Social Care (Self-directed Support) (Scotland) Act 2013: statutory guidance

Section 5: The Supported Person's Pathway

This section describes the supported person's pathway through support. It applies to adults, children and carers of all ages.

Introduction

5.1 The following diagram indicates the key stages in the person's pathway. It covers each key step from initial contact through to the provision of support and review. It is the person's route through their support from initial information through to review. The authority should consider the concept of a pathway, journey or route through support in developing its strategy, guidance and general approach to social care provision. The authority should take steps to provide the relevant training, support and processes in order to support this pathway. There may be appropriate variations to the pathway depending on the specific circumstances of the person. However the authority should use this as a starting point for its approach to determining the appropriate services, providing choice to the supported person and monitoring and reviewing the person's support.

Diagram 1: Supported person's pathway

Table 3: Supported Person's Pathway: further descriptions

Step 1: Inform

The supported person decides that they need additional support. Alternatively, a relative, friend or professional recommends that the supported person contacts social services.

Step 1a: First Contact

The supported person makes contact with social care services or community health services. They can arrive at this point direct or referred on by school, housing association, family or friends, hospital, carers centre, local voluntary organisation, etc. There is an initial screening to determine if the person should progress to a formal decision on their eligibility for support. At this stage the supported person should be provided with the relevant information and advice in relation to eligibility, assessment and support options. See section 6 in this document for further guidance on information and additional support services.

Step 2: Assess

This is the point where the initial decisions are made about the person's eligibility for support under the various legal obligations:

* Section 12A of the 1968 Act (the assessment duty relating to adults);

* Section 22 of the 1995 Act (the duty relating to children in need);

* Section 12AA of the 1968 Act (the assessment duty relating to carer's of adults), and;

* Section 24 of the 1995 Act (the assessment duty relating to carers of children).

Step 2a- Eligibility

This is the point where the initial decisions are made about the person's eligibility for support under the various legal obligations:

Step 2b: Detailed assessment/further exploration of the person's needs

Following the initial determination of the person's eligibility the person's needs will be explored in much greater detail. As part of this detailed assessment the two parties (the professional and the supported person) will begin to translate the initial needs into a more detailed exploration of the individual's personal outcomes.

See section 7 (Part 1) of this document for further guidance on assessment and eligibility.

Step 3: Plan

Support planning covers a wide range of issues but will tend to include a discussion of:

• the choices available to the supported person;
• the main risks and how the supported person and others can manage those risks; and
• the resources that will help to deliver the person's support plan.

If the supported person is a child then the process should be part of a single plan for the child. It should capture the contribution that any support assessed or provided under Section 22 of the 1995 Act will make as part of the overall plan for the child.

See section 9 in this document for further guidance on support planning.

Step 4: Choose

This describes the stage where the supported person and the professional agree the support plan.

Step 5: Support/Speak Out

This describes the provision of support to the person and the day-to-day decisions that will be made. See section 11 in this document for further guidance on the provision of support under the general principles of the 2013 Act.

Step 6: Review

The update of the original assessment, review of the person's needs and consideration of any adjustments to reflect the changing needs or any changes in circumstances etc…

See section 12 in this document for further guidance on monitoring and review.

The Supported Person's Pathway: Roles and responsibilities

5.2 A wide number of people and organisations may be involved in the assessment of needs or the provision of support for a person, family or carers. Table 4 provides a summary of the main roles and responsibilities for those who will be involved in the person's pathway.

Table 4: The Supported Person's Pathway: Roles and Responsibilities

Role	Responsibilities
The professional	The social work or health professional should take steps to ensure that the assessment is conducted in line with social care law. They should consider any wider legal duties beyond the duties provided in social care legislation for instance, in a crisis situation or where the adult's safety is at risk. They should ensure that the person's support plan is comprehensive. They should ensure that the support plan meets the assessed needs of the supported person. They may arrange for some additional assistance so that the supported person can play a full part in the assessment or support planning process. They may give voice to the person's wishes. The professional or local area team should be provided with the appropriate support and guidance from their organisation to ensure that they can apply appropriate discretion.
The supported person	The supported person, as the person in receipt of support, should be assisted to play an active part at the centre of the assessment and support planning process. They should be supported to take as active a role as they wish to take in all of the key decisions relevant to their support. This will include any decisions about initial eligibility or access to support, together with the planning and provision of that support. The local authority and/or Health Board should ensure that their staff are made aware of their duties and powers in relation to assessment functions. The authority should take steps to commission a good range of support, information and advocacy services to ensure that people receive the right information at the right time.
The unpaid carer	The primary role of the unpaid carer is to provide care and support to a family member or friend. However, in addition to this they may provide a wealth of information, expertise and guidance. Carers may be guardians or attorneys for the individuals they support. Carers are also entitled to request an assessment of their own needs. The local authority should ensure that carers are aware of their right to request a carer's assessment.
The provider	The provider may be the local authority, the NHS, an organisation from the third or independent sector or a personal assistant employed by the supported person or the unpaid carer. The provider can play an important role in the assessment and support planning process however the legal duty to meet assessed needs remains with the local authority or Health Board (if duties are delegated to the Health Board).
Senior managers within the relevant organisations	Senior managers help to shape the culture and approach right across their organisations. They can take important decisions about a supported person's care and support. In light of this, they should take steps to ensure that guidance, training and general culture of the organisation is predicated on the values and principles within this guidance. They should support front line professionals/providers to work with individuals in a flexible and innovative way. Local authority Chief Social Work Officers (CSWOs) have a key role in delivering high quality social work services. CSWOs should ensure implementation of this guidance within their local authority, in line with the specific functions of the CSWO role, as set out in The Scottish Government's Guidance on The Role of the Chief Social Work Officer (February 2009). CSWOs should also promote this guidance with relevant partner services and agencies.
The finance function within authorities/Health Boards	Finance managers/officials play an important role in determining and administering the level of spend assigned to services. They should ensure that the right processes and systems are in place, and they should support the collective objectives for care and support in their local area. Finance functions should provide the necessary support to the social work function, ensuring effective systems to support social care provision and encouraging choice, control and flexibility for social care users.
The legal function within authorities/Health Boards	Legal advisers will provide support to social services, advising on their legal responsibilities and powers. The legal function within the authority should be familiar with the relevant duties on assessment and support and how these relate to wider legal duties for instance in relation to equalities, human rights, safeguarding and adult support and protection. The legal function should support the social work function, working together to deliver an innovative approach to the provision of care and support.
The commissioning function within authorities/Health Boards and wider Health and Social Care partnership	Strategic commissioning describes the activities involved in assessing and forecasting needs, the linking of investment to agreed outcomes and consideration of the options available. It also describes the activities to plan the nature, range and quality of future services and the steps that are taken by the local authority and health board to work in partnership to put their plans in place. Joint commissioning is where these actions are undertaken by two or more agencies working together, typically health and local government and often from a pooled or aligned budget. The organisations and individuals who commission services play a key role in ensuring that a good range of support is made available in order to meet the needs and desires of a diverse population. As part of its approach to the development of effective commissioning strategies the authority should consider the implications of self-directed support, the role of personal outcomes and the importance of encouraging and supporting a suitable variety of supports for adults, children/families and carers.

Further guidance and hyperlinks:

See section 8 of this document for further guidance on facilitating a good range of choices.

Further guidance on joint commissioning is available at: http://www.jitscotland.org.uk/action-areas/commissioning/