The Reablement Review

Review in reablement has a dual purpose to:

1. Review the reablement provision itself; and
2. Establish what the person's likely needs for Care and Support may (or may not) be when reablement ends.

It is your responsibility as the allocated social care practitioner to carry out the review of the reablement service being provided. This should be carried out with Care Dorset.

The following information should be clearly but proportionately recorded in all cases:

1. Whether the different elements of the Reablement Plan are in place and working as intended (and the evidence for this);
2. Progress that has been made towards outcomes in the Reablement Plan (and the evidence for this);
3. The views of the person and any carer about the progress of reablement;
4. Who has been involved in reablement and the role they have played (including family, friends and other service such as occupational therapy);
5. Steps taken to support the person to achieve general outcomes identified at assessment;
6. Where issues were identified, what these were and the steps taken to resolve them;
7. Whether reablement is still appropriate and needs to continue; and
8. The views of the person and any carer about the need to continue reablement.

If reablement is to continue you should also record the following:

1. Why a decision has been made to continue reablement;
2. Whether any changes are needed to the reablement plan (e.g. to outcomes) or service delivery (e.g. frequency/duration of visits or involvement of others);
3. Whether any changes are needed to the monitoring arrangements; and
4. When the next review will be.

If reablement is to end you should record the following:

1. Why a decision has been made to end reablement;
2. When it may be appropriate to end reablement;
3. Whether the person has any likely needs for on-going Care and Support;
4. If so, whether these needs are already being met through an existing Care and Support Plan;
5. If not, what action needs to be taken to ensure likely needs are confirmed, eligibility determined and eligible needs met.

Whenever you carry out a review of reablement you must involve:

1. The person receiving reablement;
2. Anyone else that the person has asked you to involve;
3. Any carer that the person has;
4. The person's representative (when they lack capacity or have substantial difficulty);
5. Where the person lacks capacity, anyone else that the Local Authority deems it would be in the person's best interests to involve.

With the person's consent you should also involve:

1. Anyone who has been involved in providing reablement to the person;
2. Anyone who has been involved in monitoring reablement (for example an occupational therapy practitioner); and
3. Any family or friends of the person.

Note: Involving family and friends can increase the effectiveness and sustainability of reablement outcomes.

Under the Care Act carers have to be a part of any review, even if the cared for person does not want them to be. This is because the Local Authority needs:

1. To gather further information about the Reablement Plan in regards the way it is meeting the needs of the person;
2. To understand any risk to the carer's role in the plan;
3. To identify any needs of the carer and fulfil the duty to meet them.

When a person has not consented to the carer being a part of the review you should:

1. Advise the person that you have a duty to involve the carer;
2. Explain the benefits of the carer being involved; and
3. Agree the most appropriate way to involve the carer (for example a separate meeting with the carer).

If the person has requested particular information not relating to needs is withheld from the carer, and they have capacity to do so normal confidentiality rules apply unless doing so would put the person at risk of abuse or neglect.

Some people will lack capacity to understand or engage in the reablement review process (verbally or through another means). Where this is the case the duty to ensure their involvement still applies.

There are a range of ways that you can ensure the involvement of a person who lacks capacity, including but not limited to:

1. An appropriate other person or independent advocate to support the person to engage and ensure that they are represented;
2. Spending time with the person;
3. Consulting with a range of people who know the person;
4. Use other available evidence (for example ABC charts and other records).

All information gathering and sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

If a person does not lack capacity but does have substantial difficulty being involved in the review you must take all reasonable steps to ensure their involvement.

You must:

1. Ensure that you have provided information in an accessible way, or that the person has an appropriate person to support them to understand it;
2. Arrange to carry out the review in an appropriate format so that it is accessible. This is likely to be face to face, unless the person's difficulty arises when engaging in face to face communication;
3. Consider whether the person has an appropriate person to support their involvement and, if not, whether the advocacy duty applies.

See: Using Independent Advocacy, which includes guidance on how to establish whether a person needs an advocate and how to make a referral.

The Care Act recognises a whole host of different methods of review, any of which could be appropriate so long as:

1. The person's involvement is maximised by the method;
2. The method is proportionate to the outcomes being met by the Reablement Plan; and
3. The method enables the review to be carried out as quickly as is reasonably practical.

Possible review methods include:

1. Face to face review;
2. Telephone review;
3. Online review;
4. Combined review (with a carer);
5. Joint or integrated review (with an occupational therapist or social worker).

A review of a Reablement Plan can be carried out under the Care Act as a combined review at the same time as any review of a carers Support Plan, so long as:

1. It is deemed appropriate to do so (for example both parties involvement can still be maximised and there is no conflict between the parties);
2. Both the person and the carer agree to a combined review process and the sharing of information; or
3. The person with Care and Support needs lacks capacity to agree but a best interest decision is made to carry out a combined review.

If the person receiving reablement has a carer with a Support Plan it may be beneficial to carry out a combined review of the carers Support Plan, especially when:

1. Changes to the carers Support Plan may be needed as a result of reablement; or
2. A scheduled review of the carer's Support Plan is imminent.

Where it would be beneficial to carry out a review of the carers Support Plan you should:

1. Offer the carer a review of their Support Plan; and
2. If accepted, carry out a carer's review (or arrange for a review to be carried).

When making a decision about the method of review you must have regard to:

1. The wishes and preferences of the person;
2. The views of any carer;
3. The likely outcome of the review (based on information gathered through monitoring); and
4. The complexity of the outcomes being met by the Reablement Plan.

Some of the other factors that should be considered include:

1. Availability of a particular review method;
2. If the person has a carer, whether carrying out a combined review process would be beneficial.
3. Whether there is a concern about the person's capacity in relation to a particular decision to be made. In this situation the Care Act requires you must carry out a face to face review;
4. Whether the method of review chosen poses any challenges or risks for the person;
5. The specific communication needs of the person (specifically whether they will be able to engage in the review method);
6. The potential fluctuation of the persons needs or situation; and
7. Any need for multidisciplinary working or review.

Whenever the person with Care and Support needs is known to lack capacity a face to face review must be arranged.

Where the Local Authority requests another party work jointly in some way to benefit the person with Care and Support needs that party has a duty to co-operate with the request (unless by doing so they will be prevented from carrying out their own duties under the Care Act or other legislation).

For further information about the duty to co-operate under the Care Act, see: Co-Operation.

Before continuing or beginning to carry out any kind of review you should take some time to read through the information that is already available for the purposes of:

1. Understanding it; and
2. Thinking about how it should inform the review process.

Particular emphasis should be given to:

1. The information and evidence gathered through monitoring; and
2. Any information gathered from the person and any carer.

It is also appropriate to consult with others to gather information prior to review with the person's consent (or in their best interests if they lack capacity).

See: Gathering Information and Consulting with Others.

All information gathering and sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

Legally you must have regard to the following when arranging a review:

1. The person's views and wishes about when and how the review is carried out, including who they would like to support them;
2. The impact of any delay in review on their individual Wellbeing; and
3. Whether any information and advice can be given to them that will prevent, delay or reduce the need for Care and Support.

The most important thing you must consider when arranging the review is how you will ensure the involvement of the person. Some of the things you should think about include:

1. Whether the person will require independent advocacy;
2. Whether the person will find any review process to be emotionally difficult and what can be done to reduce their anxiety;
3. The information the person (and any carer) may need to prepare for the review;
4. Whether the person requires any support with communication;
5. Whether the person would like for anyone in particular to be involved in any review;
6. Which environment would be best to meet in (if a meeting is to be arranged); and
7. Whether the review needs to consider any physical needs the person has for medication, rest or personal care.

When arranging the review you should also identify other people who may need to be a part of it. For example, a health professional or a service provider may need to be involved.

If the person lacks capacity

If the person lacks capacity you should make arrangements with an appropriate person. Where available this should be a person legally authorised to represent them (for example a Court appointed Deputy or the Donee of a Lasting Power of Attorney) or an independent advocate.

Under the Care Act you must provide information about the review process to the person (or their representative if they lack capacity) as early as possible. This will help ensure their involvement in the review and any subsequent Care and Support processes. Wherever practical this should be provided before the review process begins.

Any information should be provided in an accessible way for the person who will be receiving it. In all cases where information has been provided by telephone a follow up letter confirming the information provided should be sent to the person.

The information that should be provided is as follows:

1. Information about what can be expected during the review process;
2. The purpose of the review process;
3. The format that the review will take (e.g. telephone review, face-to-face review);
4. The indicative timeframe for review (when will it begin and how long is it likely to take);
5. Possible outcomes of the review;
6. The complaints process; and
7. Information about possible access to independent advocacy.

If you intend to ask specific questions during the review you should provide these questions to the person to support them to prepare.

Financial assessment is often a key point of anxiety for people and it is important that you are able to provide good information and advice (either directly or by supporting the person to access it from an appropriate person or source).

You must explain the following to the person (or their representative if they lack capacity):

1. The local charging policy for any reablement that is extended beyond 6 weeks; and
2. That any subsequent Care and Support provided to them will be subject to a financial assessment.

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.

See the Financial Assessment Procedure for further guidance.

It is important that everyone who is to be involved in a review is aware of:

1. The purpose of the review;
2. The process of review; and
3. Their role in any review.

The needs of others involved in a review should also be considered, but this should not be at the detriment of maximising the person's own involvement.

If a person has a role in the review process but is not able to physically attend any planned meeting it is possible under the Care Act to consult with them separately and still include their views in any review and decision making processes.

The conversation about reablement outcomes must broadly establish whether:

1. The outcomes in the Reablement Plan have been achieved or not;
2. The person has any new outcomes they want to meet; and
3. Any improvements are required to the plan to achieve better outcomes.

Simple questions should be used to confirm that outcomes are being met, such as:

1. How have you been able to work towards the outcomes in your plan?
2. Have there been any changes to the things that are important to you to achieve, change or maintain?
3. Do you think there needs to be any changes to the plan to support you work towards your outcomes?

You should refer to the Reablement Plan to confirm what the person's outcomes were.

Action when reablement outcomes have not been progressed as intended

If outcomes have not been achieved (or progressed) as intended you must take steps to:

1. Establish if the outcomes are still important to the person;
2. Establish that the outcomes are still realistic based upon the person's strengths and abilities;
3. Establish whether outcomes have not been achieved because the person has not been able to 'carry over' learning (which is an indicator that reablement may not be appropriate);
4. Agree any changes to the outcomes (for example whether the outcome itself needs to change or be broken down into smaller goals).

See: The Skilled Conversation: Reablement Outcomes.

When arranging reablement consideration should have been given to how the service may be able to support the person to meet the general outcomes that they identified in the assessment.

During the reablement review it is important to establish:

1. Whether the service has supported the person to work towards their general outcomes as intended; and
2. If there is anything else the service can do to support the person to work towards their general outcomes.

You should refer to the assessment (or Care and Support Plan if the person has one) to confirm what the person's general outcomes were.

You have a statutory duty to promote individual Wellbeing at all times, including at review. Conversations about Wellbeing need to be proportionate and appropriate, having regard for whether Wellbeing is likely to have changed.

See: Talking about Wellbeing.

The conversation about what is working and not working must broadly establish whether:

1. The frequency, duration and timeliness of reablement is being provided as set out in the Reablement Plan (or as agreed through monitoring);
2. The Reablement Plan is, on the whole supporting the person to achieve outcomes;
3. Anything is having a detrimental impact on the reablement;
4. There are any risks to the plan or to reablement;
5. Everybody involved in reablement is satisfied with how it is progressing.

Simple questions should be used to confirm that reablement is working, such as:

1. Is everything in the Reablement Plan in place as intended?
2. Is reablement working well for you?
3. Does anything need to change about the plan or the way you are supported?

You should refer to the Reablement Plan to confirm current arrangements for providing reablement.

If the conversation about what is working/not working identifies issues you will need to manage these to reduce the risk of:

1. Reablement breaking down; or
2. Reablement not achieving optimum levels of independence.

See: Managing Issues with the Plan.

It is important to talk about risk during review for the purpose of establishing that:

1. Risks continue to be well managed;
2. There have been no changes to risk;
3. There is no risk to the person from abuse or neglect; and
4. There is no risk to the Reablement Plan's stability or sustainability.

Simple questions should be used, such as:

1. Do you feel safe?
2. Is there a chance that reablement could stop working well?

You should refer to the Reablement Plan to confirm risks and strategies in place to manage risks.

The conversation about risk may identify:

1. Additional information and advice that you can provide to support the person to manage risk. Where this is the case you must provide such information and advice;
2. Small changes required to the Reablement Plan to manage risk;
3. The need to involve another service (for example occupational therapy or assistive technology);
4. The need to raise a safeguarding concern.

Under the Care Act the Local Authority has a duty to:

1. Establish which needs a person has are eligible for Care and Support; and
2. Provide the person with a personal budget to meet any eligible needs.

If you know that a person is likely to have on-going needs for Care and Support you must take necessary steps to ensure that this duty is met following the review.

It is important that likely on-going needs are established in a timely way so that:

1. Any assessment, review or reassessment of need can take place before reablement has ended in a planned way (rather than in an urgent way);
2. Eligibility can be determined before reablement has ended;
3. If needs are eligible, Care and Support planning can take place in a considered way, ensuring that needs are met in the most appropriate and proportionate way; and
4. An appropriate handover can take place between Care Dorset and any subsequent provider.

If likely needs are not established in a timely way:

1. The person may experience a period where needs that are likely to be eligible are unmet (which is not lawful); or
2. Planning and exploring the most appropriate and proportionate way to meet on-going needs may be rushed; or
3. Care Dorset could be faced with no alternative but to meet urgent needs in the interim (which will impact on the services capacity to support others).

If an assessment of need was completed prior to reablement you should use this information to establish:

1. Whether there have been any changes in the person's needs throughout the course of reablement; and
2. Where there have been changes broadly what those changes are.

A simple question, such as 'Has there been any change to your needs' can be sufficient to determine any need to explore needs further.

You should refer to the assessment report to confirm what assessed needs were.

See: Talking about Needs for guidance as required.

If, as part of the review there is disagreement about whether a person's needs have changed it is your responsibility to make the final decision about whether needs have changed. To do this you should:

1. Consider all of the available evidence;
2. Give regard to the views of the person; and
3. Consider the different views expressed by others.

You must make sure that the evidence upon which you base your decision is robust and you must be open about the evidence that you have used.

If a person has experienced a change in need but this is only likely to be short term an assessment/reassessment of need may not be required, as long as:

1. The needs can be met and are being met by the existing Care and Support Plan; and
2. It is reasonable to believe that the needs are short term only.

You will need to agree appropriate arrangements to monitor the person's needs and circumstances throughout the remaining course of reablement. You will also need to ensure that the person (or their representative if they lack capacity) knows what action to take should the short term needs become more long term or the Care and Support Plan no longer meets the needs.

It is reasonable for a person with likely on-going needs to want to start thinking about how a likely need could be met when:

1. A likely need has been identified; and
2. The likely need is not already being met through an existing Care and Support Plan.

However, you should be mindful that at this stage the likely need has not been determined eligible, and this determination will be made following any further assessment of need that may be required. As such conversations about how to meet the likely need should be restricted to:

1. Ways that the person could meet their needs (either independently or with the support of their informal support networks or community);
2. Information and advice about other prevention services that could delay, reduce of prevent needs; and
3. Broad information about the type of services available in the marketplace that may be appropriate to meet needs (if the person appears to have eligible needs).