CQC We and I Statements
Theme 1 – Working with People: Assessing needs
We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.
I have care and support that is coordinated, and everyone works well together and with me.
I have care and support that enables me to live as I want to, seeing me as a unique person with skills, strengths and goals.
TRAFFORD SPECIFIC INFORMATION
- 1. Introduction
- 2. The Personal Budget
- 3. Personal Budget Options
- 4. Elements of the Personal Budget
- 5. Self-Funding and Personal Budgets
- 6. Independent Personal Budgets
- 7. Top Up Payments
- 8. Exclusions from the Personal Budget: Intermediate Care and Reablement
- 9. Calculating the Personal Budget
- 10. Personal Budget Principles
- 11. Use of the Personal Budget
- 12. Pooling Personal Budgets
- 13. Use of a Carer’s Personal Budget: Where the Person being Cared for has Eligible Needs
- 14. Replacement Care
- 15. Carers’ Personal Budgets: Where the Adult Being Cared For Does Not Have Eligible Needs
- 16. Appeals / Disputes
- 17. Further Reading
Personal budgets are a key part of the Government’s aspirations for a person centred care and support system. Independent research shows that where implemented well personal budgets can improve outcomes and deliver better value for money
The Care Act 2014 places personal budgets into law for the first time, making them the norm for adults with care and support needs.
A personal budget, in conjunction with the care and support plan, or support plan (see Care and Support Planning chapter), enables the adult, and their advocate if they have one, to exercise more choice and control over how their care and support needs are met. It means:
- before care and support planning begins, having an estimate of how much money will be available to meet the adult’s assessed needs and, in the final personal budget, having clear information about the total amount of the budget, including the amount the local authority will pay, and what amount (if any) the person will pay;
- being able to choose how the money is managed from a range of options, including direct payments, the local authority managing the budget and a provider or third party managing the budget on the adult’s behalf ) or a combination of these approaches;
- having a choice over who is involved in developing the care and support plan for how the personal budget will be spent, including family or friends;
- having greater choice and control over the way the personal budget is used to purchase care and support and from whom it is purchased.
It is vital that the process used to establish the personal budget is transparent so that people are clear how their budget was calculated. It is also essential that the method used is robust so that people have confidence that the personal budget allocation is correct and therefore is adequate to meet their care and support needs. The allocation of a clear upfront indicative (or ‘ball park’) allocation at the start of the planning process will help people to develop the plan and make appropriate choices over how their needs are met.
The process of allocating the personal budget should be completed in a timely manner, proportionate to the needs of the adult to be met. At all times the person should be informed where they are in the care planning process, what will happen next and the likely timeframes.
This chapter applies to people in need of care and support and carers equally, unless specifically stated.
2. The Personal Budget
Everyone whose needs are met by the local authority, whether those needs are eligible (see Eligibility chapter) or if the authority has chosen to meet other needs, should be allocated a personal budget as part of the care and support plan, or support plan.
The personal budget should give the adult clear information regarding the money that has been allocated to meet the needs identified in their assessment and recorded in their plan.
An indicative amount should be shared with them, and anybody else involved, at the start of the planning process, with the final amount being confirmed through this process. The detail of how the personal budget will be used should be set out in the finished plan. The detail of how the personal budget will be used is set out in the care and support plan, or support plan.
At all times, the wishes of the adult are considered and respected. For example, people should not be forced to accept specific options, such as moving into care homes, against their will because they are the cheapest.
3. Personal Budget Options
The adult, and anybody else the person wishes to assist them, can make informed decisions about how their personal budget operates, including:
- the adult can choose for the personal budget allocation to remain with the local authority to spend on their behalf, in line with their wishes;
- the budget can be placed in an Individual Service Fund (ISF), held by a third party provider, which works on the same basis;
- or be taken as a direct payment (see Direct Payments chapter);
- or the adult may prefer a combination of approaches. For example, some of their needs may be met by a direct payment, with the remainder of the personal budget used to meet needs via the local authority or through an ISF. Where an ISF type arrangement is not available locally, the local authority should explore arrangements to develop this offer, and should be receptive to requests from personal budget recipients to create these arrangements with specified providers.
There may also be cases where a person prefers to use a mixed package of care and support. For example, this may be a direct payment to the person for some of their needs, with the remainder of the personal budget used to meet needs via local authority or third-party provision, or any combination of the above. The method of allocating the personal budget should be decided and agreed during the care and support planning process (see Care and Support Planning chapter). It is important that these arrangements can be subsequently adjusted if the person wishes this, with the minimum of procedure. The process for allocating and agreeing the personal budget via the planning process should be as straightforward and as timely as possible so that the person can access the budget without significant delay.
4. Elements of the Personal Budget
The personal budget must always be 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.
The personal budget may also set out other amounts of public money that the person is receiving, such as money provided through a personal health budget. Local authorities should consider requests from individuals to present their personal budget in this way. Integrated health and care, and integration of other aspects of public support are the long term vision of the government. This will provide the individual with a seamless experience, and can help to remove unnecessary bureaucracy and duplication that may exist where a person’s needs are met through money from multiple funding streams.
Local authorities must carry out their care and support responsibilities with a view to promoting integration with health and other related services (such as housing), and therefore should take a lead in driving the integration of support services for their population. For example, this may involve agreeing with partner organisations how to integrate budgets and to what extent, and the establishment of a lead organisation that agrees to oversee monitoring and assurance of all budgets the person is receiving.
Where a local authority is meeting the eligible needs of a person whose financial resources are above the financial limit, but who has requested the local authority meet their needs, the local authority may make a charge for putting in place the necessary arrangements to meet needs (see Care and Support Statutory Guidance, chapter 8 on charging and financial assessment). Where this occurs, the local authority should consider how best to set this information out to the person, in a format accessible to them. This fee is not part of the personal budget, since it does not relate directly to meeting needs, but it may be presented alongside the budget to help the person understand the total charges to be paid. For example, a local authority may wish to specify this in both the plan and the personal budget for the person so all parties are clear on how costs are allocated.
Similarly, there will be cases where a person or a third party on their behalf is making an additional payment (or a top up) in order to be able to secure the care and support of their choice, where this costs more than the local authority would pay for such a type of care. In these cases, the additional payment does not form part of the personal budget, since the budget must reflect the costs to the local authority of meeting the needs. However, the local authority should consider how best to present this information to the individual, so that the total amount of charges paid is clear, and the link to the personal budget amount is understood.
5. Self-Funding and Personal Budgets
See also Self-Funders chapter.
Where the local authority is meeting the eligible needs of an adult (see Eligibility chapter) whose financial resources are above the limit, but who has requested the local authority to meet their needs, a charge may be made for putting in place the arrangements to meet needs. When this occurs, the information should be set out for the person in an accessible format. This fee is not part of the personal budget, because it does not relate directly to meeting needs, but it should be presented alongside the budget to help the adult to understand the total charges to be paid. So that everyone is clear about how costs are allocated, this fee should be included in both the plan and the personal budget.
6. Independent Personal Budgets
Following assessment, adults with eligible needs that the local authority is not under a duty to meet (either because they do not qualify for financial assistance or do not want it to meet their needs) can request an independent personal budget, setting out what the local authority would spend on meeting their eligible needs. This would enable them to qualify for state funding when their accrued costs reach the cap.
As with actual personal budgets, local authorities must keep independent personal budgets under review. It must also reassess adults on independent personal budgets if they feel their circumstances have changed, and revise the budget accordingly.
7. Top Up Payments
Where the adult or a third party on their behalf, such as a relative, is making an additional payment (or a ‘top up’) in order to be able to secure the care and support of the person’s choice when this costs more than the local authority would pay, the additional payment should not form part of the personal budget because the budget indicates the costs to the local authority of meeting the needs. However, the information about the additional payment should be presented so that the total amount of charges being paid is clear and the link to the personal budget amount is understood.
8. Exclusions from the Personal Budget: Intermediate Care and Reablement
Regulations set out the cases or circumstances where the costs of meeting the needs of care and support do not have to be incorporated into the personal budget. Because both the care and support plan and personal budget are mechanisms to enable people to have greater choice and control over their care and support, there are not many instances where this exclusion will apply.
The Care and Support (Personal Budget Exclusion of Costs) Regulations 2014 set out that the provision of intermediate care and reablement services, for which the local authority cannot or chooses not to make a charge must be excluded from the personal budget. This will mean that where either intermediate care or reablement is being provided to meet needs, the cost of this must not be included in the personal budget.
Intermediate care services are usually provided to patients, often older people, after leaving hospital or when they are at risk of being admitted to hospital. The services are a link between places such as hospitals and people’s homes and between different areas of the health and social care system – community services, hospitals, GPs and social care (see also Reablement chapter).
Local authorities should not include additional elements that would not normally be classified as intermediate care or reablement into this exclusion. In fact the Act restricts the regulations into specifying only care and support which the local authority cannot charge for, or chooses not to charge for. This ensures that long term care and support will always be part of the personal budget,. Also, broader rehabilitation services could be included to an individual to meet identified health needs as part of a joint personal budget across health and social care.
Intermediate care / reablement should usually be provided as a free, universal service under the Act, and therefore would not contribute to the personal budget amount. However, in some circumstances, a local authority may choose to combine either service with aspects of care and support to meet eligible or ongoing needs, which would require a personal budget to be developed. Removing the cost of provision of intermediate care / reablement from the personal budget in these scenarios ensures that the allocation of both services is applied uniformly across all local authorities.
In cases where intermediate care / reablement is provided to meet needs, either in isolation or combined with longer term care and support, the plan should describe what the package consists of and how long it will last. This will help the person understand what is being provided to meet their needs. However, the adult does not have a personal budget, unless there are other forms of care and support being provided. In these cases, the personal budget amount does not include the cost of intermediate care / reablement, which should be provided free of charge.
9. Calculating the Personal Budget
It is important to have a consistent method for calculating personal budgets that provides an early indication of the appropriate amount to meet the identified needs to be used at the beginning of the planning process. Local authorities should ensure that the method used for calculating the personal budget produces impartial outcomes to ensure fairness in care and support packages regardless of the environment in which care and support takes place, for example, in a care home or someone’s own home. Local authorities should not have arbitrary ceilings to personal budgets that result in people being forced to accept to move into care homes against their will.
There are many variations of systems used to arrive at personal budget amounts, ranging from complex resource allocation systems (RAS), to more ‘ready-reckoner’ approaches. Complex RAS models of allocation may not work for all client groups, especially where people have multiple complex needs, or where needs are comparatively costly to meet, such as in the case of deafblind people. It is important that these factors are taken into account, and that a ‘one size fits all’ approach to resource allocation is not taken. If a RAS model is being used, local authorities should consider alternative approaches where the process may be more suitable to particular client groups to ensure that the personal budget is an appropriate amount to meet needs.
Regardless of the process used, the most important principles in setting the personal budget are transparency, timeliness and sufficiency. This will ensure that the person, their carer, and their independent advocate if they have one, is fully aware of how their budget was calculated, that they know the amount at a stage which enables them to effectively engage in care and support planning, and that they can have confidence that the amount includes all relevant costs that will be sufficient to meet their identified needs in the way set out in the plan. The local authority should also explain that the initial indicative allowance can be increased or decreased depending on the decisions made during the development of the plan. This should prevent disputes from arising, but it must also be possible for the person, carer or independent advocate (on the person’s behalf) to challenge the local authority on the sufficiency of the final amount. These principles apply to both the indicative upfront budget and the final signed off personal budget that forms part of the care and support plan.
10. Personal Budget Principles
Three principles apply to both the indicative upfront budget and the final signed off personal budget that forms part of the care and support plan.
Authorities should make their allocation processes publicly available as part of their general information offer, or ideally provide this on a bespoke basis for each person the authority is supporting in a format accessible to them. This will ensure that people fully understand how the personal budget has been calculated, both in the indicative amount and the final personal budget allocation. Where a complex RAS process is used, local authorities should pay particular consideration to how they will meet this transparency principle, to ensure people are clear how the personal budget was derived.
It is crucial when calculating the personal budget to arrive at an upfront allocation which can be used to inform the start of the care and support planning process. This indicative budget will enable the person to plan how the needs are met. After refinement during the planning process, this indicative amount is then adjusted to be the amount that is sufficient to meet the needs which the local authority is required to meet, or decides to meet. This adjusted amount then forms the personal budget recorded in the care plan.
The amount that the local authority calculates as the personal budget must be sufficient to meet the person’s needs which the local authority is required to meet or decides to meet, and must also take into account the reasonable preferences to meet needs as detailed in the care and support plan, or support plan.
The he personal budget must be an amount that is the cost to the local authority of meeting the person’s needs. In establishing the ‘cost to the local authority’, consideration should therefore be given to local market intelligence and costs of local quality provision to ensure that the personal budget reflects local market conditions and that appropriate care that meets needs can be obtained for the amount specified in the budget. To further aid the transparency principle, these cost assumptions should be shared with the person so they are aware of how their personal budget was calculated. Consideration should also be given as to whether the personal budget is sufficient where needs will be met via direct payments, especially around any other costs that may be required to meet needs or ensure people are complying with legal requirements associated with becoming an employer (see Direct Payments chapter). There may be concern that the ‘cost to the local authority’ results in the direct payment being a lesser amount than is required to purchase care and support from the local market due to local authority bulk purchasing and block contract arrangements. However, by basing the personal budget on the cost of quality local provision, this concern should be allayed.
However, a request for needs to be met via a direct payment does not mean that there is no limit on the amount attributed to the personal budget. There may be cases where it is more appropriate to meet needs via directly-provided care and support, rather than by making a direct payment. For example, where there is no local market for a particular kind of care and support that the person wishes to use the direct payment for, except for services provided by the local authority. It may also be the case where the costs of an alternate provider arranged via a direct payment would be more than for what the local authority would be able to arrange the same support, whilst achieving the same outcomes for the individual.
In all circumstances, consideration should be given to the expected outcomes of each potential delivery route. It may be that by raising the personal budget to allow a direct payment from a particular provider, it is expected to deliver much better outcomes than local authority delivered care and support, or there may be other dynamics such as the preferred option reducing the need for travel costs, or out of hours care. In addition, efficiencies to the local authority (for example through an individual making their own arrangements) should also be considered. Decisions should therefore be based on outcomes and value for money, rather than purely financially motivated.
In cases where making a direct payment is a more expensive option to meet needs, the care and support plan should be reviewed to ensure that it is accurate and that the personal budget allocation is correct. The authority should work with the person, their carer and independent advocate (if there is one) to agree on how best to meet their care and support needs. It may be that the person can take a mixture of direct payment and local authority-arranged care and support, or the local authority can work with the person to discuss alternate uses for the personal budget. Essentially, these discussions will take place during the planning process and local authorities should ensure that their staff are appropriately trained to support personalised care and support, and to facilitate decision making.
11. Use of the Personal Budget
The person should have the maximum possible range of options for managing the personal budget, including how it is spent and how it is utilised. Directing spend is as important for those choosing the council managed option or individual service fund as for those choosing direct payments. Evidence suggests that people using council managed personal budgets are currently not achieving the same level of outcomes as those using direct payments, and in too many cases do not even know they have been allocated a personal budget. There are three main ways in which a personal budget can be deployed:
- a managed account held by the local authority with support provided in line with the person’s wishes;
- as a managed account held by a third party (often called an individual service fund or ISF), with support provided in line with the person’s wishes;
- a direct payment (see also Direct Payments chapter).
In addition, a person may choose a ‘mixed package’ that includes elements of some or all three of the approaches above. Local authorities must ensure that whatever way the personal budget is used, the decision is recorded in the plan and the person is given as much flexibility and choice as is reasonably practicable in how their needs are met. The mixed package approach can be a useful option for people who are moving to direct payments for the first time. This allows a phased introduction of the direct payment, giving the person time to adapt to the direct payment arrangements.
Where ISF approaches to personal budget management are available locally, the local authority should provide people with information and advice on how the ISF arrangement works and any contractual requirements, how the provider/s will manage the budget on behalf of the person, and advice on what to do if a dispute arises. Consideration should be given to using real local examples that illustrate how other people have benefitted from ISF arrangements.
Where there are no ISF arrangements available locally, the local authority should consider establishing them and should consider any request from an adult for an ISF arrangement with a specified provider.
12. Pooling Personal Budgets
Local authorities should also give consideration to how choice could be increased by people pooling their budgets together. For example, this may include pooling budgets of people living in the same household such as an adult and carer, or pooling budgets of people within a community with similar care and support needs, or aspirations. Pooling budgets in circumstances such as this may deliver increased choice, especially where managed budgets are concerned. Developing networks of ‘budget poolers’ could help create dynamic groups of people working together to meet needs.
Evidence suggests that in most cases people need to know the amount of their budget, be able to choose how it is managed, and have maximum flexibility in how it is used to achieve the best outcomes. Local authorities should aim to develop a range of means to enable anyone to make good use of direct payments and where people choose other options, should ensure local practice that maximises choice and control (for example use of ISFs). Local authorities should also take care not to inadvertently limit options and choices. For example ‘pre-paid cards’ can be a good option for some people using direct payments, but must not be used to constrain choice or be only available for use with a restricted list of providers.
13. Use of a Carer’s Personal Budget: Where the Person being Cared for has Eligible Needs
A carer’s need for support can be met by providing care to the adult they care for. However, decisions on whom a particular service is to be provided to affect whether the service is chargeable and who is liable to pay any charges. It is important that it is clear to all individuals involved:
- whose needs are intended to be met by a particular type of support;
- to whom the support will be provided directly and therefore who pays any charges due.
Where a service is provided directly to the adult needing care, even though it is to meet the carer’s needs, the adult is liable to pay any charge and has to agree to do so. Where the needs are met by providing care and support direct to the adult needing care, the charge cannot be imposed on the carer.
Decisions about which services are provided to meet carers’ needs, and which are provided to meet the needs of the adult for whom they care, will therefore impact on which individual’s personal budget includes the costs of meeting those needs. These decisions should be made as part of the care planning process (see Care and Support Planning chapter), in discussion with the individuals concerned, and this includes consideration of whether joint plans (and therefore joint personal budgets) for the two individuals may be of benefit.
Local authorities should consider how to align personal budgets where they are meeting the needs of both the carer and the adult needing care concurrently. Where a person has eligible needs for care and support and has a personal budget and a care and support plan in their own right, and the carer’s needs can be met, in part or in full, by the provision of care and support to the person needing care, then this kind of provision is incorporated into the plan and personal budget of the person with care needs, as well as being detailed in the support plan for the carer.
14. Replacement Care
Replacement care may be needed to enable a carer to look after their own health and wellbeing alongside caring responsibilities and to take a break from caring. For example this may enable them to attend their own health appointments, or go shopping or pursue other recreational activities. It might be that regular replacement care overnight is needed so that the carer can catch up on their own sleep. In other circumstances, longer periods of replacement care may be needed, for example, to enable carers to have a longer break from caring responsibilities or to balance caring with education or paid employment. In these circumstances, where the form of the replacement care is essentially a homecare service provided to the adult needing care that enables the carer to take a break, it should be considered a service provided to the cared-for person, and must be charged to them, not the carer.
The carer’s personal budget should be an amount that enables the carer to meet their needs to continue to fulfil their caring role, and takes into account the outcomes that the carer wishes to achieve in their day to day life. This includes their wishes and / or aspirations concerning paid employment, education, training or recreation if the provision of support can contribute to the achievement of those outcomes. The manner in which the personal budget is used to meet the carer’s needs should be agreed as part of the planning process.
Local authorities must have regard to the wellbeing principle, as it may be the case that the carer needs a break from caring responsibilities to look after their own physical / mental health and emotional wellbeing, social and economic wellbeing and to spend time with other members of the family and personal relationships (see the chapters on Promoting Wellbeing and Preventing, Reducing or Delaying Needs). Whether or not there is a need for replacement care, carers may need support to help them to look after their own wellbeing. This may be a course of relaxation classes, training on stress management, gym or leisure centre membership, adult learning, development of new work skills or refreshing existing skills (so that they might be able to stay in paid employment alongside caring or return to paid work) or pursuit of hobbies such as the purchase of a garden shed, or purchase of a laptop so they can stay in touch with family and friends.
15. Carers’ Personal Budgets: Where the Adult Being Cared For Does Not Have Eligible Needs
The local authority is able to meet the carer’s needs by providing a service directly to the adult needing care. However, there may be instances where the adult being cared for does not have eligible needs and so does not have their own personal budget or care plan. In these cases, the carer must still receive a support plan that covers their needs and how they will be met. This would specify how the carer’s needs are going to be met (for example, via replacement care to the adult needing care) and the personal budget should be for the cost of meeting the carer’s needs.
The adult needing care does not receive a personal budget or care plan because no matter what the service is in practice, it is designed to meet the carer’s needs. However, it is essential that the adult requiring care is involved in the decision making process and agrees with the intended course of action.
In situations such as these, the carer could request a direct payment and use that to purchase replacement care from an agency, rather than using an arranged service from the local authority or a third party. The local authority should take steps to ensure that the wishes of the adult requiring care are taken into account during these decisions. For example, the adult requiring care may not want to receive replacement care in this manner.
If this type of replacement care is charged for (and it may not be), then it would be the person needing care that would pay, not the carer, because they are the direct recipient of the service. This is, in part, why it is important the person needing care agrees to receiving that type of care.
The decisions taken by the carer and the adult requiring care and the charging implications should be agreed and recorded in the support plan.
If a dispute arises and the adult refuses to pay the charge, the local authority must, as far as it is feasible, identify some other way of supporting the carer.
For the purposes of charging, the personal budget that the carer receives specifies the costs to the local authority and the costs to the adult based on the charging guidance (see Charging and Financial Assessment chapter). In this case, ‘the adult’ refers to the carer, because they are the adult whose needs are being met. However, in instances where replacement care is being provided, the carer should not be charged; if charges are due to be paid then these have to be met by the adult needing care. Any such charges should not be recorded in their personal budget, but set out clearly and agreed by those concerned.
16. Appeals / Disputes
The local authority should take all reasonable steps to limit disputes regarding the personal budget allocation. This will include through effective care and support planning, and transparency in the personal budget allocation process. Additionally, many disputes may be avoided by informing people of the timescales that are likely to be involved in different stages of the process. Keeping people informed how their case is progressing may help limit the number of disputes.
Current complaints provision for care and support is set out in regulations. The provisions of the regulations mean that anyone who is dissatisfied with a decision made by the local authority can make a complaint about that decision and have that complaint handled by the local authority. The local authority must make its own arrangements for dealing with complaints in accordance with regulations (see Complaints chapter).