorities must consider whether the adult’s needs and their consequent inability to achieve the relevant outcomes will have an important, consequential effect on their daily lives, their independence and their wellbeing’ (para 6.110) – and that:
‘Needs may affect different people differently, because what is important to the individual’s wellbeing may not be the same in all cases. Circumstances which create a significant impact on the wellbeing of one individual may not have the same effect on another’ (para 6.111).
Inevitably it would appear to follow that, as with the FACS criteria, the eligibility determination will continue to be subjective and made on the basis of the assessor’s professional opinion. The ‘inherently subjective’ nature of this process led a number of commentators, including the LGA and ADASS, to suggest that the draft eligibility criteria (published in June 2014) placed the threshold of entitlement closer to the ‘moderate’ band in FACS than the ‘substantial’ band. The final (ie revised) criteria appear to be ‘tighter’ – most noticeably requiring that the person is ‘unable to achieve two or more specified outcomes’. However, in this context, regulation 3 defines ‘unable’ in expansive terms: a person is to be deemed ‘unable’ if he or she:
(a) is unable to achieve it without assistance;
(b) is able to achieve it without assistance but doing so causes the adult significant pain, distress or anxiety;
(c) is able to achieve it without assistance but doing so endangers or is likely to endanger the health or safety of the adult, or of others; or
(d) is able to achieve it without assistance but takes significantly longer than would normally be expected.
The broad definition of inability to achieve – has also led commentators to suggest that even in this final formulation, the eligibility remain more generous than under the FACS guidance.
Regulation 2 details ‘outcomes’ as being:
(a) managing and maintaining nutrition;
(b) maintaining personal hygiene;
(c) managing toilet needs;
(d) being appropriately clothed;
(e) being able to make use of the adult’s home safely;
(f) maintaining a habitable home environment;
(g) developing and maintaining family or other personal relationships;
(h) accessing and engaging in work, training, education or volunteering; Care
(i) making use of necessary facilities or services in the local community including public transport, and recreational facilities or services; and
(j) carrying out any caring responsibilities the adult has for a child.
Para 6.107 of the guidance provides examples of how local authorities should consider each of the above outcomes – while emphasising that the guidance does not constitute an exhaustive list of examples.
As noted above, the regulations and guidance are unequivocal concerning the input of carers: this must be ignored during the assessment process of the adult and during the determination of eligibility. As the guidance states (para 6.119):
The eligibility determination must be made based on the adult’s needs and how these impact on their wellbeing. Authorities must only take consideration of whether the adult has a carer, or what needs may be met by a carer after the eligibility determination when a care and support plan is prepared. The determination must be based solely on the adult’s needs and if an adult does have a carer, the care they are providing will be taken into account when considering whether the needs must be met.
The pre-Care Act rule – that the eligibility criteria can be sidestepped for people whose needs are urgent is carried forward into the new regime (section 19(3)). The guidance advises that where ‘an individual with urgent needs approaches or is referred to the local authority [it] should provide an immediate response and meet the individuals care and support needs’ and it then provides as an example, ‘where an individual’s condition deteriorates rapidly or they have an accident, they will need a swift response to ensure their needs are met’ (para 6.26).
Many local authorities use ‘panels’ of various types (sometimes termed ‘allocation panels’, ‘funding panels’ or ‘purchasing panels’) as a means of rationing services. The legality of the way that some of these panels operate is open to question – creating as they do, an additional non-statutory hurdle for people in need and their carers. The 2014 Act makes no change to this situation and so the concerns raised by the courts and the Joint Committee on Human Rights concerning the legality of such ‘panels’ overruling social work recommendations will remain relevant. The Local Government Ombudsman has also expressed similar misgivings. In a 2005 report, for example, he held that where an assessment has been carried out, a purchasing panel (and by implication a manager) cannot override the judgment of the assessor without providing clear reasons for doing so.
Due regard should be taken to the use of approval panels in both the timeliness and bureaucracy of the planning and sign-off process. In some cases, panels may be an appropriate governance mechanism to sign-off large or unique personal budget allocations and/or plans. Where used, panels should be appropriately skilled and trained, and local authorities should refrain from creating or using panels that seek to amend planning decisions, micro-manage the planning process or are in place purely for financial reasons. …
Duty /power to provide care & support for adults /carers (section 18 – 20)
The duty on local authorities to meet the eligible needs of disabled, elderly and ill people is retained and widened by the Care Act. The pre-2014 legislation contains no duty to meet carers’ eligible needs (just a power)85 nor (in general) does the pre-2014 legislation create a duty to meet the needs of ‘self-funders’ (ie people whose savings are above the capital limit – currently £23,750). Both these limitations are removed by the 2014 Act. Where an individual’s needs (ie a carer or an ‘adult in need’) meet the eligibility criteria then there will be a duty to ensure their care and support needs are addressed. The only stipulation being that they are ordinarily resident in the local authority’s area (as at present) and that if their assets are above the financial limit, that they ‘ask the authority’ to meet their needs. Until April 2014 the right of self-funder’s to require the local authority to meet their care needs will only extend to non-care home settings.
Even if a self funder with eligible needs does not ask the local authority to meet their needs – the local authority will (once the ‘cap on care costs’ comes into force in 2016) be under a duty to provide them with a statement (an ‘independent personal budget’ ) detailing what the cost would be to the local authority of meeting their needs – since this notional budget will count towards the ‘cap’.
Care & support plans (section 25-26)
The assessment process involves identifying ‘needs’ and then determining which of these (if any) are ‘eligible needs’. This stage is then followed by the development of a care and support plan that explains how the eligible needs will be met. These stages are two sides of an equation: on one side there are the eligible needs that have to be met and on the other are the details of how this will be done. In order that the individual can determine whether their assessed needs are fully addressed in the care plan, the guidance requires that they ‘must be given a record of their needs or carer’s assessment’ (para 6.98) and also their final care plan (para 10.87).
Needs versus ‘outcomes’
The Act seeks to distinguish ‘needs’ from ‘outcomes’. This chimes with the views of many commentators who consider that the ‘social model’ approach requires a ‘focus on outcomes’ rather than personal ‘needs’. There is much to be said for this, but there are dangers too.
On the positive side outcomes aim to identify the person’s ‘aspirations, goals and priorities’. The theory is that if the assessment focuses on these issues it will break free from the shackles of thought processes tied to existing service models – thinking about ‘what services are available’. Once the person ‘in need’ / carer have been helped to explain what they would like happen in their lives – then they (with the support of the authority) can seek to develop a care and support plan designed to enable these things to be achieved. The theory is that this process leads to better and sometimes more imaginative solutions.
On the negative side, however, there is evidence that the emphasis on outcomes is rhetorical rather than of substance (a criticism also made of many local authority ‘personalisation’ programmes). Much of the research concerning outcomes focused assessments identifies the importance of avoiding prescriptive ‘tick box’ questionnaires and of the need for a strong human relationships with assessors who have the skills and time to enable this approach to succeed. Local authorities are however moving to greater standardisation, more prescriptive assessment forms, less skilled / trained workforces with ever higher caseloads. increasing disconnect between what service users say and related evidence, and the thinking of government and policy-makers and what they seem to be doing.
A further reason for caution lies in the very ambiguity as to what constitutes an ‘outcome’. Just as some disabled people have historically been told that their asserted ‘need’ is merely a ‘want’ – some are now being told that their ‘need’ is no longer relevant – it is the ‘outcome’ that counts (and the local authority then proceed to tell them what this is). Not infrequently there is a pedantic circularity to the distinction – and one that should be confronted. Outcomes arise out of needs, which stem from impairments – so, for example, the regulations (when dealing with the criteria for an adult in need’) state that because of a person’s needs, a statutory ‘outcome’ could be ‘managing toilet needs’. The guidance (para 6.107) then explains how local authorities should consider each statutory ‘outcome’ for the purposes of determining eligibility – and in relation to ‘managing toilet needs’ it states that this requires a consideration of their ‘ability to access and use a toilet and manage their toilet needs.’ It would appear to follow that a ‘need’ to get to the toilet is only a ‘need’ but a need to mange my toilet needs’ is an outcome.
It is at this stage one asks whether the well-being requirement – that the authority starts from the ‘assumption that the individual is best-placed to judge the individual’s well-being’ (section 1(3)) – extends to accepting that the individual is best placed to say what they want to be able to do (their outcome) and to do so in their own terms – including using the language of need?
Provided the potential for casuistry in the ‘outcomes versus needs’ analysis is avoided, there is much to welcome in having a statutory list of ‘outcomes / needs’ – particularly as the guidance (para 6.107) states that this does ‘not constitute an exhaustive list) when determining the adult’s eligibility for care and support’.
Care and support planning – principles
Section 25 details what must be in every care and support plan (ie for a carer or an adult ‘in need’) and this duty is analysed in the guidance (para 10.36). The requirements include:
the needs identified by the assessment;
whether, and to what extent, the needs meet the eligibility criteria;
the needs that the authority is going to meet, and how it intends to do so;
for a person needing care, for which of the desired outcomes care and support could be relevant;
for a carer, the outcomes the carer wishes to achieve, and their wishes around providing care, work, education and recreation where support could be relevant;
the personal budget …;
information and advice on what can be done to reduce the needs in question, and to prevent or delay the development of needs in the future;
where needs are being met via a direct payment … , the needs to be met via the direct payment and the amount and frequency of the payments.
The effect of section 25 is that the current requirements for care and support plans will continue – but they now become statutory rather than requirements of Department of Health guidance. Existing case law concerning care plans will remain relevant – particularly so, given that it places great emphasis on the importance of local authorities following guidance. (which will now be the detail in the 2014 guidance). In R v Islington LBC ex p Rixon (1997) it was held that central importance of a care plan was described as: the means by which the local authority assembles the relevant information and applies it to the statutory ends, and hence affords good evidence to any inquirer of the due discharge of its statutory duties.
In R (J) v Caerphilly CBC it was held that care plans must ‘set out the operational objectives with sufficient detail – including detail of the “how, who, what and when” – to enable the care plan itself to be used as a means of checking whether or not those objectives are being met’. A 2014 Ombudsman’s report held (in similar terms) that an assessment must be more than merely a descriptive document: it must spell out with precision what the needs are, what the impact of the disability is on the carer(s) and whether the disabled person and the carers needs can be met and can continue to be met into the future. The assessment must result in a care plan that identifies the needs, what is to be done about these needs, by whom and when. If a direct payment is made, it must specify precisely what need these payments are intended to meet, why this level of payment is considered appropriate, or what outcome this will result in.
The most significant difference under the new regime is that every such plan for an ‘adult’ must have a ‘personal budget’ offered. (s25(1)(e) ). Since most local authorities already do this – it will probably make little practical difference.
The 2014 guidance requires that the person being assessed must be ‘genuinely involved and influential throughout the planning process and that: ‘it should be made clear that the plan ‘belongs’ to the person it is intended for, with the local authority role to ensure the production and sign-off of the plan to ensure that it is appropriate to meet the identified needs (para 10.2). The care and support plan ‘must take into consideration the individual’s preferences’ (para 10.21).
The duty to meet eligible needs is not discharged just because a person has another entitlement to a different service which could meet those needs, but which they are not availing themselves of. The needs remain ‘unmet’ (and so the local authority under a duty to meet them) until those needs are actually met by the relevant service bring provided or arranged.
Section 26 states that the amount of an adult’s personal budget is ‘the cost to the local authority of meeting those of the adult’s needs which it is required or decides to meet’. The guidance states at para 11.10 that:
The personal budget must always be an amount sufficient to meet the person’s care and support needs, and must include the cost to the local authority of meeting the person’s needs which the local authority is under a duty to meet, or has exercised its power to do so. This overall cost must then be broken down into the amount the person must pay, following the financial assessment, and the remainder of the budget that the authority will pay.
It follows from the above, that a personal budget may include an amount attributable to support that the local authority funds as a ‘discretion’ (ie support that it considers is needed – but which does not meet the eligibility criteria). Since the amount that an individual pays for their care will be added (from April 2016) to their ‘Dilnot taxi meter’ – towards their ‘cap on costs’ – the guidance needs to make clear whether the charges for discretionary services are included for ‘cap on costs’ purposes. If these charges do not count – then there is an obvious temptation for local authorities to include them in the plan as a discretionary support.
The expectation is that (for non-self funders) the personal budget will change as the care and support planning process progresses. At the start of the planning process it will be an ‘indicative amount’ shared with the person, and anybody else involved, with ‘final amount of the personal budget confirmed through this process’ (para 11.7). This means there is no need for an authority to use a Resource Allocation System (RAS) to generate a figure at the commencement of the process – an authority might have (for example) a simple set of ‘bands’. Research suggests that most RAS generate incorrect figures which have serious defects – not least their complexity and the rigidity with which some local authorities then apply them. In support of this approach the guidance advises that ‘complex RAS models of allocation may not work for all client groups’ (para 11.23) and that ‘regardless of the process used, the most important principles in setting the personal budget are transparency, timeliness and sufficiency’ (para 11.24).
The guidance (para 11.7) states that ‘Everyone whose needs are met by the local authority … must receive a personal budget as part of the care and support plan.
Direct Payments (sections 31-33)
The new legislation provides for an almost identical ‘direct payments’ regime as at present and the detail (as with the current system) is to be found in the regulations and the guidance. The only significant change is that direct payments will be available for residential care placements. This change is expected to come into force in April 2016 and pilots in 18 local authority areas are currently underway.
The relevance of local authority financial difficulties
Para 10.27 of the guidance makes clear that the current law concerning the relevance of a local authority’s financial position remains (as first detailed in the Gloucestershire judgment) namely that although authorities can ‘take into account reasonable consideration’ of their finances, they ‘must comply’ with their legal obligations. A local authority’s finances are relevant when it decides how to meet the eligible needs of an individual ‘but not whether those needs are met’. The guidance goes on to stress that authorities ‘should not set arbitrary upper limits on the costs [they are] willing to pay to meet needs through certain routes’ – although they may: take decisions on a case-by-case basis which weigh up the total costs of different potential options for meeting needs, and include the cost as a relevant factor in deciding between suitable alternative options for meeting needs. This does not mean choosing the cheapest option; but the one which delivers the outcomes desired for the best value. (para 10.27)
Sign off and copies of care plans
The ‘sign off of a plan should only occur once the authority has taken ‘all reasonable steps to reach agreement with the person for whom the plan is being prepared’ and ‘any third party involved in the preparation of the plan’ and this ‘agreement should be recorded and a copy placed within the plan’ (para 10.83). If the plan is not agreed then the authority should ‘state the reasons for this and the steps which must be taken to ensure that the plan is signed-off’ (para 10.86).
The Act also requires that a copy of the care and support plan be given to the adult in need / carer (and anyone else they request) (section 25(9) and (10)) and the guidance at para 10.87 makes clear that the copy must be ‘in a format that is accessible to the person for whom the plan is intended’ and copies should also be given to any independent advocate involved. Many care and support plans are computer generated and incomprehensible to all but the initiated. The requirement that the copies be ‘in a format that is accessible’ must require that this practice ends and plain English, jargon free plans are provided to those who require them.
And some of the rest
Prevention (section 2)
Local authorities will be under a general duty to provide a range of preventative services that they ‘consider’ will:
(a) contribute towards preventing or delaying the development by adults in its area of needs for care and support;
(b) contribute towards preventing or delaying the development by carers in its area of needs for support;
(c) reduce the needs for care and support of adults in its area;
(d) reduce the needs for support of carers in its area.
Charging and preventative services
The current requirement that intermediate care and reablement must be provided without charge is carried into the new regime. While it will continue to be a time-limited service, the guidance advises that ‘where it is provided beyond six weeks, local authorities should consider continuing to provide it free of charge beyond six weeks in such circumstances’ (para 2.61).
Where a local authority decides to charge for preventative services the guidance advices that it is ‘vital to ensure affordability’ and that it balances the ‘affordability and viability … with the likely impact of charging on the uptake’ – and that this be considered individually as well as at general policy levels.
Integration with the NHS (section 3)
Section 3 places a duty on local authorities to promote integration with health provision where it would—
(a) promote the well-being of adults with needs & carers in its area; or
(b) contribute to the prevention of the development of needs in adults / carers; or
(c) improve the quality of care for adults / carers, provided
This will include joint working in relation to the better Care Fund.
Information (section 4)
Local authorities will have an enhanced duty to provide adults in need / carers with information about care and support arrangements, including:- how the care system operates; the care and support choices they have (including the choice of providers); how to access this support and how to raise safeguarding concerns. The information duty will also include how to access independent financial advice – which will be of considerable relevance given the choices ‘self-funders’ will have to make under the new regime – particularly with regard to the ‘cap on care cost’ reforms.
The guidance explains that authorities ‘must establish and maintain a service for providing people with information and advice relating to care and support’ (para 3.11); that this must be provided for a variety of different formats; that the ‘duty in the Care Act will not be met through the use of digital channels alone’ and that the mix of provision will be expected to include ‘face-to-face contact’ (para 3.29).
Duty to promote effective high quality providers (section 5)
The Act (fleshed out by three sets of regulations36) contains a range of provisions designed to address the ‘supply side’ problems of the social care market – ie (a) the problem of large providers collapsing (such as Southern Cross failure in 2011); and (b) the increasing belief that the quality of services is generally poor and deteriorating. These provisions include ‘market oversight’ arrangements involving the Care Quality Commission (CQC) – amongst others (ss 53 – 57 Care Act 2014) and a temporary duty on social services to intervene if a particular provider ‘fails’ (ss 48-52). In July 2014 the Public Accounts Committee was of the view that the CQC (which will monitor the top 40 – 50 providers) lacked ‘the skills to undertake this expanded level of monitoring’.
Regulations38 have now been issued to provide for eleven fundamental standards39 of safety and quality that should always be met by providers of health and social care and draft CQC guidance.
Section 5 places a duty on local authorities to promote an efficient /
The social care workforce has been a direct victim of local authority pressure on providers to reduce their fees. The guidance stresses the importance of authorities ‘fostering a workforce which underpins the market’ (para 4.21) and encouraging (by for example providing funding – para 4.29) ‘training and development’. Local authorities when commissioning services must assure themselves that their fee levels do not (among other things) compromise the service provider’s ability to: (1) ‘meet the statutory obligations to pay at least minimum wages; (2) ‘provide effective training and development of staff’ (para 4.31); and (3) pay remuneration that is:
at least sufficient to comply with the national minimum wage legislation for hourly pay or equivalent salary. This will include appropriate remuneration for any time spent travelling between appointments (para 4.30).
The guidance advises that where a provider has previously been in breach of national minimum wage legislation it should in general be excluded from the tendering process (para 4.102).
Delegation (section 79)
Local authorities will be able to delegate all of their functions under the Act – with few exceptions (eg safeguarding (sections 42 – 47) and charging (section 14)). Section 79(6) makes it clear that ultimate responsibility in such cases will still rest with the local authority (any acts /omissions by the delegated body will be treated as done / omitted to be done by the local authority). A series of pilots have run since 2011 to explore the potential for delegation: these have been small scale and almost all have been third sector not for profit organisations. Section 79 opens up the possibility of full scale delegation of quite a different order and might be contemplated by local authorities facing a steep rise in their assessment / care planning obligations resulting from their new duties to carers and to self funders. In anticipation of these reforms all English local authorities have been given power to delegate virtually all of their adult social services powers.
covered in the assessment’ (para 6.38).
Review of care & support plans (aka annual harassment)
Section 27(1) of the 2014 Act places a general requirement for local authorities to keep under review care and support plans (as well as when a reasonable request by the adult in need or a carer and section 27(4) requires that if they believe that that circumstances have changed materially, then they must undertake a further needs or carer’s assessment and revise the plan accordingly. The guidance creates an expectation that the care and support plans will reviewed ‘no later than every 12 months, although a light-touch review should be considered 6-8 weeks after the plan and personal budget have been signed off’ (para 10.42 – and see also para 13.32).
The guidance requires that reviews (like assessments) must be person-centred, accessible and proportionate: must involve the ‘person needing care and also the carer where feasible’ (para 13.2) and their purpose is ‘identify if the person’s needs (or any other circumstances) have changed’ (para 13.4). Very welcome is the note in the guidance that the ‘review must not be used as a mechanism to arbitrarily reduce the level of a person’s personal budget’ (para 13.4). Reviews should not be ‘overly-complex or bureaucratic’ and should cover the specified matters – which ‘should be communicated to the person before the review process begins’ para 13.12). These include: whether the person’s needs / circumstances have changed; what parts of the plan are working / not working / need changing; have the outcomes identified in the plan been achieved and are there any new outcomes they want to meet; is the person’s personal budget adequate and is there a need to change the way it is managed / paid; are there material changes in the person’s support networks which might impact negatively or positively on the plan; have any changes occurred which could give rise to a risk of abuse or neglect; and is the person, carer, independent advocate satisfied with the plan?
Charging (section 14)
As noted, local authorities will be able to charge for the cost they incur in providing social care support services. Under the pre-Care Act law, there was a duty to charge for residential care services and a power to charge for non-residential care (including carers’ services). The 2014 Act repeals the previous law and section 14 gives authorities the power (but not a duty) to charge. In the short term it is unlikely that there will be material changes to local authority charging policies – although reference to the well-established Charging for Residential Accommodation Guidance (CRAG) will change as this is repealed – but it is replicated in large measure by the Care and Support (Charging and Assessment of Resources) Regulations and the guidance (including Annexes B, C, D and E).
The guidance states (para 8.2) that a single set of principles will condition local authority approaches to charging, namely:
ensure that people are not charged more than it is reasonably practicable for them to pay;
be comprehensive, to reduce variation in the way people are assessed and charged;
be clear and transparent, so people know what they will be charged;
promote wellbeing, social inclusion, and support the vision of personalisation, independence, choice and control;
support carers to look after their own health and wellbeing and to care effectively and safely;
be person-focused, reflecting the variety of care and caring journeys and the variety of options available to meet their needs;
apply the charging rules equally so those with similar needs or services are treated the same and minimise anomalies between different care settings;
encourage and enable those who wish to stay in or take up employment, education or training or plan for the future costs of meeting their needs to do so; and
be sustainable for local authorities in the long-term.
Welcome as is the requirement that ‘people are not charged more than it is reasonably practicable for them to pay’ this represents (for people receiving non-residential care support) a dilution of their legal rights. At present the prohibition is contained in the statute and so is only capable of being removed by Parliament (whereas guidance can be re-written on Ministerial whim).
One problem with the approach of applying ‘the charging rules equally so those with similar needs or services are treated the same’ is that local authorities may start charging carers for services. The guidance anticipates this problem – but in a relatively ‘limp’ section seeks to argue that charging carers is not inevitable stating (para 8.50):
Local authorities are not required to charge a carer for support. …. a local authority should consider how it wishes to express the way it values carers within its local community as partners in care, and recognise the significant contribution carers make. … Local authorities should consider carefully the likely impact of any charges on carers, particularly in terms of their willingness and ability to continue their caring responsibilities.
Continuity of care (portability) (sections 37-38)
The Act prescribes the way local authorities transfer responsibility for the care and support of an adult – when she or he moves from one local authority area to another. It does this by attempting to embed ‘good practice’ (ie what should happen) into legislation. The problem is that there are no sanctions if either the first or second local authority fails to act properly – and so (as now) an individual would have to make a complaint/ go to the Ombudsman if a problem occurs.
Sections 37 – 38 are replete with detailed procedural obligations – but in essence they provide that where a local authority (the 1st local authority) is providing135 care and support for an adult and another authority (the 2nd authority) is notified that the adult intends to move into their area (and it is satisfied that the intention is genuine) then it must (among other things) undertake an assessment of the adult’s needs (and those of any carers he or she may have). If the assessment(s) have not been completed by the time the adult actually moves, then the second authority must meet the needs identified by the 1st authority (until its assessment is complete).
Chapter 20 of the guidance fleshes out how the process should operate – but signally fails to deal with what will happen when a person moves and the second local authority fails to act properly – for example by failing to fund the person’s needs to the same level as the first authority until it has completed its assessment. The guidance should have cautioned against the first authority stopping the funding in such cases – but it does not.
Ordinary Residence (section 39 – 41)
The existing law concerning the determination of a person’s ‘ordinary residence’ continues under the new legislation – with one major change.
The case law concerning the notion of ‘ordinary residence’ will remain applicable – ie that it refers to a person’s ‘abode in a particular place … adopted voluntarily and for settled purposes … whether of short or long duration’.As with the current law there are two significant ‘deeming’ rules – and it is in relation to the second of these that the material change is made.
The first deeming rule (now found in section 39(5)) concerns adults in NHS accommodation: such people are deemed to be ordinarily resident in the area in which they were immediately before they entered the NHS accommodation / ambulance.
The second deeming rule concerns adults whose accommodation is arranged by a local authority in the area of another local authority. At present this is restricted to cases where a local authority arranges accommodation in a registered care home. The legislation extends this rule to include not only care home accommodation, but also shared lives scheme accommodation and supported living accommodation. Local authority responsibility only attaches if the care and support ‘can be met only’ in the specified accommodation and the accommodation is in England (section 39(1)).
Para 19.31 of the guidance explains that:
Need should be judged to “only be able to be met” through a specified type of accommodation
in the specified accommodation and the accommodation is in England (section 39(1)).
Para 19.31 of the guidance explains that:
Need should be judged to “only be able to be met” through a specified type of accommodation where the local authority has made this decision following an assessment and a care and support planning process involving the person. Decisions on how needs are to be met, made in the latter process and recorded in the care and support plan, should evidence that needs can only be met in that manner. The local authority must have assessed those needs in order to make such a decision – the “deeming” principle therefore does not apply to cases where a person arranges their own accommodation and the local authority does not meet their needs.
Responsibility will however continue even if the person moves between different specified types of accommodation in another (or more than one other) area and it will also exist where the person takes a direct payment and arranges their own care (see paras 19.32 – 19.34).
Safeguarding (sections 42 – 47))
The Act places on a statutory footing some of the safeguarding obligations that are at present, only located in the guidance (principally the ‘No Secrets’ guidance) – for example the duty to make enquiries / decide what action should to be taken.
Section 42 contains the duty to make enquiries if adult with care & support needs:
- is experiencing, or is at risk of abuse of neglect; and
- is unable to protect him/herself against the abuse / neglect.
The Act does not explain what is meant by ‘abuse’ – save to specify that it includes financial abuse which is broadly defined – eg including putting the adult ‘under pressure in relation to money or other property’ and/or the adult ‘having money or other property misused’.
The Act provides no new powers to protect adults from abuse – merely ‘process’ obligations (eg to have a Safeguarding Board; to undertake investigations and to require individuals to provide information etc). The Welsh Act provides a power of entry – to enable social services to gain access and to speak with a person suspected of being abused – and the Scottish Act contains (in addition) a power of removal. Not only are such powers absent from the English Act, the existing National Assistance Act 1948 section 47 power to remove, is repealed.
Independent advocacy (section 67)
Section 67 of the Act and the regulations place a duty on local authorities to arrange independent advocacy if the authority considers that: (1) an individual would experience ‘substantial difficulty’ in participating in (amongst other things) their assessment and / or the preparation of their care and support plan; and (2) there is no one appropriate available to support and represent the person’s wishes. As the guidance states at para 7.4:
Local authorities must arrange an independent advocate to facilitate the involvement of a person in their assessment, in the preparation of their care and support plan and in the review of their care plan, as well as in safeguarding enquiries and SARs [Safeguarding Adults Reviews] if two conditions are met. That if an independent advocate were not provided then the person would have substantial difficulty in being fully involved in these processes and second, there is no appropriate individual available to support and represent the person’s wishes who is not paid or professionally engaged in providing care or treatment to the person or their carer. The role of the independent advocate is to support and represent the person and to facilitate their involvement in the key processes and interactions with the local authority and other organisations as required for the safeguarding enquiry or SAR.
The guidance explains that a person experiences ‘substantial difficulty’ when this exists in relation to any one of four areas – namely (para by 6.33):
understanding the information provided; retaining the information; using or weighing up the information as part of the process of being involved; and communicating the person’s views, wishes or feelings. Where a person has substantial difficulty in any of these four areas, then they need assistance.
s117 Mental Health Act 1983 (section 74)
Currently ‘’after-care services’ are not defined by the 1983 Act. The Care Act inserts a new subsection (5) into the 1983 Act to limit services to those:
(a) ‘arising from or related to the mental disorder’ and
(b) reducing the risk of a deterioration of the person’s mental condition (ie that may require re-admission).
The Act confirms that ordinary residence for the purposes of s117 is determined by where a person was based immediately before they were detained and gives the Secretary of State power to resolve ordinary residence disputes. It also inserts a new ‘s117A’ that provides for regulations to introduce a limited ‘choice of accommodation’ for persons subject to s117.