Social care - self-directed support: framework of standards

Self-directed Support Framework of Standards, including practice statements and core components

Self-directed Support Standard^[1]

1. Independent Support & Advocacy

People are offered independent advice, support and advocacy to have choice and control over their social care and support and to exercise their human rights.

Practice Statements: Within every Local Authority/ Health and Social Care Partnership area there are independently funded organisations able to provide independent advice, support, information and advocacy for anyone who needs it and in ways which are accessible to everyone.

Core Components:

1.1 The right to independent advice, support and advocacy for people and carers who need it is upheld under Self-directed Support legislation.

1.2 Independent advice, support and advocacy is sufficiently funded to ensure people feel confident that the support they receive is right for them.

1.3 Independent advice, support and advocacy is tailored to the people's needs, and specialist provision is made for specific vulnerable groups.

1.4 Independent advice, support and advocacy is provided as early as possible to support the processes of good conversation, assessment, support planning and review, and to support personal assistant employers.

1.5 Independent advice, support and advocacy is inclusive, accessible and addresses communication barriers faced by particular people.

1.6 Opportunities are provided for local authorities and independent support organisations to work collaboratively and to develop trusting relationships and a shared understanding of roles and responsibilities, to share learning and to work together in the best interests of people.

1.7 Independent advice, support and advocacy organisations have access to local authority training on procedures for managing risk, child and adult protection, adults with incapacity and mental health.

1.8 Independent advice, support and advocacy providers are included in strategic planning, including community action planning, review and commissioning processes, and work closely with locality teams to improve implementation of Self-directed Support in communities.

1.9 Challenges made by independent advocacy are viewed by the authority as opportunities to learn from people's accounts of their own needs, not as a threat to systems and processes.

1.10 Independent advice, support and advocacy providers operate to clear national principles and guidelines, to ensure consistency of practice throughout Scotland.

1.11 Providers provide evidence of the quality of independent support and advocacy. In addition, local authorities provide evidence that all those identified as needing independent support and advocacy are referred to relevant providers, and subsequently receive the support they need.

1.12 Independent support and advocacy play a critical role in working with people, their carers and workers to negotiate and mediate, where it is necessary, to agree the personal outcomes of the cared for person.

2. Early help & support

Early help and community support is available to all people who need it.

Practice Statements: Early help and community support offers a universal approach where everyone is welcome to have a good conversation about what matters to them, and to identify solutions to improve their quality of life. This approach can serve as a gateway into more formal assessment and access to services. However, this approach should not be regarded as a replacement for registered statutory services when these are needed. Community solutions do require investment and ongoing commitment and support from national and local government.

Core Components:

2.1 Everyone in a community has access to relevant information, early help and community support. There are no eligibility criteria for this.

2.2 Solutions identified build on a person's own strengths, assets, natural networks, technological supports and community resources. The person and their carers are listened to and treated as an experts in identifying their own needs.

2.3 The administration involved in accessing early help and community support is minimised.

2.4 Early help and community support is part of holistic provision to reduce crisis demand, as people are supported to find help before their needs become critical.

2.5 Early help and community support models work for people, unpaid carers and communities by supporting the trusting relationships that are needed to coproduce the kind of care and support that local people want.

2.6 Early help and community support is creative, and responsive and adaptive to changing circumstances.

2.7 Early help and community support increases workforce satisfaction through greater worker autonomy, cross sector working and collaborative decision-making in community settings.

2.8 Ongoing engagement about the benefits of and investment in early help, prevention and community support models is required.

2.9 Early help and community support helps to maintain people's independence and wellbeing addressing loneliness and social isolation and helping people to feel connected.

2.10 Strategic commissioning incorporates early help and community support models.

2.11 National support is provided to develop early help and community support models throughout Scotland and to reinforce the benefits of community-led support.

3. Strength and asset-based approach

Assessment, support planning and review systems and processes are personalised, recognising people's strengths, assets and existing community supports, and result in agreed personal outcomes.

Practice Statements: Trust-based relationships and good conversations between workers and people are at the heart of assessment, support planning and review practice and processes, recognising people's strengths, assets, human rights, community and funded supports. Personal outcomes are agreed on the basis of what matters to the person.

Core Components:

3.1 Trust-based relationships and good conversations between workers and people and unpaid carers are at the heart of assessment, support planning and review practice and processes.

3.2 People's strengths, assets, human rights, existing community supports and funded social care supports are recognised and included in their support plan.

3.3 What matters to the person is central to agreeing personal outcomes which are then recorded in their support plan.

3.4 The assessment and the identification of resources are all part of the same process, which starts with the good conversation and ends in a budgeted support plan and the offer of the four Self-directed Support options.

3.5 The administration involved in accessing Self-directed Support is minimised and there is a greater focus on relationship based, personal outcome-focused practice.

3.6 All staff, including workers, managers, finance and commissioning staff, receive high quality training in Self-directed Support. Workers are continuously supported through coaching supervision to practice a strengths-, assets-, and outcome-focussed approach grounded in human rights.

4. Meaningful and measurable recording practices

Good recording practices clearly capture conversations between people and workers identifying what matters to the person, resulting in agreed personal outcomes that are clear and comprehensive. This information is used for ongoing review as well as for continuous improvement and planning of future supports.

Practice Statements: Recording practice and information systems demonstrate the extent to which practice is carried out in line with the values and principles of Self-directed Support. Records show how the person's lived experience and preferences have been acknowledged and expressed in their support plan, and connect personal outcomes to the subsequent review process. Recording systems are designed such that data can be aggregated and used for continuous improvement, resource planning and commissioning purposes.

Core Components:

4.1 Recording practices capture the detail of conversations between workers and people.

4.2 A national approach to recording practice is developed and in place across Scotland.

4.3 National key indicators for choice and control are developed and in place across Scotland.

4.4 Recording practices demonstrate the extent to which practice is carried out as intended including the difference Self-directed Support makes to people's lives.

4.5 Recording practice and information systems demonstrate how the person's lived experience and preferences have been acknowledged and expressed in their support plan, and connect personal outcomes to the subsequent review process.

4.6 Recording practices ensure that aggregate data is meaningful and measurable, and can be used for continuous improvement. Unmet need should be routinely recorded for purposes of resource planning and commissioning.

4.7 Recording practice captures where conversations are undertaken with people to ensure that processes of assessment, support planning and decisions about Self-directed Support options and budgets are clearly explained and understood.

4.8 Recording practice evidences that a range of choices has been put to the person, and details what choices and options the person has opted for, and why.

5. Accountability

Clear and supportive processes are in place for people to challenge and appeal all decisions affecting their experience of social care support.

Practice Statements: Processes ensure that people's legal rights are upheld. Human rights underpin practice, policy and processes, and actively provide opportunities for constructive feedback, learning and improvement.

Core Components:

5.1 Systems of accountability are designed to promote responsibility in the social work role, to protect people using services and to form a basis for public trust.

5.2 Processes ensure that people's legal rights are upheld. These include provision of accessible information, advocacy and mediation, the right to challenge a decision and to make a complaint.

5.3 People get accessible information about what they can expect and the level of choice that can be offered, including an honest description of any local limitations existing for each option.

5.4 People are supported to query and challenge decisions throughout their assessment, support planning and review processes, including their agreed personal outcomes.

5.5 There is a greater focus on kindness and trust built into the system where people can meaningfully engage with workers

5.6 The local authority actively seeks constructive feedback from people as opportunities for learning and ongoing improvement.

5.7 Local authority complaints processes are compliant with Self-directed Support legislation

5.8 There is an easy and transparent process in place for making a complaint.

5.9 Mediation is supported, facilitated and welcomed at all parts of the process.

5.10 People are supported to challenge decisions which do not uphold their human rights, including escalating complaints to the Scottish Social Services Council (SSSC), the Care Inspectorate and the Scottish Public Services Ombudsman (SPSO).

5.11 National information is aggregated and reported on complaints in relation to Self-directed Support.

6. Risk enablement

Workers and supported people work together to plan for positive risk enablement whilst balancing the responsibility of statutory protection of children, young people, adults and carers. Supported decision-making should be used where there are issues of capacity.

Practice Statements: People will be regarded as experts in their own lives and how they wish to meet their own personal outcomes. This needs to be taken into account and a shared responsibility to risk agreed.

Self-directed Support is not separate from safeguarding. Self-directed Support is used creatively to enhance people's and families' resilience towards preventative, protective and positive outcomes.

Core Components:

6.1 Workers have clear practice guidance to address the balance between innovation, choice and risks.

6.2 Practice culture is based on positive risk taking to support workers to work in a risk-enabling way. Workers follow evidence-based best practice and receive regular and effective reflective supervision.

6.3 Risk assessment considers both the negative consequences associated with certain actions and activities, and positive risks where there is beneficial impact on mental and physical wellbeing.

6.4 Risk assessment follows the principle of least restrictive practice.

6.5 All decisions and actions to support risk are proportionate. Workers ensure their decisions are defensible, and the reasons for decisions are evidenced and recorded appropriately.

6.6 Effective, consistent, trusted relationships and good communication underpin effective risk assessment.

6.7 To reduce the incidence of substitute decision-making, workers are trained in supported decision-making.

6.8 Workers need to be able to identify and deal with issues where there are conflicts in interest between Power of Attorney or Guardians' views and what the person wants.

7. Flexible and outcome-focused commissioning

People and commissioners work together to plan, design, and quality-assure flexible local supports, to ensure that people have choice and control over what matters to them.

Practice Statements: Social care services and supports are planned, commissioned and procured in a way that involves people and offers them real choice and flexibility in how they meet their personal outcomes.

Provision of services and supports start with the good conversation that has been had with the person, what matters to them and what they need to help them live their best life.

Core Components:

7.1 Local approaches to commissioning will take into account strategic commissioning of local needs, including the requirement for specialist supports, and will enable individual commissioning where people opt to manage a personal budget to commission their own supports under Options 1 and 2.

7.2 The third and independent sectors and communities are meaningfully involved in developing personalised social care support services which are effective in meeting personal outcomes.

7.3 Trusting relationships that go beyond the merely transactional are built between authorities and partnerships, people, carers, providers and communities.

7.4 Funding, support and time is allowed for a process of disinvestment in order to reinvest in more personalised supports. Investment is based on a thorough understanding of the social care market, local geographical factors and unmet need.

7.5 There is understanding of, and commitment to outcome-focused, collaborative, community and trust-based commissioning.

7.6 Fair work remuneration is in place across the social care sector.

7.7 Ensuring the lived experience of people who use services is central to the design and quality assurance of services.

7.8 Community Planning partnerships, in conjunction with Health and Social Care Partnerships and Children and Young People's Services, actively engage with communities to support the identification and development of local community supports.

7.9 The potential for sectors (including housing, culture and community planning) to collaborate and practice community-based commissioning is taken forward with an understanding of local community need.

7.10 Workers are supported to engage with communities, to build relationships and gain understanding of community assets and networks. This could be through the adoption of a Community Social Work approach.

7.11 Training is developed to support the outcome of getting it right for communities, and is offered to workers from across finance, legal, contracts, and procurement teams.

7.12 Commissioning approaches are further developed for Option 2.

7.13 Accurate local intelligence including unmet need is gathered through regular engagement, as well as assessment and review processes.

7.14 There is further national development of collaborative commissioning for very specialist supports.

8. Worker Autonomy

Workers are enabled to exercise professional autonomy in support planning and set personal budgets within agreed delegated parameters.

Practice Statements: Workers feel trusted, confident and resilient, and are enabled to be autonomous in exercising their professional judgement, and using their own knowledge, skills and abilities, in partnership with supported people. Workers have the authority to plan support and set personal budgets within agreed delegated parameters

Core Components:

8.1 Local policy and procedures should be flexible enough to allow workers to be autonomous in exercising their professional judgement.

8.2 Workers and their managers have delegated authority to access budget up to nationally agreed amounts.

8.3 Workers feel trusted, confident and resilient, and know how and where to access support if required.

8.4 Workers feel safe and confident when they take managed risks.

8.5 Workers use their knowledge, skills and abilities in order to empower people to exercise maximum choice, creativity and flexibility in achieving their personal outcomes.

8.6 Workers are creative in their use of the full range of flexible commissioning approaches, and are not limited to matching people with existing commissioned services on framework.

8.7 Team leaders must provide workers with regular and high-quality reflective supervision which encourages relationship-based practice, focused on people's rights and personal outcomes, which goes beyond caseload management. This will offer a safe and supportive opportunity to discuss managed risks.

8.8 Leaders should ensure that caseloads are manageable and allow for the development of relationships between workers and people.

8.9 Decision-making panels should only be consulted where the total cost of care, after all strengths and assets have been considered exceeds a national agreed amount. This might be comparable to the national care home rate.

8.10 People should not have to wait longer than a set period of time, agreed nationally, for approval from panel to authorise supports which meet agreed personal outcomes.

8.11 Decision-making panels have a responsibility to communicate with the person about the reasons behind all decisions made regarding funding.

9. Transparency

Practice, systems and processes are clearly understood and are explained in ways that make sense to the person. All decisions that affect a person's choices, support, and personal budget are recorded and shared with them.

Practice Statements: People are helped to understand that Self-directed Support allows for maximal choice and flexibility in using a budget to achieve what matters to the person in the form of agreed personal outcomes. The process leading to decisions about a person's social care budget and support, and their level of financial contribution, is recorded, shared and explained in ways that make sense to the person.

Core Components:

9.1 All people are entitled to have a good conversation and to access community-led supports.

9.2 Local authorities develop transparent systems whereby community supports, technology, aids and adaptations are considered and provided seamlessly to support people before considering the provision of a budget to pay for direct supports.

9.3 All frontline workers, including social workers, community care workers, occupational therapists and community link workers, will have knowledge and awareness of technology, aids and adaptations and what is available in the community in order to help people direct their support.

9.4 The offer of a range of options and the choices made by the person will always be clearly recorded, to provide evidence that the person has been listened to and their preferences supported.

9.5 It is recognised that different people with similar circumstances may require different budgets depending on their own strengths, assets, and family and community supports.

9.6 Having a good conversation is recognised as an intervention in its own right, and should not be mechanistic or transactional.

9.7 People are told the likely level of the budget available irrespective of the option they choose.

9.8 Systems are designed in such a way as to encourage trust and support timely responses.

9.9 There is regular engagement with supported people to ensure that the voice of lived experience helps to shape policy.

9.10 People are able to see what is written about them without having to resort to Freedom of Information (FOI) requests or court action to access their records.

10. Early planning for transitions

People are given the help and support they need to plan for, and adjust to, new phases of their lives.

Practice Statements: Transition planning processes have the person's wellbeing, aspirations and personal outcomes at the centre. People are given the time, information and help they need to make choices and have control of their care and support as they move into new phases of their lives.

Core Components:

10.1 The Principles of Good Transitions are embedded within social work and social care policy, strategic planning and practice across all sectors as a framework for all people as they move into new phases of their lives.

10.2 People are given the time, information and help they need to make choices and have control of their care and support during periods of transition.

10.3 Transition planning and support is proportionate to need. Some transitions such as moving into young adult life, or moving into residential care, will require a coordinated, multiagency approach, whilst others will be managed sufficiently between the person and their support staff.

11. Consistency of Practice

People can expect a consistently high-quality experience of practice, as articulated in these standards, regardless of their local authority area.

Practice Statements: To reduce inconsistency of experience across the country, a consistently high-quality approach to practice is required, including assessment, support planning and review; eligibility; charging and contributions; commissioning and procurement, and the process by which budgets are calculated.

Core Components:

11.1 Practice must focus on exploring what matters to the person. There is a recognition that services and supports may be different in different local authorities, depending on availability and geographical constraints.

11.2 There is a nationally consistent approach to prevention, early help and anticipatory forms of support that shift focus from crisis intervention towards what matters to the person and their quality of life.

11.3 There is a nationally consistent approach to assessment that is asset- and strength-based, takes account of natural supports and technological supports, and includes income maximisation.

11.4 There are nationally consistent approaches to eligibility criteria; charging and contributions criteria; commissioning; procurement and budget allocation and calculation, including levels of delegated authority for workers and managers.

11.5 There are nationally consistent guidelines on what budgets can or cannot be spent on.

11.6 Supported people can have confidence that their agreed personal outcomes will be met in a comparable way to others in similar circumstances across Scotland.

11.7 Local authorities work collaboratively to ensure that people can move from one local authority area to another while retaining a level of provision sufficient to meet their agreed outcomes.

11.8 Local authorities work collaboratively to ensure that there is minimum bureaucracy when people move from one local authority area to another.

12. Access to Budgets and Flexibility of Spend

People are involved in the development of their budget and have maximum flexibility to use this in the way that they choose to achieve agreed outcomes. The available funding is allocated in a way that is transparent, fair, equitable and sufficient, across all communities and for all individuals.

Practice Statements: Local authorities and partnerships have clear and equitable systems and processes in place to involve people in the development of their budget; and to calculate and provide people with sufficient levels of budget to enable them to meet agreed personal outcomes and lead full and meaningful lives. Social workers have the authority and are enabled to exercise professional autonomy to plan support and set personal budgets within agreed delegated parameters.

Core Components:

12.1 Supported people and carers have as much involvement as they wish with as much help as needed in the processes through which their budgets are agreed, allocated and reviewed. Supported people and carers have the right to choose not to be involved in discussions around their budgets.

12.2 Each person, unless they choose to opt out, is told the relevant amount they have available for each option to achieve their personal outcomes, underpinned by a fair and equitable assessment process, a shared understanding of the resources available, and the means by which the budget is held by or on behalf of the person.

12.3 The relevant amount is the amount that the local authority considers to be a fair and sufficient estimate of the cost of securing provision of support for the person to enable them to meet their outcomes.

12.4 Workers have delegated authority to access an agreed level of budget for individuals. Systems and processes align with workers statutory duties and bureaucracy is minimised.

12.5 Financial assessments consider the person’s circumstances and the impact of charging and contributions policies where these apply.

12.6 The methods by which a budget is calculated is transparent and understood by people and workers. A clear distinction is made between chargeable and non-chargeable supports.

12.7 Local partnerships work collaboratively to ensure there is minimal disruption and bureaucracy when people move from one local authority area to another.

12.8 People are informed and involved in making decisions about what they can and cannot spend a budget on. Budgets spends should be fair, proportionate, legal, equitable, auditable and necessary to meeting personal outcomes. Flexibility and creativity in how a budget can be spent is encouraged.

12.9 Personal budgets can be spent in any way that is legal and that is related to meeting agreed personal outcomes. The personal budgets of more than one supported person may be pooled in order to meet their personal outcomes. Allowable spend is not limited to purchasing traditional ‘on framework’ commissioned and contracted services. Personal budgets cannot be invested to generate income. 

12.10 All budget administration processes are transparent, efficient and minimise bureaucracy while meeting statutory requirements for monitoring and best value. Where any administrative problems arise, these must be resolved in a timely and compassionate manner in order to avoid stress and breakdown of trust.

12.11 The person’s worker is involved in all financial decisions that are made about the person’s budget allocation, including having delegated authority to access budgets up to agreed levels, budget allocation and any changes to budget amount/spend.  

12.12 Budgets are calculated and expressed in a way which demonstrates that personal outcomes will be met for all individuals in a fair and equitable way, taking into account strengths, assets and community resources available.

12.13 The option to employ Personal Assistants and fund other personalised supports in conjunction with commissioned services can be explored with the supported person in an inclusive way, to maximise the person’s choice and control. 

12.14 People can be flexible about spending different amounts on their support from one week to the next, and at different times of the year, within limits which are agreed between the worker and the supported person. People also have flexibility to move between options on request.

12.15 Regular reviews ensure that people continue to be able to achieve their personal outcomes. This process involves reviewing their budget to ensure the amount, and the way it is being used, is adequate to meet agreed outcomes.

12.16 The need for partnerships to manage organisations’ budgets and ensure money is spent appropriately should be balanced with their duty to give flexibility of spend to supported people and carers. Any change to a person’s budget should have a sound rationale which is clearly communicated to them according to their preferences; which could be via their worker. Any recoupment from a person’s budget should not be undertaken without consultation with the person, and potentially a review or reassessment.

12.17 Local authorities can administer budgets with respect to Health-related outcomes, if the cost is transferred from the NHS to the local authority. This can then be incorporated into a person’s Direct Payment or Option 2.  All systems and processes across organisations must be streamlined to reduce bureaucracy and minimise delays.  

12.18 There is a collaborative working relationship between social workers and professionals in Finance, Audit, Legal, Contracts, Commissioning and Procurement. This includes a mutual understanding of the role and responsibility each professional has to ensure that supported people have maximum flexibility to use their budget in the way that they choose to achieve their agreed personal outcomes.

12.19 Finance, Commissioning, and Audit processes are regularly reviewed to ensure they align with SDS values and practice, support worker autonomy and allow for fairness and parity across all SDS options. Feedback from supported people is included in the review of finance and audit processes.