- Mr. Ron Davey has memory problems and needs support to maintain his independence at home with his wife. His indicative budget is £161.84 per week. - His plan is to receive home care support with personal care, attend a day center three times a week for social stimulation and respite for his wife, and have outreach support to help accept services. The total estimated weekly cost is £169.50, within his budget. - The plan will be managed and reviewed by social services. It will be checked on July 22nd by visiting Mr. and Mrs. Davey at home and contacting service providers to ensure the plan is working effectively.

1. - 1 -
My Support Plan
This Support Plan is to be completed once you have completed the ‘My help, care and support needs’ questionnaire and
have been informed of your indicative budget. The purpose of this plan is to set out how you want to spend this money in
order to meet your needs and personal outcomes.
1. Basic Information
Name: Ron Davey*
SWIFT ID: 13256
Who has supported you in completing this plan? Sarah Whittaker*
What is their relationship to you? SOCIAL WORKER
What is your indicative allocation? (Weekly) £161.84
2. About Me
Please describe what your interests are and what is important to you. Who are the important people in your life? What is
working well and what is not working well in your life?
Mr Davey finds it difficult to always remember why he needs additional support because of his memory problems.
He is a very private person who would prefer to not have outside support but with encouragement is gradually starting to
accept the need for help.
He can no longer concentrate on tasks around the house or in the garden but gets very frustrated and needs to be
constantly occupied.
His wife, plus his desire to remain at home, are both very important to him and he does accept that support will ultimately
help to relieve his wife of some of the day to day difficulties and maintain his independence in his own home.

2. - 2 -
3. What I want to achieve, maintain or change
Please list in the first column what in your life you want to achieve, maintain or change.
Please list in the second column how you plan to do this.
Please list in the third column who could help you do this.
My Outcomes
What I want to achieve, maintain or change
How will I do this?
What activities, support, products and services will
help me do this?
Who could
support me?
To maintain independence in own home. Help with personal care needs. Home care
To support his wife in return for her caring for
him.
Regular periods of Respite for Mrs Davey Day Care and
Time Out
services
To try and avoid any further deterioration in
memory problems.
Social Stimulation and support. Day Centre

3. - 3 -
4. My action plan
Please complete the table below to show what you are going to do to meet the outcomes in section 3.
It is important that you show how you are planning to use your indicative budget by showing how much each activity will
cost. If it is a regular activity put weekly costs. You can also list one off purchases such as buying a piece of equipment.
What am I going to do?
(list the activities, support, products,
services you have identified in column 2 in
the table above)
What date will
I start this
activity?
How many hours
will I be doing this
each week?
Approximately how
much will it cost? Is
it a one off cost or a
regular, weekly
cost?
Service provision
(this can be filled out later
once you have found the
best provider for you)
Service type Provider
Time Out Services to provide carer respite Ongoing 3 hours per week.
Currently weds
afternoons
£12.75 p.hour x 3 =
£38.25 per week
Time Out Social
Services
Day care at Anytown Resource Centre.
To provide social stimulation and carer respite
1.7.2010 One day per week £35 per day Day Care Social
Services
Help to get washed and dressed.
Anytown Outreach team to provide specialised
support to encourage acceptance of services.
24.5.10 start
date.
To continue
Initially am call only
to be increased to
am and pm call as
confidence
increases
To increase to half
hour call am and half
hour call pm.
7 hrs x £13.75 =
£96.25 per week
Home care Outreach team
at Anytown.
HOW MUCH WILL IT COST EACH WEEK? £ £169.50
HOW MUCH ARE THE ONE OFF COSTS? £ nil
WHAT IS THE TOTAL COST FOR THE YEAR? (52 weeks/ year) £ £8814
DOES IT MATCH THE INDICATIVE ALLOCATION? Y

4. - 4 -
5. Making sure My Support Plan will work, and will be safe for me and others
Please take some time to identify what can go wrong in your plans to meet your outcomes and list them in the table below.
Then think about what you can do to try to stop this and think about what must be done if things do go wrong after all.
What in your
Support Plan could
go wrong?
How likely is it
that things will go
wrong?
(Please answer
with unlikely,
possible, likely,
very likely)
What may happen if
things do go wrong?
(the impact)
What can you do to
stop this happening?
What will need to be
done if things do go
wrong?
If Mrs Davey
becomes unwell
and unable to offer
the present degree
of care at home to
her husband
Unlikely Mr Davey will need 24
hour care as he
cannot be left alone
Support Mrs Davey and
increase level of
support as care plan
becomes accepted
Potential residential
care if Mrs Davey not
able to look after her
husband at home.

5. - 5 -
6. How my support will be managed
Please tell us how you would like to manage your the activities, services, support and products listed in your plan.
Please
tick
Do I want these managed by myself, by Adult Services or by someone else on my behalf?
I will do it
myself
Adult Services / I would like the arrangements to be managed and reviewed by Social Services
Someone else
on my behalf
(e.g. a family
member,
friend, agency)
7. How I will stay in control of my life.
You may want to ask someone to help you make decisions about your support and how it should be provided. Please tell
us who by ticking the relevant statement(s) below, and telling us who it will be and how you know them:
I will make the decisions myself
Adult Services / I would like Social Services to help me to make future decisions
Formal advocacy support
Informal support networks
Through a decision making agreement Please provide us with a copy of the agreement
Other (please detail)

6. - 6 -
8. Checking my plan is working
Please write here how and when your plan will be checked to make sure it is working.
Care Plan to be checked July 22nd
2010.
Social worker will visit Mr and Mrs Davey at home and check how services are working out directly with the home
care and day care services.
Your signature
SIGNED _________________________ NAME ___________________________ DATE_____________
Signature of the person who supported you to complete this
SIGNED _________________________ NAME____________________________ DATE_____________
Signature of care manager approving the support plan
SIGNED _________________________ NAME____________________________ DATE_____________
Signature of senior care manager _________________________ Date___________________________
OFFICE USE ONLY:
Panel required: Yes/No Panel date:
Validation outcome (including reasons):
Agreed final amount: £