Actions and Next Steps
Amendment
In May 2025, this chapter was replaced with an updated version following a full review. The new version includes an update to Section 2, Providing Information about a Person or Carer to reflect amendments made to the chapter Providing Information about a Person or Carer following a full tri.x legal review.
This procedure should be used to action the outcome of a contact, written referral or review request regarding a person with Care and Support needs. It should not be used when the contact, written referral or review is in regard to a carer.
If the contact relates to a carer, see Actions and Next Steps (Carers).
Note: This procedure is used by all teams.
The Local Authority (and anyone representing the Local Authority) has a duty under Section 4 of the Care Act to either provide directly or provide access to a range of information and advice relating to adult Care and Support, including financial advice. This duty applies equally in respect of all local residents regardless of whether the person with Care and Support needs is known to, lives in, or is already receiving services from the Local Authority.
Methods of how information and advice can be provided:
- Translating and interpreting services.
This includes:
- Face-to-face interpreting;
- Document translation: provided in Word but other formats may be requested;
- Transcription of printed information, including council letters, into Braille and audiotape;
- Telephone interpreting: a three-way conversation for urgent cases where an interpreter can’t be present;
- Internet (Main Merton pages, Local directories);
- Leaflets.
See: Providing Information and Advice to read more about what the Care Act says about the duty to provide information and advice, including how information and advice should be provided and the specific information and advice requirements around finances.
The Local Authority has a duty to provide good information around finances at an early stage. This provides people with an understanding from the beginning about how they may be expected to contribute financially towards the cost of any Care and Support/Support they receive. This is particularly important whenever a transfer is made to another service that may result in an assessment, review or reassessment.
See: Specific Requirements on the Provision of the Information and Advice around Finances for guidance on the requirements of the Care Act.
See the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment.
The Adult Support Services Directory - Merton directories provides a range of online information and advice for adults on employment, education, health, housing, financial advice and things to do in the community.
People can also access the Merton Community Hub for help and advice about which organisations may be able to help them. They can do this without having had an adult social care assessment.
The hub offers:
- Cost of living advice;
- Mental health and wellbeing advice;
- Help for isolated households;
- Support to stay independent at home;
- Telephone befriending;
- Advice and practical help to stay active.
Tel: 020 8066 4086
Email: help@mertoncommunityhub.org.uk
Local Information, Advice and Preventative Support
Adult Social Care and Public Health commission a number of services that provide information, advice and preventative services to prevent, reduce and delay the need for health and social care statutory support.
These preventative services include the:
- Civic Pride Grant Programme;
- Preventative Activities;
- Community Dementia Services;
- Carers Hub;
- Warm and Well Programme;
- Befriending.
Making Every Contact Count
MECC Link is a simple but flexible Very Brief Intervention (VBI) and signposting tool that has been carefully designed to support an approach to positive behaviour change called 'Making Every Contact Count' (MECC).
MECC Link helps you to raise awareness, motivate and signpost people to help them to improve their health and wellbeing. At the touch of a button, you can access information on a full range of self-care, national and local support services.
MECC Link - Simple signposting to better health and wellbeing
Civic Pride Grant Programme
The 3-year Civic Pride Grants Programme is aligned with the Innovation and Change Department and launched in April 2023-March 2026.
The 3-year Civic Pride Fund Supporting the Voluntary and Community Sector April 2023-March 26 programme aims to ensure that support is available for all Merton residents. It brings together preventative services that provide information, advice and support in the community to strengthen Merton resident’s physical, social, emotional, and economic resilience.
Listed below are the Civic Pride preventative services that provide information, advice and support:
Southwest London Law Centres provide legal casework and representation services in Merton, providing a new Merton-based Housing and Welfare Benefits Caseworker and a Crisis Navigator, based in the community, providing early triage and crisis navigation support.
Springfield Advice and Law Centre provides a legal advice service for mental health services users, offering advice and casework representation in debt and welfare benefit matters, including expanded advice outreach sessions.
Citizens Advice Merton and Lambeth provides a range of information, advice, casework and specialist support services to people across the borough relating to social welfare law. Services will include further enhanced Merton Adviceline, and face-to-face information support and advice provision.
Merton Vision are providing direct outreach support to residents with a visual impairment who are isolated and/or struggling with the cost of living. The service also provides one to one support services to a new client group (Hard of Hearing/Deaf people) in addition to people with a visual impairment. Merton Vision also provide a range of support and activities based at the Merton Vision community centre, including volunteer support, preventative activities, building travel confidence, communication support, low vision and lighting advice and social interaction.
Age UK Merton are providing an integrated Community Support Service (CSS), bringing together established Information and Advice and Living Well services, to further grow strengths and capabilities for older clients in Merton. Age UK also provide befriending support, help at home services, support with low level hoarding and a range of activities for older people at their base in Mitcham. Age UK Merton also have a Happy and Active Guide for older people. Alongside other community organisations in the Borough both offer a range of fitness and physical activity classes.
Merton Centre for Independent Living are increasing the capacity of the Information and Advice service through an accredited caseworker support for Deaf and Disabled residents in Merton relating to welfare benefits, social care, concessionary travel, housing, grant applications and health.
Merton Mencap are providing a Community Facilitator service which supports adults with learning disabilities and/or autism to live to more independently and achieve positive life-goals. Merton Mencap also provide a range of activities including the My Life My Community Hub every Saturday for adults with a learning disability and/or Autism, the Mencap Community Café, gym sessions, travel training and holidays.
Commonside Community Development Trust are providing a drop-in community café, a range of activities for older and vulnerable residents in Pollards Hill and a hot two-course meal Monday to Friday. Commonside Trust also provide a base for the Ukraine Welcome Hub and Skill Up Support.
Association for Polish Family (PFA) provides support for the Polish and EE communities in Merton mainly through the provision of information, support, and non-accredited advice, including outreach sessions. PFA also works closely with Commonside Community Development Trust to provide the Ukrainian Welcome Hub.
Wimbledon Guild are providing a preventative, strengths-based Wellbeing Support service, offering a holistic assessment and 1:1 support for vulnerable, isolated older people with limited connections in the community. Wimbledon Guild also provides practical help and support such as small and cash grants, talking therapies (individual and group support) a range of activities to help people get active and feel connected through befriending, volunteering and group activities. There is also a café Monday to Friday for people to pop in and meet people.
For older people who would like encouragement to get physically active look to the Merton Moves Scheme run by Wimbledon Guild, which provides six weeks coaching to find and take up a new activity.
Preventative Activities
Detailed below are other organisations that are funded by Adult Social Care and Public Health to prevent, reduce and delay the need for health and social care. There are many other preventative activities and can be found on the Merton Adult Support Services Directory, or support customers to contact their local leisure or community centre.
Attic Theatre Company are providing two weekly singing groups and in addition a dance and movement workshop for people with Dementia and their carers.
Friends In Helier are providing a range of activities, outreach support and outings for older people to socialise, join in with activities and eat a hot meal together.
The Merton and Morden Guild of Social Service are providing 16 preventative activities per week for older people in Merton.
Merton Community Transport are providing an excursion club (two trips per month) supporting members of the community struggling with loneliness and isolation to places of interest.
Northeast Mitcham Community Association are providing a range of activities for older people which includes 2 lunch clubs and a falls prevention group.
The ‘Get up and Go’ programme run a range of fitness activities for those with mild frailty living in East Merton and Morden. Activities range from seated exercise to pilates to new age Kurling.
Community Dementia Services
The Community Dementia Service, provided by Alzheimer's Society is commissioned by Adult Social Care to provide both hub based and community support and in the last year has helped around 300 carers and 100 people with Dementia with a variety of support including hub and community-based activities, wellbeing assessments and support planning, information, advice, signposting and education.
The Alzheimer’s Society also co-ordinate the Dementia Action Alliance and encourage local businesses and organisations to become dementia friendly. For more information about support available via Alzheimer's Society and other local support, including Council Tax support, please see: Dementia services - Merton Council.
Support for Carers – Carers First Merton
Support for Carers (commissioned by Adult Social Care and provided by Carers First Merton in partnership with Merton Mencap) provides preventative support to Adult Carers (people over 18 caring for another adult) in Merton to access a range of interventions, assessments, support plans, reviews in accordance with the Care Act and information, advice and guidance specific to the caring role. Carers First Merton also support access to activities, training, workshops, online and in-person support groups and events to assist and provide support to Carers in their caring role. Carers First Merton also works with local and national partners to signpost to and make referrals on behalf of Carers to ensure that they receive the support that they need. Carers First Merton also support Young Carers from the ages of 5-18 years old.
To refer a Carer, or for further information please contact Carers First Merton.
Tel: 0300 303 1555, during office hours (10am-5pm Monday to Friday)
Website: www.carersfirst.org.uk
Email: hello@carersfirst.org.uk
Warm and Well Programme
The Warm and Well Programme is a partner initiative between the Council, Thinking Works, Age UK Merton and Wimbledon Guild. The programme aims to expand its current offer to support more residents facing fuel poverty and the impact on their wellbeing due to the increased cost of living.
The service provides:
- Warm and Well Project co-ordination to raise awareness of energy saving advice and support;
- Information and Advice to maximise income and access to relevant benefits;
- Energy efficiency advice for homeowners and support to access larger grants if eligible;
- Free heating checks and repairs to eligible residents;
- Free handyperson service to eligible residents (charge for materials);
- Cash and small grants to residents in financial need.
Use the above links to refer a person to any part of the warm and well programme, or contact Merton Community Hub. For more information:
Tel: 020 8946 0735
Email: info@wimbledonguild.co.uk
Befriending
If someone (aged 65+) is lonely or isolated, you can contact Merton’s befriending scheme run by Age UK Merton and Wimbledon Guild. They can match people up with a volunteer based on shared interests for a weekly befriending visit. There is also a small project for people with mental health issues to access befriending support.
Merton Talking Therapies
Merton Talking Therapies, iapt (swlstg.nhs.uk)
The service provides free confidential psychological and wellbeing interventions for common mental health problems (anxiety disorders or depression).
Referrals are accepted from people aged 18 years and over who are Merton residents, or non-Merton residents who are registered with a Merton GP. This includes those in temporary accommodation in the borough.
Self-referrals are welcome.
Sometimes it is helpful to contact a charity or other organisations for support, see: National Contacts for details of national organisations.
Information and advice must be provided in an accessible way so that the person can best understand and make use of it.
If you feel the person will need support to understand any information then you should:
- Ask the person what would help, for example providing information in writing, a face-to-face meeting, breaking information down or presenting it in a simpler format;
- Consider whether the person has someone who is appropriate and can support them;
- Consider the benefit of independent advocacy.
Under the Care Act the Local Authority has a duty to not only provide information and advice where it is needed, but to ensure that the information and advice it provides has been effective.
Therefore, when information and advice has been provided you should agree appropriate arrangements to follow up with the person in order to review how effective this information has been.
The timescales for this follow up should reflect the individual circumstances and level of risk.
Where someone else is following up on the information and advice given (rather than following up on it yourself) you must make sure that you have recorded this in a way that ensures the person follows up on it at the agreed time.
The Local Authority has a duty to safeguard the confidentiality of personal information.
This duty arises in two ways:
- A statutory duty to store and process data in accordance with the Data Protection Act 2018;
- A duty under the common law to keep confidential any information which has been provided in confidence.
It is important to note that the Data Protection Act 2018 and UK GDPR do not prevent the sharing of information when necessary and proportionate to do so, to safeguard vulnerable adults and children.
For further information and guidance, see: Providing Information about a Person or Carer.
If the information gathered during a telephone contact suggests the person would benefit from further assessment or intervention, a referral should be taken so long as:
- The person/carer is making the referral/contact themselves;
- The person/carer has given their consent; or
- The person lacks mental capacity to make a referral and a decision has been made under Best Interests that a referral/contact should be made; or
- The person is at risk of harm from abuse or neglect.
When a referral is taken the following information should, if possible, be included:
- All personal details, including the person’s/carer’s full name (and also preferred name or previous surname), address and preferred contact details (such as email, phone number etc), date of birth, national insurance number and NHS number;
- The name, relationship and contact details of the person making the referral (if not the person/carer themselves);
- When and how the person/carer consented to the referral;
- If the person has not consented to the referral, was a mental capacity assessment carried out and is the referral being made under Best Interests;
- What the presenting issue and needs are from the person's/carer's perspective and what they would like to happen;
- What the presenting issue is from the referrer's point of view (if the referrer is not the person/carer) and what action they may recommend;
- What options have been considered with the person/carer to resolve the issue so far, including what support the person/carer has had from family and community networks;
- What information and advice has been provided to the person or what information and advice may be required;
- What prevention services have been used, considered or may be of benefit;
- Any specific communication needs of the person/carer that need to be considered so they can understand and be involved in any adult Care and Support process;
- Whether the person/carer is likely to have substantial difficulty in any adult Care and Support process, and if so whether an independent advocate has been considered;
- Details of any previous or current Care and Support/Support services (whether the Local Authority is providing them or not);
- With the person's/carer's consent, the name and contact details of anyone involved in their life who should be involved in any assessment (family member, friend or professional); and
- Any other information deemed relevant by the person/carer or referrer (if the referrer is not the person/carer).
Sometimes it is clear which service/team in the Local Authority should receive the referral. Where this is clear, local processes should be followed to transfer the referral to that service/team.
Sometimes it is less clear which service/team should receive a referral. For example, if the person/carer's needs could potentially be met by more than one team.
Decisions should involve the person/carer and the potential services with the aim of reaching a shared agreement as quickly as possible. Any delays should not negatively impact the person/carer or put them at risk through the delay of any Care and Support/Support needs being met.
Though not a requirement, it would be prudent to apply the same criteria that the Care Act requires to be applied when deciding the most appropriate team/service:
- The views and wishes of the person/carer about which service/team would best support them must be regarded;
- The service/team must possess the skills, knowledge and competence to carry out the anticipated Care and Support functions; and
- The service/team must possess the skills, knowledge and competence required to work with the particular person/carer in question.
tri.x has developed a tool that can be used as required to support consistent decision making about team suitability.
See: Team Suitability Decision Support Tool.
The service area or team receiving the referral should make effective use of the information gathered so far and not make the person/carer (or anyone else previously consulted) repeat information unnecessarily.
It is important that the person making contact speaks to the right practitioner at the right time. Sometimes you may find that you are not the most appropriate practitioner to manage the contact.
When the person making contact (written or verbal) requests to be contacted by a particular practitioner, you should establish if this is appropriate (for example, are they still the allocated worker/practitioner?).
You should not transfer a telephone call or written contact to a named practitioner if it is clear that they are not allocated to the person. This will not be helpful to the practitioner or to the person as it could delay resolving the contact.
A review is the mechanism by which an existing Care and Support Plan (or Support Plan) is evaluated. This can lead to a revision of the plan or further intervention, such as a reassessment of need.
All review requests should be sent to the allocated worker/practitioner, or the team responsible for reviewing the Care and Support/Support Plan.
If the practitioner is not available, you should:
- Inform the person of when the practitioner will next be available. If it is not clear then let the person know;
- Leave the practitioner a message alerting them to the contact, any action undertaken and confirming if information was given to the person about when to expect a call back;
- Forward any original copies of e-mails and any original letters by internal email or secure email/postal delivery only;
- Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required while the practitioner is unavailable;
- Agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
- Make a record of all the above.
If the practitioner is not available within a reasonable timeframe for the action indicated by the contact, you should discuss with their line manager what action should be taken in the interim.
There are many prevention services available such as reablement, Occupational Therapy, health services or assistive technology. They may be provided by the Local Authority, community organisations or partner agencies, such as health. All available prevention services in the local area should be explored before undertaking a longer term intervention. If a prevention service is already in place, there may be other prevention services which are beneficial to work alongside and should also be explored.
Under Section 2 of the Care Act the Local Authority has a duty to prevent needs for Care and Support/Support.
See: Preventing Needs for Care and Support to read more about the duty to prevent needs for Care and Support, including the types of prevention services recognised by the Care Act, when to provide prevention services and how to charge for prevention services.
It is important that when supporting a person or a carer, you explore all preventative opportunities within the voluntary and community sector before thinking about social care support.
For information about these opportunities, please refer to the ‘Providing Information and Advice’ section above.
In addition to the Voluntary and Community Sector, the following are links to health and social care services in Merton that may also be able to assist in preventing, reducing or delaying the needs:
Equipment and minor adaptations
Staying independent at home: Personal alarms and home monitoring – Mascot Telecare - Merton Council
Reablement service: short term help at home - Merton Council
Occupational therapy - Merton Council
Substance Misuse Support
People over the age of 18 who would like support with alcohol or drug use problems can contact Via Merton for free. Via Merton provide specialist drug or alcohol advice, support and treatment.
Tel: 0300 303 4610
Email: Merton@viaorg.uk
Address: 7-8 Langdale Parade, Mitcham, CR4 2F
People can also use Merton’s Drinkchecker service to quickly review their alcohol use and get tips about reducing the risk of alcohol related health problems.
If, as part of any conversation or information gathering you become concerned that a vulnerable adult or child is experiencing, or at risk of abuse or neglect you must respond appropriately by raising a concern.
See Safeguarding Adults, which also includes information about how to raise a children's safeguarding concern.
If you are concerned that an adult or child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by ringing 999.
Whenever the outcome of a contact or referral is that the person will be involved in any adult Care and Support process (including any assessment or safeguarding) the Local Authority has a duty under the Care Act to make an independent advocate available to the person when:
- There is no appropriate person to support and represent them; and
- They feel that the person would experience substantial difficulty being fully involved in the Care and Support process without support.
Decisions about the need for advocacy should be made as early as possible because advocacy must be provided before the Care and Support process can begin. As such if you know that advocacy will be likely you should discuss this with the person and the referral should be made as early as possible.
The Local Authority also has a power (but not a duty) to make advocacy available in other situations on a case by case basis if it deems this appropriate and is able to do so. This could include advocacy to support a person to understand information and advice, or advocacy to support a person to explore possible options available to them.
tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.
People who lack capacity will likely be legally entitled to advocacy under both the Care Act and the Mental Capacity Act 2005. The Care Act statutory guidance recognises that it would not normally be appropriate or practical for a person to have 2 advocates and gives the Local Authority the responsibility to make a decision about the best type of advocacy support.
See:
The Duty to Provide an Independent Advocate.
The Independent Mental Capacity Advocate.
Having substantial difficulty is not the same as lacking mental capacity.
See: Determining Substantial Difficulty for information about how to determine substantial difficulty.
People eligible for an Independent Mental Health Advocate (IMHA) under the Mental Health Act 1983 will likely be entitled to advocacy under the Care Act.
The Care Act statutory guidance recognises that it would not normally be appropriate or practical for a person to have 2 advocates and gives the Local Authority the responsibility to make a decision about the best type of advocacy support.
There are various factors that should influence this decision (such as existing rapport with an advocate or the likely outcome of the Care and Support process) and the Local Authority must ensure that whatever it decides, it does not deny the person any of the specialist advocacy skills they need or are entitled to.
Regardless of whether or not independent advocacy is available in the local area the duty to provide it still applies. A failure to do so is a breach of this duty and of the law. It is the role of commissioners to ensure that advocacy services are in place and available when required, and it is the role of practitioners to make timely referrals to advocates to prevent unnecessary delays in the meeting of its duty.
In some circumstances urgent interim measures may need to be agreed without an advocate in place in order to reduce immediate risk to the person from inaction. However, Care and Support processes that will decide long term and important decisions must not be carried out without advocacy support.
The duty upon the Local Authority is to make independent advocacy support available to any person who requires it. Once made available the duty is met.
If a person decides that they do not wish to engage in the advocacy support that has been made available to them they do not have to do so, but the Local Authority must still provide it.
The Local Authority is expected (under the Care Act) to support the person to understand the role of an advocate and promote its benefit to the person to reduce the likelihood that they will not engage.
Sometimes the required support/ intervention would be better carried out or led by a different service area or team. For example:
- If the person has multiple needs that cross into more than one service area and it is felt that a practitioner working in a different area would possess more expertise; or
- If the person was referred to a long term intervention team but after consultation it is felt that a prevention service may be more appropriate.
Any process for transferring a person's case between service areas or teams should be as simple and seamless as possible. It should involve the person and the potential services with the aim of reaching a shared agreement. Any transfer should not negatively impact the person or put them at risk through the delay of any Care and Support needs being met.
Though not a requirement, it would be prudent to apply the same criteria that the Care Act requires to be applied when deciding the most appropriate worker/practitioner:
- The views and wishes of the person about which service/team would best support them must be regarded;
- The service/team must possess the skills, knowledge and competence to carry out the anticipated Care and Support functions; and
- The service/team must possess the skills, knowledge and competence required to work with the particular person in question.
tri.x as developed a tool that can be used a required to support consistent decision making about team suitability.
See: Team Suitability Decision Support Tool.
The service area or team receiving the case should make effective use of the information gathered thus far and not make the person (or anyone else previously consulted) repeat information unnecessarily.
Sometimes there may be a clear benefit to a joint assessment or intervention with another service area, team or professional. The Care Act recognises this and permits the Local Authority to make any arrangements it deems appropriate in order to facilitate joint working with others.
If there are likely to be delays in your commencement of joint work the person who requested the joint work will need to:
- Consider whether to proceed with their intervention; or
- Await your availability.
See: Joint Work for further practice guidance about effective joint working.
Any decision to request joint work should be made with the person (or their representative). Where the person is unable to provide consent to joint work decisions should be made in their best interests.
Joint work requests should be made in the manner preferred by the service, team or professional to which the request is being made. This may or may not take the form of a referral.
The request should explain clearly the nature of the joint work required and any specific skills, knowledge and competence requirements to support allocation.
When you have been asked to work jointly with another service, team or professional you should contact them to confirm your involvement and discuss the most effective way to work together. The things you should establish include:
- The work they are doing/will be doing/have done and whether they have any information that you need to know or can use to avoid duplication;
- Whether there are opportunities to co-ordinate systems and processes and if so, how this will be managed;
- What the expectations are in terms of joint working (for example will you be expected to carry out a joint assessment, meet with the person together, produce joint records or just consult and share information);
- What the anticipated outcome of the joint work is (for example joint funding of support, on-going joint-work to monitor);
- What does the person with care and support needs know about the joint-work to be carried out (and if they don't know who and how should this be explained);
- Who will be the primary contact for the person (or their representative) to go to with any queries; and
- Who will be responsible for communicating progress and decisions to the person.
See: Joint Work for further practice guidance about effective joint working.
Some areas of joint work are specialist in nature. The procedures for these pieces of work can be found in the Specialist Procedures section. The following are examples of the procedures that can be found there:
- NHS Continuing Healthcare;
- Continuity of Care;
- Cross Border Placements.
For reablement, see: Revising a Reablement Plan.
Under the Care Act, when a person is already receiving Care and Support from the Local Authority they may request a change to their Care and Support Plan at any time and the Local Authority must consider the request. Where the request is deemed reasonable the Local Authority has a duty to review the plan.
The review is the mechanism by which the need for a revision is determined. As such, under the Care Act a Care and Support Plan can only be revised following a review.
Where a change is requested to a plan and there is no planned review scheduled consideration should be given to arranging an unplanned review. Any review must be proportionate to the needs of the person and undertaken in a timely way so as to reduce the risk of a crisis developing and needs not being met.
If the person has an allocated worker this person should carry out the review, unless the review is urgent and the allocated worker unavailable.
Before transferring the review request you should confirm that the practitioner the review request is being transferred to is able to carry out the review.
If the practitioner is not available you should speak with a manager to establish whether:
- The request should still be transferred to the allocated worker to action when they become available;
- Alternative arrangements should be made to carry out the review.
Where the information gathered at contact suggests there has been no change in the person's needs, and that a change to the personal budget amount is not required it may be possible to complete a 'light touch' review without further allocation.
Jamal has support from a domiciliary care agency on a Monday, Wednesday and Friday before he goes to work. His employer is going to change his days of work and Jamal needs to change his Care and Support Plan to reflect the new days that he is going to be supported.
When the information gathered at contact suggests there has been a change in need or circumstance, and that a change in the personal budget amount is required any review carried out is likely to lead to a reassessment of need. Because this is a longer term intervention allocation for this should be considered.
Jamal has support from a domiciliary care agency on a Monday, Wednesday and Friday before he goes to work. He has sought reduced hours at work because his health condition has deteriorated and he often feels too tired to work. He no longer requires support in the morning as often, but feels he now requires additional support in the evenings and to prepare his meals.
Not everyone contacts the Local Authority in a timely way so as to allow for an assessment, reassessment or review and exploration of options to take place prior to any initial decisions being made about the need for Care and Support.
For example, some people only approach the Local Authority when they are in a time of crisis, high risk or when there is a sudden or unexpected change in their Wellbeing.
In these cases, there may appear to be an urgent need for support that cannot wait for an assessment or review process to be carried out.
The Care Act recognises this occurrence and gives the Local Authority powers to meet such needs without having carried out a formal assessment process.
To see what the Care Act says about meeting urgent needs without an assessment or review, see: The Power to Meet Needs.
Having the power to meet needs without an assessment or review means that the Local Authority can decide whether or not to do so, based on the available information and specific circumstances of the person and their situation.
Under the Care Act, the Local Authority can put any interim or urgent measures in place that it deems appropriate to meet the needs of the person and manage the situation. This can range from domiciliary care visits to a stay in residential accommodation.
The same legal considerations apply when meeting urgent needs as they do when meeting non-urgent needs:
- The impact on the person's individual wellbeing;
- Whether any preventative service can be provided that will delay, reduce or prevent the need for Care and Support;
- Whether information and advice can be provided to support the person to find their own solution, or to delay, reduce or prevent the need for Care and Support.
It is vital that you understand your duties in relation to the above. Please use the links below to access further information as required.
- Promoting Individual Wellbeing for information about the duty to promote individual wellbeing;
- Preventing Needs for Care and Support for information about the duty to prevent, reduce or delay needs;
- Providing Information and Advice.
In addition, you should be mindful that nobody has yet assessed (or reassessed) the needs of the person and you may be relying on historical information or information from sources currently under significant strain or pressure to act. As such the information presented may or may not be an accurate reflection of the person's needs following an assessment.
Interim support should therefore only be seen as a temporary measure to reduce risk of harm and support the person in the short term until a needs assessment can be carried out and long term options explored and agreed with them. As such, you should be cautious about providing interim Care and Support that may be problematic to cease following assessment.
tri.x has developed a tool that can be used as required to support consistent decision making about the provision of urgent or interim support.
Wherever possible, every conversation with a person should be from a strengths based perspective. This means that before you talk about service solutions to the presenting issue you must support the person to explore whether there is:
- Anything that the person can do to help/support themselves; or
- Anything their family, friends or community can use to help themselves.
A strengths based approach is empowering for the person and gives them more control over their situation and how best to resolve any issues in the best way for them. The end result may still be that the Local Authority intervenes with an assessment or other support, but this decision will have been reached knowing that it is the most proportionate response available.
Adopting a strengths based approach involves:
- Taking a holistic view of the persons needs in the context of their wider support network;
- Helping the person to understand their strengths and capabilities within the context of their situation;
- Helping the person to understand and explore the support available to them in the community;
- Helping the person to understand and explore the support available to them through other networks or services (e.g. health);
- Exploring some of the less intrusive/intensive ways the Local Authority may be able to help (such as through prevention services or signposting).
SCIE have produced clear and practical guidance around how to use a strengths based approach in practice. See: Care Act Guidance on strengths-based approaches.
All funding requests for urgent and interim support should be made in line with local processes and requirements.
It can be difficult to make a decision about the level of funding required to meet the urgent or interim Care and Support needs because:
- There will be no personal budget allocated to the person; or
- There will be a personal budget but this will not be based on their current needs.
The Care Act does not discuss or set funding limitations in relation to the provision of any Care and Support. This includes urgent and interim Care and Support. Instead, the golden rule of the Care Act when making any funding decision is that 'the amount of funding agreed must be sufficient to meet the needs that are to be met at that time'. Decisions must also be made in a way to ensure that the person will be satisfied the process was fair and robust.
Other than sufficiency, the factors that decision makers must consider are:
- The views and wishes of the person about how their needs should be met;
- The availability of other potential options in the marketplace; and
- The cost of available suitable services in the marketplace.
Other factors that should be considered are:
- The complexity of the person's needs;
- The level of risk/sense of urgency; and
- Whether the practitioner requesting the funding has provided relevant information and advice, whether they have explored prevention services that may be appropriate and whether they have explored how the person's own networks of support could help; and
- Where the person is not ordinarily resident; if they receive Care and Support already in another Authority the nature of the Care and Support they receive.
Decision makers should also take into account that the Local Authority is also permitted under the Care Act to consider how to balance its legal requirement to maintain universal services to the entire local population with the power to meet urgent needs. In doing so it must:
- Not base its decision on finances alone;
- Consider things on a case-by-case basis; and
- Not set arbitrary limits (fixed amounts for a particular type of need or service).
The outcome of the funding decision should be communicated to the person at the earliest opportunity. The method of communication should reflect that requested by the person and any specific communication needs they may have. For the purposes of the Care Act communication about the outcome of a funding decision is subject to the same requirements as the provision of information and advice, and the duty to make it accessible therefore applies equally.
Where communication is provided by telephone, a follow up letter or email confirming the conversation and the funding decision should be sent to the person as a formal record.
When communicating the outcome you should include the following information:
- The funding decision itself;
- The rationale for the decision;
- Any information and advice relating to adult Care and Support, and the prevention, delay or reduction of needs;
- What will happen next and the timeframes involved;
- How to complain about any aspect of the decision or proposed outcome.
Any funding decision rationale should be clearly recorded in line with local recording requirements.
The Local Authority is not required to record urgent and interim support on a Care and Support Plan because:
- The support is being provided under the Local Authority's powers (as opposed to duties);
- The person has not yet been assessed (or reassessed); and
- There has been no decision about eligible needs.
However, the following must be clearly recorded:
- The urgent or interim support being provided;
- The contribution to the cost of the support being made by the Local Authority;
- The contribution being made by the person;
- The duration of the support;
- How the support will be reviewed;
- What outcomes the support aims to achieve; and
- The next steps, including timeframes for any assessment.
Under the Care Act the process of arranging to meet urgent and interim Care and Support needs is the same as arranging to meet needs agreed through a non-urgent Care and Support Planning process.
The Local Authority is permitted under the Care Act to charge any person for Care and Support (including Care and Support provided on an urgent basis) unless:
- It chooses not to; or
- The person has been financially assessed as having insufficient funds to contribute; or
- The support being provided is reablement (up to 6 weeks is non-chargeable); or
- The support being provided is equipment (up to the cost of £1000 is non-chargeable).
For further information about charging for all services under the Care Act, see: Power of the Local Authority to Charge.
See the Financial Assessment Procedure for further guidance.
Where urgent support is provided to a person who is not ordinarily resident contact should be made at the earliest opportunity to the Local Authority in which they live to inform them of the intention to meet an urgent need.
Where the person is already in support of a service from the other Local Authority information should be gathered to support any decisions made about which support should be provided.
Agreement should be reached with the other Local Authority about how any urgent Care and Support services will be monitored, when they intend to assess for eligible needs and how reimbursement of costs incurred can be sought.
tri.x has developed a tool to support decision making around ordinary residence.
See: Ordinary Residence Decision Support Tool.
Also see the Ordinary Residence Procedure for further information.
Where the outcome decision is for the person's case to be allocated to an individual worker to carry out an assessment, review or further intervention this allocation should take place in a timely way so as to:
- Avoid any unnecessary delays to the person;
- Reduce the risk of a deterioration in the situation; and
- Maximise the use of measures that will prevent, delay or reduce needs.
Where there are a significant number of people awaiting allocation for further work or assessment there should be a fair and consistent prioritisation process in place that takes into account:
- The level of risk;
- The level of need;
- Current support in place and the sustainability/effectiveness of this;
- The urgency;
- The likelihood of deterioration; and
- The potential for fluctuation.
An element of monitoring should be incorporated into any allocation process to ensure that you remain aware of every person's situation and are able to respond appropriately to any changes or need to re-prioritise allocation.
The Care Act recognises that each worker (regardless of whether or not they have a professional qualification) will possess specific skills, knowledge and experience that will enable them to carry out different Care and Support functions or work with particular people well.
Because of this there is no expectation that a particular role should carry out a particular function; instead the Local Authority should allocate tasks to the most appropriate person for the job.
Allocation decisions should take into account:
- The skills, knowledge and experience of the worker in carrying out the function or process required;
- The skills, knowledge and experience of the worker in working with the particular needs of the person (for example health needs or communication needs); and
- The views and wishes of the person themselves in relation to the skills required of the worker and who they feel would best support them.
tri.x has developed a tool that can be used as required to support allocation decisions.
See: Allocation Support Tool.
Sometimes the information gathered at contact, referral or through consultation with others will evidence that:
- Allocation for further assessment is not required; and
- The most appropriate and proportionate response is to provide minor works or low level equipment.
When arranging minor works and low level equipment (either directly or through a partner agency) you must ensure that appropriate mechanisms are in place to:
- Support the person (and any carer) to use the equipment provided safely;
- Monitor the effectiveness of the works and equipment; and
- Review the need for further assessment or intervention.
You should refer to available local guidance to confirm which works and equipment can be provided through the minor works scheme.
You should familiarise yourself with available local guidance that confirms who is responsible for maintaining or repairing equipment in a range of circumstances.
Where equipment maintenance is not the responsibility of the Local Authority you must remain mindful that meeting the person's needs remains the duty of the Local Authority at all times. There could therefore be a need to support the person to get the equipment maintained (for example by contacting the repair service on their behalf) or to provide interim equipment or an alternative measure to meet the need whilst any equipment maintenance is carried out.
Direct support refers to the range of ways that an Occupational Therapy practitioner works directly with a person or a carer to ensure safe and effective use of equipment, aids or an adaptation.
Direct support includes:
- Training of informal and paid carers in the safe and proper use of equipment; and
- Supporting the person to safely and confidently use equipment or adapt to their environment after an adaptation.
Direct support:
- Builds the person's confidence to use equipment and access their adapted environment;
- Builds the confidence of any carers to use the equipment;
- Ensures that people using the equipment are suitably skilled to do so;
- Ensures that people using the equipment know when it may be faulty;
- Reduces the risk of unsafe use of the equipment;
- Reduces the risk of injury from unsafe or improper use of the equipment;
- Maximises the effective use of the equipment or adapted environments to promote independence or prevent, reduce and delay needs.
Last Updated: May 20, 2025
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