5. What happens next?
Producing a care plan
Once it is decided that the person has needs which make them eligible for support, the HSC trust has a duty to provide sufficient support to ensure that these are met.
The person who carried out the assessment should write a 'care plan'. This describes which services are to be provided. The person with dementia and their carer should be closely involved in the development of the plan.
The care plan should include:
- the needs that have been identified
- the desired outcomes and how they can be met
- a risk assessment
- a plan for dealing with emergency changes
- the result of any financial assessment
- the support that carers are willing and able to provide
- the support to be provided to meet the assessed needs
- the date on which the plan will be reviewed.
The person with dementia and their carer should be given a copy of the care plan. If they are not, they should ask for one. They should also be given the name of the person responsible for ensuring that services are then provided, often known as a care manager. The care manager can be contacted if there are any difficulties.
People who pay for their care with their own money can still benefit from a care plan, to help them to make the best use of their resources.
How are services arranged?
The local HSC trust will give the person with dementia or their carer the option to arrange their own support services (see 'Direct payments and personal budgets' below). The carer will need to be considered to be a 'suitable person' – the local HSC trust has criteria on who this can be. Services may be provided directly by the HSC trust or arranged through other agencies, such as health or housing providers, or voluntary or private organisations.
Some services, such as community nursing, are arranged through the GP, either directly or after discussion with social services.
How long do services take to arrange?
In some cases, the HSC trust may provide a service straight away. Once it has been agreed that services are needed, the HSC trust must ensure that these are provided. However, there may be a wait while they are organised. There should not be excessive delay. If there is likely to be a delay, the HSC trust may find another way to meet the assessed need until the desired service can be provided.
What are reviews?
People's circumstances change, so the services they receive should be reviewed from time to time. Reviews take place to see whether the person's needs have changed. Care plans should be reviewed at times or intervals specified in the care plan (eg within the first six months and then annually), or as needs change. If there is a change in the situation of the person with dementia or their carer, they should contact the local HSC trust, whether or not a regular review is due. They should also contact them if they feel that they need more help, or different kinds of services.