The great care plan conundrum

Most people in this field will have heard of a care plan, support plan or care and support plan. They are a key document in the whole system that serve a number of different purposes. Yet there is one big problem, the elephant in the room that not many people outwardly acknowledge: most care plans are rubbish.

A big part of the problem is that it is almost impossible for one document to serve all of the purposes for which a care plan (or whatever terminology is used in each area) is relied upon. The second issue is that a care plan as envisaged by the textbooks is, in practice, made up of at least 2 documents.

Let me explain

From a practical standpoint, a care plan is an important document that care providers use to ensure that all of the staff are delivering care in an appropriate way. So it will set out what the individual’s day is like, what they do and don’t need support with, important information about administration of medication and other key information that the carers need to know. So it really ought to be a simple, straightforward document that all carers assisting a person can read and have access to.

Yet care plans are very important to the person being supported as well: they should capture important information about what the individual likes and doesn’t like, the activities they enjoy, particular approaches carers should use and the like. Ideally, it should be something that the individual can access and understand as well, at least in part.

So this form of care plan is generally prepared by the provider and includes pictures of the person and things that are important to them. Many are written in the first person, which is often an attempt at making the document look like it is very person-centred without the content necessarily being very person-centred. But I know this doesn’t annoy everybody the way it does me!

That’s the document that is usually the most helpful and is generally what people think of when they think of a care plan.

But a care and support plan is actually a statutory document. It is a requirement under the Care Act 2014 that each individual receive a support plan as per s25. There are even requirements for what must be included in that support plan which are set out in section 25(1). This document is prepared by the social worker or, more commonly, but it has to be prepared with input from the person that it benefits, along with their carers and others they ask to be involved, or who are interested in their welfare.

More commonly, the local authority’s computer system creates this document with specific input from the social worker. As a result, these documents tend to be very broad brush and it is not uncommon for this support plan to just say ‘the person needs 24 hour care and this is delivered in X care home for Y amount a month. The detail of how needs are actually met is generally left for the provider to do in their support plan.

There are a number of issues with this, not least the contractual nightmare that ensues when a care provider and local authority disagrees as to what care is being paid for. Seriously, I spent days on it. And yes, somehow civil litigation and contractual disputes also became my job for a while.

I digress, but anyway, most people receiving support from the local authority will have both of these support plans somewhere on their file of papers. But there is no uniformity, really, and I once had a care provider land me with a support plan that was 200 pages long. But we’ll get to that.

It gets even more complicated if the local authority is seeking authority for a placement the person isn’t in yet. Because this generally means the provider won’t have even started their care plan. The social worker has probably done theirs, because this is usually needed to secure funding for a placement. But it doesn’t usually give much detail about what the package of care will be on the ground for P. This is often a big issue because the court tends to be pretty reluctant to approve a placement on vague assurances that needs will be met. And those representing P, whether through the Official Solicitor or otherwise, will need to have sufficient evidence to satisfy themselves the placement is appropriate. It is very rare that it can be agreed a placement is in best interests without clear evidence that needs will be met. But I’ve written about all of that before.

Where I am most commonly involved with discussions about a care plan, it is because it is needed for Mental Capacity Act purposes. Whenever the Court of Protection is being asked to make a decision about someone’s care, the first thing it expects to see is a care plan. It envisages that care plan to be a document that is freely available to the local authority, but also to be a document that clearly sets out what care the person receives on a day to day basis and how that is meeting their needs. Which, of course, means that the document that they actually want is the provider’s support plan, not the one prepared by the social worker. And the provider may or may not be particularly swift in preparing that plan, updating it, and sharing it with the local authority.

Where it gets even more complicated, as if this wasn’t messy enough, is cases where the care amounts to a deprivation of liberty. You see, whether authorised through the court or through a standard authorisation under the Deprivation of Liberty Safeguards, authority is not given for a ‘blank cheque’ deprivation of liberty. It is authorised only so far as is necessary and proportionate to mitigate identified risks. Indeed, the standard order that is made under the streamlined procedure for deprivation of liberty cases is clear that the measures in the care and support plan are authorised.

So which document is the court expecting to see?

The answer is both, and neither. The whole process is set up on the assumption that the social worker has access to the support plan and a working knowledge of what P’s day to day care entails. But in practice that is pretty rarely the case. They have ready access to the local authority’s support plan, but this won’t help them identify what restrictions are in place ‘on the ground’. As anyone who has ever filled in a COPDOL11 form will know, the court is expecting quite a lot of detail about what restrictions are in place and why these are considered to be appropriate and proportionate. So for that, the provider’s care plan is needed, as that should include information as to the restrictions that are in place.

But that assumes the provider’s staff has accurately identified what the restrictions are in order to capture them in the care plan. A lot of the time, that is wishful thinking.

And even if they have, there’s unlikely to be any detail about why this is proportionate or what options have been tried before settling on this restriction because that would make the document too complicated to be any use for the provider’s practical purposes. Carers rarely have time to go through hand over notes, so they are not going to read a lengthy care plan, which would then completely undermine the usefulness of the documents because what is the point of having a plan if no one has actually read it to then be able to follow it?

So do we need a third document setting out restrictions?

In an ideal world, no. Because there ought to be a way of preparing one document with all of the information that the provider needs, the local authority needs and the court needs in a concise wat. And I am sure there is. But no one has time to design such a magical document, and even if they did, it would be contrary to someone’s policy to adopt it and multiple documents would still come into existence.

So, instead, the court generally settles for the provider’s care plan, with an accompanying statement setting out the rationale and proportionality explanation. Because pragmatism often wins out.

But what if the provider’s care plan doesn’t set out what the restrictions in place are? Or what if it is a 200 page handwritten nightmare?

Quite simply, it’s not fit for purpose. When in-house, I would take a two-pronged approach in such cases. Firstly, I’d raise the issue with the internal quality and compliance team. Because if a care plan isn’t fit for purpose and isn’t setting out what care the person gets in an accessible way, then how can the provider possibly give any assurance that appropriate, personalised care is being delivered? They might be delivering the best care in the world, but they won’t be able to evidence that they are doing so, so that excellence will stand for nothing.

Secondly, I’d work with the social worker to prepare a document I generally called the ‘outline care plan’ which contained more detail than the local authority’s main document, but not the level of detail that the provider’s care plan should contain. After all, neither the court nor the Official Solicitor is actually particularly interested in P’s favourite colour, or how they like their tea. Instead, it would contain the information the court needed to grant the authorisation to get things moving and generally prevent too much criticism coming the local authority’s way.

Now, I simply ask lots of annoying questions until someone finally tells me what I need to do know. Local authorities generally find me very annoying. But it matters.

It matters to P, because if no one knows what care they are actually getting on a day to day basis, then how can anyone properly scrutinise whether the arrangements are the least restrictive option? And it matters to the court, because if it isn’t giving this level of scrutiny, then the protection afforded by article 5(4) is rendered ineffective and of little real value. It also matters to the local authority and care provider because only the restrictions identified are authorised. Indeed, the standard order makes it very clear that any increase in restrictions need to be reviewed by the court, so if the professionals can’t identify what is authorised, then how do they know when they need to go back to court? And if they don’t know when they need to go back to court, then they remain at risk of an unlawful deprivation of liberty claim, drawing in to question the point of the whole exercise.

It’s a muddle that few people set their minds to. Except pedants like me….

NB I am aware that under the Care Act there is a distinction between a care plan and a care and support plan, but it’s a distinction that doesn’t mean much in practice. I am also aware that it gets even more complex when there is a s117 aftercare plan in place as well.

In case it isn’t obvious from the fact I still haven’t identified the authority I used to work for, or the organisation I now work for, the views expressed on this blog are my own opinion and not the opinion of that local authority or organisation