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A council successfully defends a cut to a Care Act care plan by phasing in a big cut, slowly


CASCAIDr’s CEO has long suggested during training sessions that mincing towards meanness is much harder to challenge, even with use of public law principles, in the context of adults’ social care or CHC services, than making a giant cut overnight.

If commissioners aren’t care aware, and care managers and reviewers are risk averse or incentivised to make immediate savings, of course too MUCH risk or too LITTLE risk will be factored into any programme of cuts.

Such is the impact of no longer training social work students in how LAW actually WORKS, or front line public sector staff and senior managers in “difficult conversations”, it is suggested.

However, in a recent case, Lewisham Council has shown that massive cuts can be justified, as long as they are implemented slowly and the impact is genuinely monitored.

That, we have to say, is defensible social work, rationing public money properly, but it is not the modern way.

Making a judgment as to a Court’s reaction, in cases like this, is one of the reasons why CASCAIDr exists. This would not have been a case that we would have been likely to lend our support, all the way to court, although just as in the pre-Act Cambridgeshire, and post-Act Oxfordshire cases it seems that it was the proceedings that succeeded in MAKING the council do the job properly in the end. What a waste of resource, is all we can say.

In the 2018 ‘VI’ case, R (VI) v Lewisham LBCthe claimant was a long-term recipient of social care services – firstly, commissioned services and then through direct payments.

She was a 55-year-old woman with muscular dystrophy, who was bed- and wheelchair-bound and who required carer support for all personal care. She had reduced dexterity in her hands. She was continent, and used to wearing pads during the day and night if no carers were expected, although she did not like having to do so and the pads sometimes overflowed.

She’d been used to having 104 hours a week for a number of years including a specification for double handed care 3 times a day and night time care through a sitting service. Then a hoist was fitted, but no change was made; the council very fairly openly admitted to its failure to review being the reason the planned cut was not made when first assessed for.

En route to the final plan for the cut, the council had said this in writing, rather unfortunately:

“Lewisham is unable to provide an overnight service to enable you to continue to be supported to the toilet during the night. Lewisham has limited resources and that requires that we ensure we make the best use of the resources for all clients. Lewisham social services believe that pads are the solution to managing incontinence over the night time period and that is an approach used for all clients with similar needs. It has therefore been recommended that your night time need should be managed through the use of incontinence pads. The use of pads is considered a practical and appropriate solution to your night-time toileting needs.”

The judge agreed that a decision in the terms of that sort of communication could not amount to an assessment complying with the Act, because it was a generic decision relating to the management of incontinence rather than one reflecting a consideration of the Claimant’s individual needs and well-being.

[We agree and often use this argument: that’s a policy change about what is appropriate or not in relation to the duty to meet needs and we don’t see why it should not have been consulted over. But in light of the McDonald case, if it HAD BEEN CONSULTED OVER PROPERLY, it cannot be said that the policy was automatically unlawful, however – it all depends. What is clear is that it would not be lawful if it had been automatically appliedthat would have been a fetter of discretion.]

By 2016, Lewisham had completed a care and support plan that reduced the Claimant’s hours to 52 hours a week.

In practice, though, even now, no reduction was implemented, apparently due to administrative oversight and the Claimant continued to receive direct payments at the rate of 104 care hours a week.

[It is perhaps no wonder that people despair of social care ever running efficiently with cases such as these!]

What happened eventually?

By 2018, the proposed cut was going to take the care down to 40 hours a week, mostly by removing the night time hours allocated within the 104 hours.

The claimant alleged that Lewisham’s latest review conclusion that her needs for care and support could be met through a reduction of over 50% in her carer hours from what it had once been set at, was irrational.

It was said that since her condition was degenerative, cogent reasons were therefore required for concluding that her care needs had reduced from the previously assessed level.

The basis on which the Defendant asserted that the Claimant’s needs had hitherto been ‘over-provided for’, was ‘flawed’, it was asserted. Over- generosity can be a justification for a cut, of course, because it’s all coming out of public money, and all the council need ever do is to meet need appropriately, not aspirationally!

The Claimant also contended that failure to co-operate with NHS services, particularly over occupational therapy and physiotherapy, had flawed the assessment of the Claimant’s needs and ignored the best way to prevent care needs arising in the future.


An MDT meeting had ultimately been convened at the Claimant’s home, attended by the Claimant, two social workers and two district nurses.Ms Dawson’s typed note of the “MDT Outcome” stated as follows:

“Trial 6 week period agreed for reduction of care package, removing the night time care of 7 hours for incontinence support, pad changing and body turning with close monitoring from DN [district nurse] x2 weekly.

Exact plan to be confirmed and agreed alongside start date with DN and [the Claimant]. [Direct payments] team to be informed of change to care plan.

To be reviewed as ongoing via DN assessments/visits.”

This plan was to be reviewed at 6 weeks by the social worker, with district nurse visits twice a week in the meantime to monitor and record.

In August the council completed a care and support plan for the Claimant including a reduced care package of 40 hours a week, based on four one-hour single handed personal care visits a day (3 visits on Sunday) (27 hours in total), 7 hours a week meal preparation, 3 hours weekly domestic and shopping support and 3 hours weekly community support.

The Claimant made the point that the 22 August 2017 plan and 23 August 2017 letter flowed from the generic June 2016 decision and did not attempt to assess the impact on the Claimant’s well-being of the removal of her night time care.

But the social worker’s evidence was as follows:

i) The incontinence service had recommended the use of more robust pads in 2017, which were supplied.

ii) The Claimant had not sought medical advice about faecal difficulties, and there was no evidence of her having raised this with social workers or the occupational therapy service. There was no sign of any link between such episodes as had occurred and the reduction in the care plan.

iii) There was no evidence of pressure sores occurring since the care plan reduction. Further, “District Nurses have been very closely involved, their professional opinions have been sought in order to be confident that there are no significant risks of pressure sores, that toileting can be managed through use of pads and a specialised mattress used to address the issue of positioning and assist pain management, and that the Claimant is not being placed in unnecessary risk.”

In March 2018 the Defendant finalised the care needs assessment and sent it to the Claimant.

[i] “[The Claimant] was formally diagnosed with Muscular Dystrophy … in 2007. … It was reported that there is ‘no treatment or cure … and the condition is slow progress … won’t be ambulant … will need a wheelchair.”

[So the fact of degeneration was clearly acknowledged as relevant to considering what was needed.]

[ii] “[The Claimant] was assessed in June 2016 as she was receiving a 104 hours weekly care package. This identified double handed care. However, through further assessment and review discussion [the Claimant] confirmed that she did not use the service as double handed as it was not needed and instead had used the hours to implement a night time carer service seven days a week.

The view presented by the DNs at the MDT meeting was that given [the Claimant’s] equipment and level of mobility, removing her night care allocation would not put her at significant risk of developing pressure sores.

To manage risk, we agreed that the DNs would visit twice weekly to monitor pressure areas. This was also to manage [the Claimant’s] understandable anxiety. Currently the district nurses continue to visit [the Claimant] twice weekly. All their reports state that her skin is intact and no evidence of pressure sores.”

Lewisham therefore contended that the Claimant’s stance amounted to little more than a disagreement with the outcome of the assessment. A careful reading of the assessment demonstrates that it:

  • was completed with multidisciplinary input from both health and social work professionals;
  • fully involved and consulted the Claimant;
  • had clear regard to the factors as required by section 9(4);
  • complied with the provisions of the Act, regulations and guidance; and
  • took into account all material considerations.

Lewisham also contended that the woman had failed meaningfully to consider any alternative more suitable avenue for dispute resolution, including ADR or by exhausting the Defendant’s own complaints process and, if necessary, escalating any complaint to the Local Government and Social Care Ombudsman.

[That submission was not taken up by the judge, and we think that that is a further indication that the courts will not often be persuaded to regard arguable cases as able to be resolved by way of a different jurisdiction that does not encompass matters of illegality.]

The judge agreed that certain of the statements in the assessment are expressed in a somewhat conclusory way:

[x] (“Joanne explained that there is no evidence suggesting that there is a need for this additional intervention“)

[xx] (“It was explained that this is not based on assessed need and therefore not approved“).

“Those passages might be said to lend support to the Claimant’s submission that the decision-maker has taken the 2016 and 2017 decisions as read, without actually performing an assessment of the Claimant’s needs and the impact on her of the reduction in care.”

The point might also be made that passage [ii], referring to the June 2016 decision, appears to be erroneous in assuming that the Claimant herself had used spare care hours to implement night care, whereas in fact the 2011 and 2014 assessment both concluded that the Claimant required night care.”

“Viewing the assessment in the round, I consider that the decision-maker has not simply adopted the 2016 and 2017 decisions but has had regard to all the current circumstances in considering the Claimant’s needs and well-being.”

“The assessment acknowledges that the Claimant’s condition is degenerative (passage [i]). It notes that the trial removal of night care in August 2017 followed consultation with district nurses. It considers the evidence as it currently stands in relation to the Claimant’s toileting needs, including the series of reports from the district nursing team referred to in passage [xiv] reporting an absence of pressure sores and intact skin.

“The Defendant has also recognised that this is a matter which needs to be kept under careful review, and has continued to do so with weekly district nurse visits and periodic social worker visits.”

“The fact that the Claimant complained of wet leggings after outings on Sundays of approximately 5-5½ hours highlights the need for close monitoring of her needs at night during a longer period.”

“However, viewing the assessment as a whole it is not possible in my judgment to conclude that the Defendant’s approach has been irrational or that it has failed to have regard to the prescribed factors including the Claimant’s individual well-being.”

The judge said, with regard to pain, that it was noticeable that physical and mental health, of which pain relief and pain management would form part, were not included in the list of specified outcomes forming part of the eligibility criteria for Care Act purposes (see § 56 above). However, he said, “physical and mental health and emotional well-being” is one of the well-being factors referred to in section 1(2) of the Act and counsel for the Defendant was right in my view to accept that pain is therefore a relevant consideration when taking a decision under the Act.”

[CASCAIDr would comment here that the very definition of achieving the domains in the criteria includes reference to achieving but only with significant pain, anxiety or distress, or endangerment to self or others, or a much longer time to achieve the task, so it is ridiculous to suggest that such things are not part and parcel of task of considering the best value way of meeting ‘outcomes’!]

Fortunately the judge went on to say this: “It would follow that when deciding how to meet an eligible need, a local authority should take into account the fact (if the case) that one way of meeting the need is more likely to avoid or alleviate pain than an alternative way of meeting the eligible need.”

“I agree with the Defendant that the assessment gave holistic consideration to the well-being factors, including the impact of the revised care package upon the Claimant over the period of six months since it was first introduced in August 2017.

The Defendant has monitored (and continues to monitor) whether the Claimant has any additional eligible care needs that may have arisen as a result.

There is no or very limited evidence to support the Claimant’s assertion that her mental health and physical well-being have significantly deteriorated to the extent that the care package needs to change.

Neither the district nurses nor the evidence from the Claimant’s GP has given reason to believe that the removal of night time care has led to deterioration in the Claimant’s physical or mental well-being, whether in the form of pressure sores, increased pain or mental health problems.

The assessment does assess the Claimant’s eligible needs against the specified outcomes of relevance to the Claimant’s particular circumstances. The materials available, including the Claimant’s own evidence, do not identify accessing and engaging in work, training, education or volunteering as being of day-to-day relevance to the Claimant.

That position may change, but as matters stand I do not consider the assessment to have been unlawful on this ground.”

On the role of the target or general duty concerning integration with health services in the Care Act: the judge said this:

“I do not consider that the general duty in section 3(1) of the Act, or the associated provisions of the guidance, impose an absolute requirement to have specific health (including in this case physiotherapy) input during the course of making an assessment of care needs.

In the present case the assessment noted that an occupational therapy assessment had been completed on 9 September 2017, and that the Claimant had a profiling bed, mobile commode, powered chair and agreement from management for provision of a seating matters chair (see passage [vii]).

It specifically considered the Claimant’s complaint about having insufficient care hours in order to attend seated exercise groups and concluded that the current hours should be sufficient ([xviii]).”

If that assessment were to turn out to be incorrect or doubtful, then a reassessment may well be required, but I do not consider it possible to conclude that the Defendant’s decision in its March 2018 was unlawful as a result of failing to take account of needs for physiotherapy services.”

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LGO decision on financial abuse through non-payment of social care charges

This LGO’s decision from July 2018 offers some guidance on LA duties where vulnerable individuals have a DWP appointee. 

Background

The service user, a young woman, had disabilities causing deficits regarding keeping herself safe and living independently. She lived with her father who acted as her DWP appointee; he dealt with her correspondence and managed her finances.

She received a DP to support delivery of her care, and in her direct name; she was financially assessed as able to make a contribution. He father failed to pay most assessed contributions for 18 months or so, running up a debt of about £2000.

She was deemed to have capacity to choose her father to look after her finances, and initially said she wished him to continue doing so, which the DWP took serious account of. But he continued to let arrears mount up for another year, and the debt increased; the daughter then expressed a wish to take more control of her finances, and she moved into supported living.

The father agreed with the LA that he would stop acting as appointee but he did not action that agreement.

When the care staff at her tenanted accommodation realised she didn’t have enough money to meet her costs, they raised a safeguarding alert with the LA.  The LA neither held any strategy meeting or formally assessed her capacity and said the debt created did not constitute “significant harm” (this was pre-Care Act) – but did contact the DWP

Eventually the DWP revoked the father’s appointeeship.  The LA said the debts – by now totalling almost £3000 – were the daugher’s responsibility and would not be waived. The daughter got a representative to tell the LA that she didn’t fully understand how to manage her finances, but could do so, with support.

The Ombudsman held that the LA realised that that the woman needed help with her finances because the DWP had appointed Mr X as her appointee in the first place. They were aware that the father was not spending the daughter’s money in her best interests, and may not have understood his responsibilities.  It was aware that the daughter was kept short of money.

Findings of the LGO

The LGO view was that the LA should have completed a capacity assessment around finances.  If the LA was relying on the statutory presumption it should have recorded that it was doing so because there was enough doubt to raise the need to consider whether the presumption was rebutted. 

It should have supported the woman to manage her own finances if with support, she would be able to manage her finances; if she had capacity the LA should have considered other ways to support her vulnerabilities and sought her consent.

The council failed to give the daughter sufficient information or support to make an informed decision about who should manage her finances, and to ensure she understood the DP agreement she had signed.  It failed to meet her communication needs or consider appointing an advocate. It LA failed to consider properly whether she was or could be subject to financial abuse and failed to protect her from significant harm (a substantial debt).  It was aware that she didn’t wish to challenge her father due to her fear that it would damage their relationship but should have thought about what that could expose her to, in a more structured way.

Recommendations of the LGO

The LGO recommended that the LA should waive all arrears (almost £2000) accruing after it realised that the father was not paying the daughter’s assessed contributions; pay her £350 for the avoidable distress, time and trouble caused to her and ensure that assessments and support plans address finances adequately when there is any indication that the person needs support in that area; and finally, ensure communication needs and safeguarding concerns are appropriately recorded.

Considerations/learning for councils  

How do you ensure that appointees are clear, regarding their obligations to pay assessed contributions on behalf of the person for whom they act?

And how does this sit with a council’s need to exercise their discretion, conscientiously, to consider discounts from assessed income, for DRE – private expenditure from the funds, which are, after all, still the client’s funds, over which the council has no preferred creditor status?

Does the existence of an appointee act as a ‘flag’ for any council or CCG that the person they act for is more likely to be vulnerable/ require additional safeguards?

How effective are the council’s mechanisms for ensuring that vulnerable individuals understand their financial obligations e.g. regarding acceptance of DPs? 

How good are the capacity assessments around being able to understand the basics of a direct payment in the first place, let alone manage the payment and management obligations, such that an Authorised Person may be needed, to hold a budget as a principal, not merely as the manager (the agent) of a capacitated client? 

How good are councils at supporting individuals to have capacity around managing their own benefits based finances and/or make informed decisions about others managing them?

How do councils arrange to act quickly to avoid debts accruing to vulnerable individuals, particularly where someone else is not making required payments on their behalf?

How promptly do councils or CCGs raise alerts with the DWP if they have concerns about an appointee’s actions?

Do they ever use the specific duty of co-operation, if the DWP seems reluctant to engage with them – this would force the DWP to respond in writing, under the Care Act, s7.

How would your local safeguarding professionals respond to situations such as this?

The decision can be found at – https://www.lgo.org.uk/decisions/adult-care-services/charging/17-015-575

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A short note on the SEND Tribunal: the ‘single route of redress’ national trial

This post is by Yo Dunn, who runs ConsultYo, a legal framework consultancy and training business, specialising in autism issues – www.consultyo.com

From 3 April 2018 for two years a national trial is taking place which empowers the First-tier Tribunal Special Educational Needs and Disability (SENDIST) to make non-binding recommendations about health and social care aspects of Education, Health and Care (EHC) plans. The new powers are contained in the Special Educational Needs and Disability (First-tier Tribunal Recommendations Power) Regulations 2017.

The powers are only able to be exercised where a parent or young person is appealing some aspect of the EHC plan decision-making relating to special education to the tribunal[1]. This means that, like EHC plans themselves, this option is not available as a mechanism to challenge health or social care decision making in relation to a child or young person who has only health and/or social care needs and does not also have special educational needs. Further, the tribunal power relates only to aspects of health or social care needs or provision which are “related” to the child’s special educational needs, plus any social care provision which is being made under s.2 Chronically Sick and Disabled Persons Act.

Despite the non-binding nature of any recommendations themselves, there are elements of compulsion on health and social care responsible bodies.

During the tribunal process, responsible commissioning bodies can be compelled (under the Tribunal Procedure rules) to respond to requests by the Tribunal for information or evidence and to send a witness to a hearing if required by the Tribunal.

These procedural powers are potentially useful to complainants who may be struggling to obtain relevant information or documents from a health or social care commissioning body.

Perhaps even more usefully, the regulations require responsible commissioning bodies to respond in writing to any non-binding recommendations the Tribunal makes, giving reasons. Again, this is potentially useful to complainants who may be struggling to obtain a clear decision-making rationale which can then be challenged via Judicial Review based on the lawfulness of the decision making.

The power for the tribunal to make non-binding recommendations applies to recommending that particular health or social care needs are specified in the EHC plan, and/or that amendments be made to the provision specified for those needs. Note that the tribunal is not empowered to recommend amendments to the outcomes specified in the EHC plan (a limitation which also applies to the education content). This may be highly relevant where the outcomes are expressed in a manner which is vague, aspirational or loose, because appropriateness of any proposed provision will be related to the outcomes it is intended to achieve.

If, despite the non-binding nature of the recommendations, a plan was to be actually amended in response to a Tribunal recommendation, a crucial consideration is whether anyone can be held to account for whether the provision is actually made. Section 42 Children & Families Act 2014 creates clear statutory duties on: the local authority to “secure” the educational provision specified in an EHCP (s.42(2)) and the responsible commissioning body to “arrange” the healthcare provision specified in an EHCP (s.42(3)). However, there is no analogous duty regarding social care provision. Consequently, the tribunal recommendation power adds little or nothing to the enforceability of social care provision, even once it is specified in an EHCP.

The existence of this new power is likely to lead to questions as to whether an appeal to Tribunal has been pursued as a first resort approach to resolution and, if not, why not. This question will inevitably arise when approaching the Ombudsman and/or at the permission stage of a Judicial Review. In some cases, the answer may be that health or social care recommendations could not be pursued in front of the tribunal because there were no educational issues in dispute or that any education dispute had been resolved whilst the health or social care dispute remained. In other cases, it may be appropriate to point to the non-binding nature of the recommendations together with evidence, if any, of the local authority’s willingness or otherwise to modify the EHCP in response to recommendations (such as those from relevant professionals). Finally, in case where the content or wording of outcomes are disputed, the lack of tribunal power to recommend changes to outcomes may be relevant to whether an appeal to tribunal is a viable alternative for dispute resolution.


[1] This is because the qualifying criterion for issuing an EHCP is that it is necessary for Special Educational Provision to be made for the child or young person, see s.36(3) Children and Families Act 2014

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Bootcamp Applicants

The Caseworker Bootcamp will be held in the East Midlands on 10/11/12 May.

Venue Location: Best Western Yew Lodge Hotel, Packington Hill, Kegworth, DE74 2DF T: 01509 672518

Places are limited, and we intend to select up to 20 people to share in this opportunity. We will let you know by the end of February, 2019, please note.

For those who want to try, can we say this: we need caseworkers who already know about legal precedent,  the grounds for judicial review, where to find case law, where to find expert commentary on a case, how to apply critical thinking to existing case law, the Care Act guidance and CHC framework (well) and what the effect on the existing case law is, given that we now have the Care Act, etc. There may be a question sent back to you, to give you a chance to show that you do actually have these skills.

There will be a Getting to Know You All session on the Friday night, and dinner out in the local area.

There will then be Workshops on Saturday morning and afternoon, and again on Sunday morning and afternoon. We’ll meet for drinks on the Saturday evening and then see what people want to do for food options. We will finish at 4.30pm on the Sunday.

The workshops will cover the following: 

  • Our Care Act compliance questionnaire, and how caseworkers use it
  • Our standard wording when writing, for instance, to a council’s Monitoring Officer
  • Our wording about the most important pre and post Act case law
  • Discussion of the most common scenarios that we are being called in on
  • Discussion and familiarisation with CASCAIDr’s Litigation Strategy so that we can all spot the problems that need to be considered as good cases to support in order to make more precedent

The cost of the bedroom, lunches and breakfasts x 2 nights is CASCAIDr’s investment in all our futures. If this development opportunity  for YOU would be of benefit to a current employer or to yourself in your own business, we would hope you would be willing to pay for ONE night’s accommodation, however, as we are a charity.

We ask that those who are selected agree to fund their own food and drinks on the Friday and Saturday evenings, and fund their own travel to the venue to arrive, by 7pm Friday evening.

To qualify for CASCAIDr’s subsidy for this unique training opportunity, you need to be able and willing to do freelance work, at least once a month, on a CASCAIDr matter; work that might take 5 – 6 hours and earn you between £250 and £600.

Here’s a link to the sort of cases that we are fielding these days, and their outcomes: https://bit.ly/2SHM6CO

Bootcamp Applicants
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Analysis of concerns of Human Rights Watch – with CASCAIDr comments on top

Unmet Needs: Improper Social Care Assessments for Older People in England 

Headline report conclusions

“Older people in England are at risk of not getting adequate assistance to live independent, dignified lives due to uneven assessments for social services.”

Some said that assessors appeared not even to understand their disabilities and support needs. In other cases, before beginning an assessment, assessors announced that services would be cut, regardless of an individual’s actual need.

And in some cases services were denied or cut significantly, affecting older people’s health and wellbeing.

CASCAIDr’s comment: seeing these as indications of ‘improper’ assessments is an interesting approach, when any of the above are potentially unlawful assessments, in terms of current and perfectly clear public law and care law principles!

Methodology
Human Rights Watch (HRW) spoke with 27 older people and 20 family carers in 11 LAs: Tower Hamlets, Cumbria, Bournemouth, North Yorkshire, Hertfordshire, South Derbyshire, Essex, Barking and Dagenham, Salford, Dorset, and Surrey.

HRW also interviewed 51 representatives of charities, as well as lawyers, service providers, academics, policy experts, staff from the NHS, CCGs and current and former LA staff.

They also conducted group interviews arranged by partner organisations in supported housing accommodations and community centres in East London, Bournemouth and Poole.

HRW sent letters to the 11 LAs, the DHSC and the MHCLG requesting answers to questions related to the findings. Only three LAs responded: Dorset CC, North Yorkshire CC, and the LB of Barking & Dagenham (see Annex 1 to the report). The other LAs and the ministries did not respond.

Problems with Social Care Assessments

The report contains excerpts of some of the interviews conducted, including the headline quote:
‘[They] just came in with an agenda of cutting my 15 hours per week to 6.5. They announced it. They told me ‘We are not there to give you more, but we are going to cut it.’ They had worked out that that was what I needed [before they arrived].’

Other interviews highlighted what family members saw as unrepresentative assessments, and the difficulty they had experienced in appealing against them.

CASCAIDr’s comment: The idea that one can actually achieve more savings by having staff prepare the clients for the worst, when so doing itself suggest widespread and ‘corporate’ fettering of assessment and care planning judgement, from above, should be a matter of shame for the sector, and it IS of legal significance in public law terms.

Suspension of Services During Appeals

This section details how some people lost services once they had filed an appeal, how the Care Act is silent on the suspensive effect of an appeal, how two LAs stated they have the discretion to maintain services pending appeals, and how the DHSC is currently developing a process for streamlining appeals, to be introduced by April 2020.

CASCAIDr’s comment: Any social care lawyer could have told them that the fact of a complaint or a dispute is no defence to the duty to meet assessed eligible unmet needs.


Lack of External Oversight of Social Care Assessments


This section sets out how there is currently a lack of sufficient oversight and monitoring of assessments to ensure consistent accuracy and objectivity. Three LAs (as above) responded to HRW’s enquiries on monitoring needs assessments and indicated processes for reviewing social care needs assessments are conducted within each council’s own structures, and they were not aware of any systematic independent monitoring or monitoring of assessments by the central government.

CASCAIDr’s comment: There is none, and it is not an accident. There is only the Monitoring Officer’s role, largely unheard of by those who should know about it, judicial review, which usually needs a lawyer and legal aid and the capacity of the law firm to handle the work – OR paragraph 10.86 of the Guidance which requires a proper management review before giving upon securing agreement and just saying ‘Complain or bring legal proceedings if you don’t like it.’ No wonder it’s taking ages to incorporate adult social care into the tribunal system in this country. It would cause mayhem!

International Legal Standards

The report refers to The Right to Health and to Family and Private Life and The Right to Live Independently in the Community. It includes a reference to the UN Committee on the Rights of Persons with Disabilities review of the UK in October 2017.

CASCAIDr’s comment: Brexit Fever and widespread disdain for the ECJ and ECtHR’s influence on our legal system does not bode well for any further incorporation of THOSE principles into domestic law, do they? Just try contending that you should be funded at home, when a care home is cheaper, without referring to human rights, is all we can say, to all those who see no point in the Convention or the UK’s own Human Rights Act.

Report recommendations (in full):

To the UK’s Government

• Ensure that older people have access to the services they need to realize their rights to live independently in their communities with their rights to health and private and family life protected.

• Establish a mechanism to monitor and evaluate social care needs assessments and the staff who conduct them to ensure consistency and equality nationally.

• Ratify the Council of Europe’s Revised European Social Charter.

To the UK Parliament

• The Health and Social Care Committee and the Housing, Communities and Local Government Committee of the House of Commons should examine the impact of austerity measures on local authority social care provision under the Care Act 2014.

To the Ministry of Housing, Communities and Local Government

• Review successful appeals against initial social care needs assessments and collect data about the reasons assessments were identified as problematic; data should consider the age, gender, ethnicity, location, and place of residence of those assessed as well as the types of shortcomings in initial assessments; use this information to make corrections and improvements in the system with a goal of ensuring provision of services to which people are entitled and reducing the number of times individuals must appeal in order to secure social care services.

• Direct local authorities to establish and document clearly the specific reasons to justify services being safely reduced or eliminated pending an individual’s appeal of an initial social care assessment and in all cases to strongly consider continuation of services pending appeals.

To the Department of Health and Social Care

• Include, in the reform of social care appeals processes planned for 2020, the suspensive effect of appeals.

• Execute a plan for the long-term stability and sustainability of the social care system in England to ensure that the human rights of older people are fully respected.

To Local Government authorities

• Ensure the accuracy of needs assessments, including when there are not enough resources locally to meet those needs.

• Document clearly the specific reasons to justify services being safely reduced or eliminated pending an individual’s appeal of an initial social care assessment and in all cases to strongly consider continuation of services pending appeals.

• Ensure that individuals are fully informed of their rights and available options to appeal social care assessment decisions and provide reasonable accommodations to individuals who may require assistance in the appeals process.

CASCAIDr’s comment: does anyone reading this catalogue of woes have any doubts as to the need for this charity, or wonder why we set it up?  

Please donate to our cause, if you see the point of legal rights, here!

Public law principles make all of the above essentials  for good  governance and legality.

They should already by embedded, after 20 years of community care judicial reviews, in the hearts and minds of those supposed to be leading the sector forwards – not back!


Based on a summary written by Adam Webb, and used with permission – thanks Adam

mradamwebb@gmail.com

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CASCAIDr’s first year of operation

So please donate to keep us going into a 2nd year and beyond, by clicking on:
DONATE to CASCAIDr

How many of CASCAIDr’s first year’s 200 or so clients were

So, please donate to keep us going into a 2nd year and beyond, by clicking on: DONATE to CASCAIDr

What have been the OUTCOMES, for some of CASCAIDr’s most successful clients?

Threatened cuts to people’s packages, services or budgets, have been cancelled or reduced

“MR and SN have nominated your organisation for a Gold #IAMchallengingbehaviour Star Award as you are continually challenging the behaviour of those people and systems that stop people getting a good life.”

Adequate, practicable budgets have been secured (as opposed to arbitrary or blatantly cost-capped budgets) for a person’s own use in a person’s own home

“The reality is that we did not even have to concede any ground!  We are still pinching ourselves to check whether we are not in fact dreaming that this actually happened! For this, we must again wholeheartedly thank you for your support and guidance throughout!”

People have been able to access or enforce proper processes, such as professionally competent assessments, and paperwork including written reasons, after we’d got involved

 “I just had a call from a delightful and sincere sounding lady from Adult Social Care. She is going to speak to the learning difficulties side of social services to see which team should do a new assessment, or if it should be a collaborative affair with the CMHT. She is also arranging a visit from an occupational therapist. I am cautiously optimistic. Thank you both for your continued support. I am so grateful.”

Necessary, wanted and suitable care home placements have been commissioned, when councils had first said ‘We don’t place people in care homes, ever’ – or ‘not in THAT company’s care homes’

 “Just had the call we’ve been hoping for, J has got the funding for [the preferred provider]! Thank you so much for your input, we are thrilled.”

Care Plans that had never been written up before, have been formalised so that people can see what they’re regarded as needing, and can check the cost assumptions

“My Parents and I have read your email and both attachments thank you – they are fantastically well written. I will go to a bank this week and open a bank account in readiness for a finalised budget and plan”. 

Two people were saved from being removed from care homes after living there for over 15 years and 33 years respectively

“They’ve withdrawn the notice and agreed to follow due process. Mrs X is over the moon and so grateful. She would have had no chance at this time of year of finding someone with availability for legal aid work”.

The proper use of the MCA has been forced into people’s Care Act processes where it had inappropriately been left out, so that their needs and human rights have been properly taken into account

“You are a huge hit with K’s mum, and K seems much happier now; in no small way due to the work we have done with you, as we suspect it has helped [the provider] to really think about the situation.”  

Ordinary residence disputes have been magically managed away and the right council has paid up

 “ I explained everything (almost) that you went through with me yesterday about why the way we’d been manoeuvred into taking over the out of area emergency placement, when X council made the contract, and T is incapacitated and J has no status regarding his funds, was unlawful. A new social worker has now been appointed.”

Top-ups for care home rooms, above the council’s offered budget, that had been said to be inevitable, have been cancelled and refunded or the out of area rate taken as the guide price

“I am absolutely ecstatic myself and cannot wait to tell Mum.  It has made me appreciate that we are in a privileged position to have had your help and that for many families this outcome would not have happened.”

Direct payments have been increased or not reduced, and some disputes about misuse or non-use or going back to a directly commissioned package, have been resolved

 “Thank you for the good work that you do with the charity. You have achieved everything you predicted for my brother and for us, as defectors from direct payment difficulties, and compensation on top -we are really grateful.”

People have been found to necessitate care by their own relatives in the same household, and permission has been granted or left in place

 “Thank you for the immediate response and honesty…X has been amazing and I totally understand the position he is in, and truly appreciate the help given in difficult circumstances.”

Care charges have been reduced, by reference to disability-related expenditure evidence, and at least one refund was secured

“..my financial resources will be severely stretched,
for the rest of my life, but I do so appreciate all you do for me.”

Carers have been awarded rationally sufficient budgets for themselves so as to sustain caring –or replacement care has been added to the service user’s package, after carers could stand no more

“With the advice you have provided so far, I feel more confident.  I will deal with this matter on my own now. I would like to say a huge thank you for everything you have done for my mum, and also myself, I have learned so very much from CASCAIDr’s work.” 

People have been supported to challenge CCGs’ Continuing Health Care decisions, and have either succeeded, or got a split package – and some have even got money back – in one case £50K

“The retrospective is awarded from Feb 2014… I’m pleased and very grateful for all your help getting to this point.”

CCGs have been threatened with judicial review for cost-capping and have ended up preparing quasi-Care Act care plans for commissioning an appropriate service and operating DoLS properly

 “Thank you to you and your case worker. I have now gone through the letter and have a few comments and tweaks maybe for your consideration. An excellent letter. I do not know what their defence(s) could be, given all their failures.”

One severely disabled person has been assisted to secure housing from the Housing Authority, in co-operation with service provision from social care, despite also having a history of substance misuse, and assumed reluctance to engage

“My bosses are on board with all this, and our funders also see the importance of this for both this service user and, of course, the potential for other cases to benefit from what we’re learning.”  

People have been assisted to selfprotect, against councils using the Court of Protection as a threat, to deter them from involvement in decision-making or from holding the council to proper account under public law and the Care Act

I’ll paraphrase, but what you said would happen, did happen within a few minutes of LA’s solicitor’s opening comments, the Judge turned on her and said ‘Stop right now! Stop where you’re going right now! I’m not having it! I’m not going to approve your draft orders. We’re all here to decide what’s best for Mr X’s support and it’s entirely proper that Mr Y is included in these decisions. I suggest you speak to your clients and come up with another plan because I’m not having it.’ We were so relieved.”

Complaints have been won and compensation recommendations secured, from the Local Government and Social Care Ombudsman

 “Thanks for all your help. I’m sure we wouldn’t have got the LGO decision without it.”

Providers from the private, public and third sectors have been assisted to stand up for their clients’ rights, and not just their own fees difficulties

“CASCAIDr’s support for our management’s thinking, in relation to what had seemed like an ultimatum from the council, has really helped turned things around for our charity.”

Independent supervision of a fresh assessment after a successful LGO complaint has been provided to a local authority

 “Thank you – that is really useful and helps us frame some of the points in your response to the Assessment and Carers Assessment for us to use in future training and guidance. I really appreciate this additional comment.”

Many more people now know what the local authority’s Monitoring Officer actually has to do, as the statutory officer responsible for governance, with a referral of alleged illegality.

So, PLEASE donate to keep us going into a 2nd year and beyond, and supporting our planned formal Litigation Strategy and our first residential Bootcamp for new Caseworkers in the Spring – by clicking on: DONATE to CASCAIDr

Finally, what sort of matters has CASCAIDr had to try to signpost to other sources of help, as completely out of our scope?

CASCAIDr specialises in public law matters for clients in the health and social care sector, from age 16+ – so we’ve had to signpost away matters to do with children, special education, safeguarding issues, adoption, DWP benefits matters, a negligence claim, a neighbours’ dispute – but not before taking the time to look at the problem. Please do look at our home page before getting in touch, as it all helps to keep us viable!

So, if you’ve got this far, PLEASE donate – to keep us going into a 2nd year and beyond, by clicking on: DONATE to CASCAIDr

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What to Say If: you are told that you are not able to have a direct payment …

A.   Because we are not doing them at the moment / the process is just too complicated and it will take too long

“I am sure that councils do not have the legal right to say that it just doesn’t suit them to give money out as a substitute for services.

The Care Act says that if 4 conditions are met, you must give me a direct payment. So I will need your reasons, please, in writing, as to which of the 4 you do not think I meet, so that I can address them, with the benefit of legal advice.

The Guidance (which you have to have regard to, the case law and the Care Act say so) says this:

….processes must not restrict choice or stifle innovation by requiring that the adult’s needs are met by a particular provider, and must not place undue burdens on people to provide information to the local authority.

The Guidance also says this:

Where refused, the person or person making the request should be provided with written reasons that explain the decision, and be made aware of how to appeal the decision …

So it’s obvious that you have to do that much, at least, in order to be seen to be treating me in accordance with the rules of procedural fairness for any public body.

The reasons have to be given to me in an accessible format according to the guidance, setting out:

‘which of the conditions in the Care Act have not been met, the reasons as to why they have not been met, and what the person may need to do in the future to obtain a positive decision. The consideration stage should be performed as quickly as is reasonably practicable, and the local authority must provide interim arrangements to meet care and support needs to cover the period in question.’

These are the 4 conditions you need to focus on, please:”

  • the adult has [mental] capacity to make the request, and where there is a nominated person [a helper suggested by the person seeking the direct payment], that person agrees to receive the payments
  • the local authority is not prohibited by regulations under section 33 from meeting the adult’s needs by making direct payments to the [special category of] adult or nominated person
  • the local authority is satisfied that the adult or nominated person is capable of managing direct payments, either by himself or herself, or with whatever help the authority thinks the adult or nominated person will be able to access
  • the local authority is satisfied that making direct payments to the adult or nominated person is an appropriate way to meet the needs in question

 

B.   Because we don’t think it’s an appropriate way to meet your needs…

“What exactly do you mean, please, by not appropriate? It’s a very woolly concept, and I am sure that you can’t just trot it out without explaining what you are really bothered about.

The guidance (which you are obliged to have regard to) says that ‘generally’ a direct payment should be regarded as appropriate:

  • In all cases, appropriateness is for local authorities to determine, [subject to ordinary principles of judicial review such as rationality, an evidence basis, absence of pre-determination or a fetter of discretion etc] although it is expected that in general, direct payments are an appropriate way to meet most care and support needs.
  • Direct Payments “remain the Government’s preferred mechanism for personalised care and support” and
  • Local authorities must not use this condition to arbitrarily decline a request for a direct payment. 

Also, in the well-being section of the Care Act, control is specifically mentioned:

S1(2)(d) control by the individual over day-to-day life (including over care and support, or support, provided to the individual and the way in which it is provided);

  • Are you saying that there’s no point in my having a direct payment because if YOU can’t find a service I won’t be able to either?

 

  • Because if so, can I remind you that if you give me a direct payment you can actually give me permission to employ unregulated care workers, which is something YOU cannot do, or buy, as a council, and that would solve your commissioning and market management problem, would it not?

 

  • Or are you saying that it’s inappropriate because the same items or services can be bought more cheaply by you than by me, because you are a bulk purchaser?

 

  • If so, I have taken advice about that, and I have been advised that there is no legal basis in the Act or regulations for saying that cost comparisons for the same service or thing, via direct commissioning or by way of giving me a direct payment, are a legally relevant consideration to the question of appropriateness. Economic viability of a direct payment route to meeting needs is not mentioned in the legal framework for adult social care, whereas it is, in the personal HEALTH budgets framework.

 

          –    In so far as the Guidance envisages that you can take cost differentials into account, when setting the budget, that is a different matter, to appropriateness. Even then, that bit of the guidance is unsupported by any reference to primary or secondary legislation. I accept that it might make a difference to budget setting if the cost differential for the same thing via the different buying routes was massive, but not if it is simply the effect of my being an individual purchaser in the local market, whilst you are a bulk buyer.”

 

C.    Because you haven’t got sufficient mental capacity to ask for one

“What is your evidence basis for doubting my capacity? The Mental Capacity Act says that everyone should be presumed capacitated unless the contrary is established, so you can’t just assert incapacity without sharing your thinking with me/us.

The Guidance (which you have to have regard to, because the case law and Care Act say so) says this:

The following considerations should be made when assessing capacity:

  • does the person have a general understanding of what decisions they need to make and how they need to make them?
  • does the person have a general understanding of the consequences of making, or not making the decision?
  • is the person able to understand, retain, use and weigh up all relevant information to support the decision?
  • can the person communicate the decision? (this may involve the use of a specialist or independent advocate)
  • is there need to bring in additional expertise to aid the assessment?

 

My /our take on these facets of capacity is this: [explain your position carefully]… “

 

D.    Because you wouldn’t be able to manage one, day to day

“The Guidance (which you have to have regard to, because the case law and Care Act say so) says this:

‘Local authorities should therefore take all reasonable steps to provide this support to whoever may require it.

To comply with this, many local authorities have contracts with voluntary or user-led organisations that provide support and advice to direct payment holders, or to people interested in receiving direct payments.

This condition should not be used to deny a person from receiving a direct payment without consideration of support needs.

Consideration should also be given to involving a specialist assessor in determination of support requirements’

  • So, please tell me what is available locally through steps that you the council have taken to provide this support.
  • I understand too that the law allows me to nominate a relative who can be paid for their time in administering the direct payment as long as you think it’s necessary – well you seem to think it is, and I have a relatives who’s up for doing that, but it will take up at least 2 hours a week, so what shall we say per hour, please, on the footing that they’re going to be self-employed?
  • Are you saying that it’s NOT necessary and that I can’t choose to have my relative do that, simply BECAUSE you’ve spent money on commissioning or grant funding a payroll support service? Or are you saying that I can choose my relatives to help but not for money, because of your other arrangements? Can you explain, please, how that is consistent with giving me choice and control?”

 

E.   Because we don’t approve of your preferred helper

“Er, why not please? What do you have against them?

If you have some evidence basis for regarding them as not suitable to help, then you need to tell me and them, so that we can attempt to address your concerns, and in order to abide by the rules of natural justice and procedural fairness that apply to all public bodies.”

 

F.   You can’t have one, unless you use one of our preferred providers for the care services you’ll be buying

“Come off of it!

The Care Act and the Guidance both make it crystal clear that you cannot tell a direct payment holder who to spend the money on. I know that you have a power to make it a condition that the money is NOT spent on a particular person (ie a named individual or a company) but even then you’d have to explain why, to be fair to everyone concerned.

You can’t seriously think that you can stipulate as that sort of negative condition that the provider cannot be ‘anyone who is not on our framework or preferred provider list’ can you? That’s indefensibly too broad and just a cheeky way of trying to tell us who we MUST spend it on.

  • And can we ask why would you even want to be doing that? Preferred providers must be struggling anyway to meet your own demands for services, in the current climate, regarding workforce difficulties that are known to be operating nationwide.

 

  • Is it because you’ve somehow persuaded all those framework providers to agree not to charge direct payment holders any more per hour than what you’ve been able to bully them down to accepting from yourselves? How could making tendering for your business dependent on what these providers would agree to charge other people altogether for their services, ever be legally enforceable?”

 

 

 

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What to Say If: you are told “You can HAVE a direct payment, but the size of your budget for your direct payment will be calculated based on the cost for which we could meet your needs if we were buying the services.”

“…And if that’s not enough, well then, we guess that you’ll be withdrawing your request for a direct payment, yes? or else accepting the budget as less than you know is needed via a DP route, as a matter of your own choice…”

 

Anyone thinking that this is the bit of the Self Help guide that applies to them, needs to go take a wet flannel and sit down and commit to reading what follows, two or three times, using all their intellectual firepower.

It’s hard, because it has been left regrettably unclear, until someone brings a case to court about it.

The guidance says this:

11.25 The Act states the 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 established.

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 chapter 12).

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.

11.26 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

[ie no direct payment to be offered at all, and ONLY directly commissioned support offered in the first place, CASCAIDr would beg to be told?]

where the costs of an alternate provider arranged via a direct payment would be more than the for what the local authority would be able to arrange the same support, whilst achieving the same outcomes for the individual.

11.27 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.

11.28 In cases where making a direct payment is a more expensive option to meet needs, the care plan should be reviewed to ensure that it is accurate and that the personal budget allocation is correct.

[a wholly circular fudge, it seems to CASCAIDr!]

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.

 

So, what one might have to consider and/or ask, in order to get to the heart of the issue, is this:

“I get that the setting of the budget has to take account of local market rates but local market rates to YOU, the council, might logically and predictably be less than they would be to a person buying as an individual. So what are you really saying here?

  • Are you saying that my preference for having a direct payment so that I can buy services from a particular provider – who charges more than you can get the service for – is a ‘want’ and not a need?

 

  • Of course I get that if I choose to have a luxury or particularly high class quality service, then that MUST be a want and not a need, and then if I take the direct payment based on the cost of meeting my needs and not ‘wants’, then that’s down to me and I will have to make do and stretch the budget or else top up from my own or my family’s human or financial resources
  • Can I remind you though that the guidance says that councils could decide that the better outcomes that I can achieve through use of a direct payment and the council not having to commission for me, any longer, mean that the council paying out more for that route COULD WELL BE SEEN as BEST VALUE And that ‘Decisions should therefore be based on outcomes and value for money, rather than purely financially motivated.’

 

  • But honestly, there is no evidence that the provider I want, who’s offering to meet my needs as you’ve assessed them to be, for £x an hour, is going to be doing anything specially top notch or luxurious – it’s an ordinary provider who’s in business to provide services to ordinary people, which costs more than just fulfilling one large council volume-based purchase.

 

  • If I were to be getting anything special that is not part of ordinary reasonable expectations for a home care service out of this provider (like always having access to the same 2 workers, which would be lovely, but which I can’t honestly say is essential) I would agree with you that that would be down to me.

 

  • But no normal person would expect to have to go to bed at 6pm, and you are supposed to commission for a reasonable quality of service taking people’s wellbeing including their emotional and psychological wellbeing into account, in the first place.

 

  • If direct payment holders can’t choose providers like the one I have chosen, there will be no diversity in the market, which is something that you have a duty to have regard to as part of market management for the whole care market, not just the council’s commissioned for clients…

 

 

  • In so far as the Guidance hints that you can take cost differentials into account, when setting the budget, that bit of the guidance is unsupported by any reference to primary or secondary legislation.

 

  • It doesn’t actually say that you can offer it to me at the lower level, and still be acting within the legal framework for direct payments, does it? It sort of waffles (see paragraphs 11.25, 11.26, 11.27 and the Andrew example in the guidance) and begs the question when it comes to what should be done if nobody can innovatively make the money somehow stretch through negotiations….

 

  • I accept that it might make a difference to budget setting if the cost differential for the same thing via the different buying routes was going to be massive, but not if it is simply the effect of my being an individual purchaser in the local market, whilst you are a bulk buyer. It is wholly rationally predictable that a provider would charge more to an individual than to a council: the clients will be disabled and vulnerable people, not all of whom will manage their budgets perfectly, and there will be more phone calls for variations and more bad debts, in the end, for the provider.

 

  • If you stick to your position and offer me less – as a budget for this DP – less than we all know it will cost me to buy the service as a direct payment purchaser, how will you reflect that shortfall in the s25 care plan that you are obliged to give me even if I have a direct payment? How will you show that it actually meets my needs?

 

  • Are you effectively saying ‘Take it or leave it, and if you don’t want to take the budget for use as a direct payment, then that’s your choice, in the end, and that you will just crack on and meet my needs directly?’

 

  • I have been advised that that’s not a defensible approach if so, because it leaves your duty to promote my wellbeing wholly out of account – wellbeing including this notion here:

           S1(2)(d) control by the individual over day-to-day life (including over care and support, or support, provided to the individual and the way in which it is provided);

 

  • Remember, the guidance says that councils could decide that the better outcomes that I can achieve through use of a direct payment and the council’s not having to commission for me any longer, mean that the council paying more for that route IS able to be seen as BEST VALUE.

 

  • And that ‘Decisions should therefore be based on outcomes and value for money, rather than purely financially motivated.’
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A section 117 client’s services were restored after our involvement

…They hadn’t received the letter at that point, so I gave them a copy to read. They left, after almost 2 hours, agreeing to reinstate J’s support after just leaving it for 3 months

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A trainee social worker uses the law for her own Mum’s interests in getting out of ‘respite’ care to go back home

“The support you have provided has been fantastic, regardless of the outcome. I do not believe I would have even been able to get this meeting arranged and I have learned so much.”

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