Actions and Next Steps (Reablement)

What is on offer:

Information and advice for Lincolnshire residents, their carers and families, and professionals about:

• Community support and providers;
• Activities and events;
• Venues, buildings and facilities in Lincolnshire;
• Home care agencies;
• Care homes;
• Mental Health; and
• Support with Digital and Technology.

Who is it for:

Anyone can visit the website and create a booklet of information, and view a community map of helpful community organisations.

How to access:

Tel: 0300 303 8789
Email: CTSL@ageuklsl.org.uk
Website: lincolnshire.connecttosupport.org

There are a range of printable factsheets and guides available in the ‘Leaflets, Booklets and Customer Information’ section of the Local Resource Library.

The factsheets are intended for electronic use, e.g. viewing online or attaching PDF’s to emails or for local printing/photocopying where people need a paper copy.

You can ask for information and advice to be sent out by Business Support. This will save you time and ensure the person is getting the information and advice they need. To make a request, there is a correspondence step in Mosaic which can be used at any time. This step can be left open to allow the allocated practitioner to use the step if further information and advice is required to be sent out. The correspondence step will need to be completed when the case involvement ends.

If the person is facing a difficult health decision or just does not know how to find out about available support, Healthwatch Lincolnshire can help.

Tel: 0205 820892 (9am to 3pm Monday to Thursday; 9am to 12pm Friday)
Email: info@healthwatchlincolnshire.co.uk
Website: www.healthwatchlincolnshire.co.uk/advice-and-information

The Mental Health helpline is a joint initiative across health, social care and the third sector providing free and confidential emotional support, advice and guidance across Lincolnshire.

Who is it for:

People feeling low, anxious or stressed who might benefit from speaking to someone, can speak to a highly trained and experienced support worker who will be able to provide appropriate support.

Tel: 0800 001 4331 (People can also self-refer by calling the 24/7 helpline)
Website: www.lincolnshiretalkingtherapies.nhs.uk/how-we-can-help

A network of people and organisations which can help people to connect with the services and support that will most effectively meet their needs and enhance their lives. Support for carers and anyone with mental health problems

Tel: 01522 300206
Website: www.shinelincolnshire.com

A family of websites that bring together everything in the local community that boosts wellbeing.

Website: www.haylincolnshire.co.uk

An informative website with links to free to downloadable apps and advice from the NHS, and easy to access, tools and support that anyone can use to quit smoking, lose weight, get active etc.

Website: www.nhs.uk/better-health

Contact between people and adult care practitioners should be seen as an opportunity to identify issues of poverty, debt, and financial wellbeing. All practitioners should offer information and advice about benefits maximisation and debt support where required.

See: Welfare Benefits (Connect to Support Lincolnshire)

See: Benefits and financial support if you are caring for someone (LCC website) 

People can also be supported by the following organisations to work out what benefits or tax credits they, or someone they care for is entitled to:

• Citizens Advice;
• Law Centres; 
• Macmillan benefits advisors for people affected by cancer;
• Age UK benefits advice for older people; 
• Gingerbread Single Parent Helpline;
• Money Helper – other free help and advice.

If someone is experiencing significant debt issues, they may be eligible for the Debt Respite Scheme.

See: Debt Respite Scheme (Breathing Spaces) Procedure.

Mobility benefits and transport provision

Mobility benefits should not prevent people using a personal budget to fund transport costs associated with meeting needs to access their community. For example, accessing the community requires a car, a driver, fuel cost, and escort costs. Access to transport provided through mobility benefits and schemes such as Motability may enable the personal budget to be adjusted accordingly, based on what the benefit/ Motability vehicle may reasonably enable the person to achieve. However, personal budgets should take into account additional costs over and above the vehicle required, to meet need.

Carers First provides information, advice and statutory services to carers.

See: Carers First 

Lincolnshire County Council has teamed up with Carers UK to offer a Digital Resource for Carers in our area with digital products, online resources, local information and support for carers on a single platform.

See: Digital Resource for Carers

Sometimes it is helpful to contact a well known national organisation with a dedicated information and advice service or help-line. See: National Organisations with Information and Advice Helplines for details of some national organisations offering this service.

Some national organisations do not have dedicated information and advice services but can still provide such support upon request. See: National Contacts for Adult Care and Support for a wider range of useful national contacts for adult Care and Support.

You can also see the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment, including questions relating to Disabled Facilities Grants.

Information and advice must be provided in an accessible way so that the person for whom it is intended can best understand and make use of it.

If you feel the person for whom the information and advice is intended will need support to understand it, then you should:

1. consider whether the person has anyone appropriate who can help them to understand it;
2. consider any steps that you can take to support them to understand it (for example, talking through the information over the telephone or summarising it in a simpler format); and
3. consider the benefit of independent advocacy.

If the person has a diagnosis of dementia, it may be appropriate to make a referral to the Memory Support Service. They can help the person to understand information provided to them and to navigate the care system.

See: Memory Support Service.

When the person making the contact requests specifically to speak to, or be contacted by, a particular person you should establish as quickly as possible whether the contact should be forwarded to that practitioner.

You should check available systems to establish whether the person is allocated to the practitioner they have requested to speak to.

You should not transfer a telephone call to a named worker if it is clear that the worker is not allocated to the person. This will not be helpful to the worker or to the person as they will not be speaking to the right person to resolve the contact.

If the practitioner is not available

If the practitioner is not available, you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a colleague or manager who may know.

If you know when the practitioner is likely to become available, you should:

1. inform the person of this;
2. leave the practitioner a message alerting them to the contact, any action undertaken and confirming the information given to the person about when to expect a call back;
3. 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 should the practitioner be unavailable for more than a few hours;
4. agree with the person what they should do if the practitioner does not make contact at the expected time; and
5. make a proportionate record of all the above.

If it is not clear when the practitioner will become available, you should:

1. inform the person of this;
2. leave the practitioner a message alerting them to the contact, any action undertaken and what information has been given to the person;
3. 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; and
4. agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
5. make a proportionate record of all the above.

When a written contact is addressed to a named worker you should establish as quickly as possible whether the contact should be forwarded to that practitioner.

You should check available systems to establish whether the person is allocated to the practitioner that the written contact is addressed to.

You should not transfer a written contact to a named worker if it is clear that the worker is not allocated to the person. This will not be helpful to the worker or to the person as they will not be dealing with the right person to resolve the contact.

Before transferring the contact you should:

1. confirm that the practitioner to whom the written communication is being transferred, is available within a reasonable timeframe for the action indicated by the contact, or that you have agreed with a manager how the contact will be managed;
2. where the communication is a letter or an e-mail, whether the practitioner wishes to receive the original contact (if not this should be filed securely); and
3. where a written response confirming the contact has been received is required or requested, agree who will provide this.

The most secure way to transfer a written contact is to send a message to the practitioner alerting them to the contact and where it can be found on the recording system.

Any original copies of e-mails must be sent via internal secure e-mail systems only and any original letters must be sent via internal postal services or secure delivery only.

If the practitioner is not available

If the practitioner is not available, you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a colleague or manager who may know.

If the practitioner is not available within a reasonable timeframe for the action indicated by the contact, you should:

1. leave the practitioner a message alerting them to the contact, where it can be found on the recording system and any action undertaken, including what has been agreed with the person if contact has been made with them;
2. 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 and writing any acknowledgement letter to confirm arrival of the contact;
3. when the practitioner is not available within any timeframes indicted in the written contact or for more than a few days, inform the person making the contact of this;
4. agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
5. make a proportionate record of all the above.

All health and care professionals should be aware of frailty and identify where people would benefit from assessment and planning that minimises the impact of frailty on people’s wellbeing.

Triggers are:

1. Are you older than 85 years?
2. Are you male?
3. In general, do you have any health problems that require you to limit your activities?
4. Do you need someone to help you regularly?
5. In general, do you have any health problems that require you to stay at home?
6. In case of need, can you count on someone close to you?
7. Do you regularly use a cane, a walker, or a wheelchair to move about?

A person hitting three or more of the seven triggers should be referred to their primary care team to request a full frailty assessment is undertaken. This referral should be made using the Lincolnshire Frailty Pathway Letter, which is available in Mosaic. 

For more information about the Lincolnshire Frailty Pathway, including resources and a practice toolkit see: Lincolnshire Frailty Pathway.

The Wellbeing Service is a countywide service supporting adults across Lincolnshire and is delivered by a partnership of all seven Lincolnshire District Councils, known as Wellbeing Lincs.

The key principles of Wellbeing Lincs are to:

• enhance wellbeing;
• improve people’s access to support services;
• reduce and delay escalation to statutory services;
• provide direct support and signpost access to community resources.

The Wellbeing Service can support people with:

• loneliness and social isolation;
• disability;
• changes to financial circumstances;
• lack of family support;
• ill health;
• bereavement; and
• changing medical needs.

For further information and to find out how to make a referral see: Processes for Arranging All Support and Services Procedure

What is on offer:

Go smoke-free, Lose weight, Move more, and Drink less.

A free healthy lifestyle service helping Lincolnshire residents achieve or work towards improving their health, wellbeing and resilience.

Various offers of support are available in each of the four pathways and are currently provided through a hybrid model of onsite and remote delivery, via telephone, for people who have difficulty accessing technology or web-based programs, such as seated exercise, weight management groups and yoga available if the person is eligible (see below).

Who is it for:

LCC staff, carers, and Lincolnshire residents aged 18+ (aged 12+ for smoke free) who have an interest in changing to healthy behaviours:

Smoke-free – any worker or resident in Lincolnshire who wants to stop smoking. They are up to four times more likely to quit smoking with support from OYL, which offers nicotine replacement therapy combined with behaviour change.

Lose weight and eat well – BMI 30+ or 27.5+ for Black, Asian and Minority Ethic (BAME) individuals. (NHS BMI calculator)

Move more -for anyone doing less than 150 minute of physical activity per week.

Drink less – for people consuming more than 14 units per week who want to reduce their alcohol intake.

How to refer: (Temporarily- self-referral)

Tel: 01522 705162
Email: hello@oneyoulincolnshire.org.uk
Website: www.oneyoulincolnshire.org.uk/lincolnshire-residents

The Motability Scheme is a simple method of leasing a new car, scooter or powered wheelchair. The scheme enables disabled people to use their government-funded mobility allowance to lease a new car, scooter or powered wheelchair every three years, or a Wheelchair Accessible Vehicle (WAV) every five years (for new WAVs) and three years for nearly new WAVs.

The scheme is available to anyone who receives one of the following and has at least 12 months’ award remaining:

• The Higher Rate Mobility Component of the Disability Living Allowance (DLA);
• The Enhanced Rate Mobility Component of Personal Independence Payment (PIP);
• The War Pensioners’ Mobility Supplement (WPMS);
• The Armed Forces Independence Payment (AFIP).
• The higher Rate Mobility component of Child Disability Payment (Scotland) as of July 2021.

Motability Car Leases and Wheelchair Accessible Vehicles 

A standard Motability car lease can be taken out for three years and is a regular car that is available through the scheme.

Motability Scheme leases generally run for five years for new Wheelchair Accessible Vehicles (WAV) and three years for Nearly New WAVs. A WAV is a vehicle that enables a disabled person to travel as a passenger whilst seated in their wheelchair. Other vehicles that allow the disabled person to drive from their wheelchair are also available, which enable people to drive without needing to transfer to a seat.

Every lease includes:

• Insurance;
• Servicing and maintenance, MOT Test;
• Full breakdown assistance;
• Replacement tyres;
• Replacement batteries for scooters and powered wheelchairs;
• 60,000 mileage allowance for over three years, or 100,000 over five years for a WAV;
• Annual car tax;
• Windscreen repair/replacement;
• Many adaptations at no extra cost.

Leasing a car or Wheelchair Accessible Vehicle (WAV) will also cover:

• 20,000 mileage allowance per year of lease;
• Window and windscreen repair or replacement;
• A choice of adaptations, many at no extra cost.

Vehicles are available at a number of different costs, some of which are lower than the weekly allowance, but with some more expensive cars an additional payment, known as the Advance Payment, will be needed to cover the cost of the lease.

Adaptions to vehicles are also available through the Motability Scheme, in order to support a person’s needs as effectively as possible, as well as providing them with a high level of safety and comfort. Adaptions include:

• vehicle access;
• equipment loading;
• driving adaptations.

Motability Scooter and Powered Wheelchair Leases

Motability Scheme leases generally run for three years from the date that you took delivery. Included with the wheelchair and lease are:

• a new scooter or powered wheelchair of the person’s choice every three years;
• help from specialist dealers;
• breakdown assistance from Motability Assist;
• replacement batteries and tyres;
• servicing, maintenance and repairs;
• insurance equivalent to fully comprehensive cover;
• weatherproof storage cover for when the product is not being used.

Useful Contacts

Motability

Personal Independence Payment and Disability Living Allowance Support

Whenever the outcome of a contact or referral is that the person will be involved in any adult care and support process (including a reablement assessment or safeguarding), the Local Authority has a duty under the Care Act to make an independent advocate available to the person when:

1. there is no appropriate other person to support and represent them; and
2. they feel that the person would experience substantial difficulty being fully involved in the Care and Support process without support.

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.

See: Advocacy Decision Support Tool

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.

Having substantial difficulty is not the same as lacking mental capacity.

See: Determining Substantial Difficulty for information about how to determine substantial difficulty.

See the Mental Capacity Act 2005 Resource and Practice Toolkit, with guidance about assessing capacity and making best interest decisions.

An appropriate person for general representation purposes is not the same as an appropriate person for independent advocacy under the Care Act.

See: An Appropriate Other Person for information about the difference and how to establish whether there is already an appropriate person.

The role of an independent advocate appointed under the Care Act is not the same as the role of a general advocate or any other type of advocate (for example, an Independent Mental Capacity Advocate or an Independent Mental Health Advocate).

An independent advocate appointed under the Care Act must both facilitate and ensure the involvement of the person with substantial difficulty in the care and support process that is taking place.

For information about the ways in which an independent advocate should fulfil their role, see: The Role of an Independent Advocate.

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 two 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 whether any important decisions are likely to be the 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.

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.

See: Advocacy Decision Support Tool

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 two 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.

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.

See: Advocacy Decision Support Tool

The advocacy referral can be made at any time and should be made without delay as soon as the duty applies.

The process

All referrals to the Advocacy service should be made via the VoiceAbility website which can be accessed on the following link: VoiceAbility | Advocacy and involvement.

Practitioners should start the mandatory ‘Adult Advocacy Monitoring’ step in Mosaic Once a referral has been submitted online, you will receive a copy of the completed referral from VoiceAbility.

This should be uploaded onto the Adult Advocacy Monitoring step.

The monitoring step asks Practitioners to record basic referral details and is a quick and easy way to ensure key information is captured.

The form asks:

• The details of an advocate if they are already involved;
• The date of referral;
• The type of advocacy service requested (drop down list);
• Closure reason (the form remains open until the Advocate has ended their involvement).

The form also allows you to:

• Upload the advocacy referral form to the step;
• Upload any closure documents to the step.

This is a simple way to keep all evidence related to advocacy in one place.

About VoiceAbility

VoiceAbility provide an independent advocacy service in Lincolnshire, designed to help people gather and understand the information they need in order to express their needs and desires, and to support people to express those needs and desires. VoiceAbility use person centred techniques to ensure the service meets the needs of each person and time is spent developing methods which best suits the person requiring the service.

The types of advocacy, provided by VoiceAbility in Lincolnshire, include Care Act Advocacy, NHS Complaints Advocacy, Independent Mental Capacity Advocacy (IMCA), Independent Mental Health Advocacy (IMHA), Relevant Person’s Representative, Rule 1.2 Representative, Children and Young People Advocacy and Non-Statutory General Advocacy.

Voice Ability Lincolnshire will help people to:

• have their feelings and opinions heard, respected and responded to;
• be involved in health and social care decisions made about them;
• have the support and confidence to question decisions;
• have their issues resolved as far as is possible;
• have support to access sources of advice and information;
• make an informed choice and take control;
• be supported in times of crisis;
• be supported to challenge discrimination and poor standards of service.

Referrals will be accepted from a wide range of sources including:

• in person, by telephone, correspondence, email;
• from a third party with the person’s consent (subject to agreed protocols);
• by a person acting in the best interests of a person who lacks capacity (subject to agreed protocols);
• Adult Care professionals;
• Health professionals;
• Safeguarding teams;
• Deprivation of Liberty Safeguards Team;
• Healthwatch Lincolnshire;
• Lincolnshire Partnership Foundation Trust (LPFT) staff;
• Local Authority and NHS complaints departments.

Additional information is available to Adult Care staff through the Advocacy and Involvement page on Lincolnshire County Council’s intranet.

See: Advocacy and Involvement

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.

If you are aware that advocacy support is required, and is not yet available, you must not proceed to carry out any care and support process (including a reablement assessment) until it is in place.

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 them, so as to reduce the likelihood that they will not engage.

Where the outcome decision is for the person's case to be allocated to an individual worker to establish reablement needs, this allocation should take place in a timely way so as to:

1. avoid any unnecessary delays to the person;
2. reduce the risk of a deterioration in the situation; and
3. optimise the benefit of the reablement intervention.

Where there is a significant number of people awaiting allocation, there should be a fair and consistent prioritisation process in place that takes into account:

1. the level of risk;
2. the level of need;
3. current support in place and the sustainability/effectiveness of this;
4. the urgency;
5. the likelihood of deterioration; and
6. 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:

1. the skills, knowledge and experience of the worker in carrying out the function or process required;
2. 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
3. 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

If it becomes clear that a reablement assessment or service may not be the most appropriate and proportionate way of establishing or preventing, reducing or delaying needs, the case will need to be transferred.

For example:

1. The person's needs have changed since the time of referral and they may no longer be well enough to engage with reablement at that time;
2. From the information gathered it is clear that the person would not be able to engage with a reablement service;
3. The person is not ordinarily resident in the Local Authority area (so not eligible for reablement); or
4. The person no longer consents to reablement.

Any process for transferring the referral to another service area or team(s) 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:

1. The views and wishes of the person about which service/team(s) would best support them must be regarded;
2. The service/team(s) must possess the skills, knowledge and competence to carry out the anticipated care and support functions; and
3. The service/team(s) must possess the skills, knowledge and competence to work with the particular person in question.

tri.x has 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.

Adult Frailty and Long Term Conditions Teams

Adult Frailty and Long Term Conditions Team locality boundaries are determined by person's postcode. The system uses the first section of the postcode and the first digit of the second section.

Care should be taken with people living on the county border, as this convention does not always ‘respect’ county boundaries and the postcode list is not designed to determine whether the person is a Lincolnshire resident or not. It is necessary to determine whether the person is resident in Lincolnshire prior to using the list, i.e. to which District Council do they pay Council tax, and then use the postcode list to determine which Lincolnshire Team is responsible for the case. As an example, a Lincolnshire resident with NG23 5** will be the responsibility of Grantham and a Lincolnshire resident with NG23 7** will be a Lincoln South / Hykeham case.

The postcode list is available in the Local Resource Library under Access to Information, Advice and Services (Section 3).

Learning Disabilities Teams

Learning Disabilities team boundaries are detailed in the postcode list, which is available in the Local Resource Library under Access to Information, Advice and Services (Section 3).

The boundaries for Learning Disabilities Teams are aligned to Lincolnshire’s ward boundaries, as follows:

• Grantham / Stamford and Bourne – covering all South Kesteven District wards;
• Sleaford / Spalding – covering all South Holland District and Southern wards of North Kesteven District;
• Lincoln / Hykeham – covering Lincoln City and northern wards of North Kesteven District;
• West Lindsey – covering all West Lindsey District wards;
• Boston / Skegness – covering Boston Borough and south eastern wards of East Lindsey;
• Louth – covering north and western wards of East Lindsey.

The Intake Team covers the whole county and is responsible for initial work with new people coming into the Learning Disabilities Services.

Effective reablement often involves an element of joint working. For example, with:

1. Occupational Therapy;
2. Social Work;
3. a health professional;
4. a service provider.

The Care Act encourages joint working within organisations and across organisations, permitting anyone carrying out a care and support process to make any arrangements it deems necessary in order to facilitate joint working.

Note: Neighbourhood working should be used where people with complex or long term conditions would benefit from a joint assessment and planning.

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.

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.

The need to involve others should be identified at an early stage, preferably before the reablement service begins. This will allow:

1. any equipment or Telecare to be in place at the time reablement starts; so that
2. Reablement workers can support the person (and their carer) to use the equipment safely and with optimum effect during reablement; and
3. the risks to reablement from complexities in the person's situation or additional needs to be reduced.

The process of requesting joint work during reablement should be as simple as possible to allow for a swift response.

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:

1. 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;
2. Whether there are opportunities to co-ordinate systems and processes and, if so how this will be managed;
3. 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);
4. What the anticipated outcome of the joint work is (for example, joint funding of support, ongoing joint work to monitor);
5. What does the person with care and support need to know about the joint-work to be carried out (and if they don't know who and how should this be explained);
6. Who will be the primary contact for the person (or their representative) to go to with any queries; and
7. Who will be responsible for communicating progress and decisions to the person.

See: Joint Work for further practice guidance about effective joint working.