1. The Role of Adult Social Care

Citizen and Carer Adult Social Care Journey (publicly accessible)

The local authority’s adult social care service supports adults with care and support needs, and their carers, to live fulfilling and independent lives in their own homes for as long as possible. When this is no longer possible due to a change(s) in their health or circumstances, adult social care will assist them to finding suitable, alternative accommodation. It is essential that the adult and their carer continue to exercise choice and control in the decisions that are made with them, about their care and support. As well as being involved in the choice of type and location of their living arrangements, it may also involve continuing relationships with family and friends, maintaining leisure activities or developing new interests. This process is known as the citizen journey.

Staff in the adult social care service understand and respect cultural and religious differences, and those of sexuality and sexual identity. They work with adults and carers – regardless of age, ability or financial status – to help them get the help they need, when they need it.

Ordinary life often involves risk, which can increase if someone’s health or circumstances change. In such situations, adult social care helps adults and their carers understand and manage risk, whilst still ensuring they are able to exercise choice and control (see Risk Assessment).

Leading a fulfilling life is more than simply routine daily tasks. As well as physical health, adult social care considers people’s emotional and social wellbeing (see Promoting Wellbeing). Using a term called self-directed support, staff ask adults with care and support needs, and their carers, what areas they need care and support with and the difference they hope this support will make to their lives.  Staff can also assist adults and carers to identify their strengths, as well as areas they wish to develop.

Via the Information and Advice Service (see Information and Advice) sometimes adults with care and support needs, and their carers, can achieve the change they want through informing them of the services and opportunities available locally.

Some adults with care and support needs who lack mental capacity may need an advocate to support them in ensuring decisions are made in their best interests and that they remain the centre of the services which provide their care and support needs. In such situations, adult social care work with advocates, whoever that person may be (see Independent Advocacy and Independent Mental Capacity Advocates).

1.1 Adult safeguarding

Everyone has a right to live a life free of the fear of abuse or intimidation. Adult social care has a legal responsibility to help prevent adults experience, or be at risk of, abuse or neglect. The service must investigate abuse when it takes place and protect adults who experience abuse (see Adult Safeguarding).

1.2 Other areas of care and support

In addition, adult social care provide care and support in the following areas:

  • Carers: many adults rely on family and friends for their care and support needs. Adult social care works with carers to ensure they get the support they need, and that they are not unfairly disadvantaged by their caring role. They are entitled to a carer’s assessment to ascertain their support needs, and a support plan (see Assessment).
  • Reablement: the reablement service is a time limited provision which assists people who are starting to find daily tasks more difficult. Following assessment, installing  equipment (such as grab rails or bathing aids) may be sufficient, and / or the input of trained care and support workers who assist the adult and carer to find new ways of carrying out tasks in the home (see ReablementPreventing, Delaying or Reducing Needs).
  • Care and support planning: this is a written description of what adults and their carers say are their care and support needs, what they want to change in their lives and how they will achieve this change (see Care and Support Planning). The care and support plan puts the adult in control, and makes them central to the decision making process. If longer term support is required staff assist them to decide what this support is and how it should be provided. This may include agreeing how much financial support they will need to meet their needs and help them to buy and manage the care to support themselves (see Assessment, Eligibility, Personal Budgets and, Charging and Financial Assessment).
  • Ongoing case management by social workers: for some adults with care and support needs, exercising choice and control can be complicated, due to physical and /or mental health needs. Sometimes, family relationships result in it being more difficult to ensure safety, dignity, choice and control.  The Social Work Service works with adults and their carers, to help them manage their care and support (see Case Management). Whilst ensuring their immediate needs and safety, adult social care staff also work towards helping them manage their own care in the future, as much as possible.
  • Financial assessment: care and support services are not available free of charge. If an adult is assessed as being eligible for social care (see Eligibility), they will be required to pay for the services they receive (see Charging and Financial Assessment). If a person does not have sufficient resources to pay, the local authority will pay for part or all of it depending upon their financial circumstances.
  • Hospital discharge: some adults are referred for care and support services because they have been admitted to a hospital ward / unit or an accident and emergency department (see Hospital Discharge). Where adults have  more needs, which require the support of adult social care, staff will work with them and their carers to identify what support they need to recover as much independence as possible (may be even more than prior to hospital admission). This may include a period of rest and recovery or reablement, in their own home or in a residential or nursing home (see Assessment, EligibilityReablement and Case Management).

2. Key Aims of Personalisation and the Citizen Journey

See also Personalisation

Personalisation within the citizen journey is at the centre of all work undertaken by adult social care. Below are the key aims of personalisation, which is inherent in the citizen journey:

  • the adult with care and support needs is the central focus for all involved;
  • adults have increased choice and control;
  • there is easy access to information, advice, advocacy and signposting to universal services;
  • there is reduced delay and duplication of services;
  • enquiries and requests are resolved at the earliest opportunity;
  • assessments to establish agreed goals and outcomes, result in personalised, cost effective care and support plans that addresses their individual care and support needs;
  • adults are supported to maximise and maintain their independence;
  • the eligibility criteria are implemented fairly, effectively and transparently;
  • care and support plans for adults, and support plans for carers, may involve a wide range of services as appropriate, including leisure, employment, education, transport, housing, community safety, and health. The voluntary and community sectors may be providers of such services.

These key aims should underpin all stages of the citizen journey and therefore the work of staff and managers working with adults with care and support needs, and their carers.

3. Step by Step Summary of the Citizen Journey

Below is a summary of the end to end steps available from adult social care and its partners, via the citizen journey. Links to specific chapters provide more detailed information.

  • Step 1 – First Contact, Access and Information: advice, information and referral (see Information and Advice);
  • Step 2 – Reablement: regaining independence (see Reablement);
  • Step 3 – Eligibility: who is entitled to what sort of care or support (see Eligibility);
  • Step 4 – Ongoing Case Management: complex support for people with longer term conditions (see Case Management);
  • Step 5 – Personal Budget: calculating the money allocated to meet current care and support needs and achieve future goals and outcomes (see Personal Budgets and Charging and Financial Assessment);
  • Step 6 – Care and Support Planning: create a plan to show how the personal budget will be spent to meet current care and support needs and achieve future goals and outcomes, and organising care and support and putting the plan into action (see Care and Support Planning);
  • Step 7 – Payment Options: ways of managing personal budgets (see Charging and Financial Assessment);
  • Step 8 – Reviewing progress: checking current care and support needs are being met and goals and outcomes achieved (see Review of Care and Support Plans).

4. Further Reading

4.1 Relevant chapters

Promoting Wellbeing

Preventing, Reducing or Delaying Needs

Information and Advice

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