Deciding the Outcome of a Reablement Review and Making a Formal Record

Broadly there are 3 possible outcomes following review:

1. Reablement will continue with no changes required to the Reablement Plan; or
2. Reablement will continue with some changes to the Reablement Plan; or
3. Plans will be made to end reablement.

Depending on which outcome is decided a range of actions could be required, including:

1. changing monitoring arrangements;
2. revising the Reablement Plan;
3. planning to end reablement;
4. changing the reablement provider;
5. accessing another prevention service; and
6. providing information and advice.

Throughout the process of review you should talk to the person (or their representative) and others about the likely outcome of the review, endeavouring to reach an agreement about this as the process progresses.

The Local Authority is responsible for making the final decision about the outcome of the review. As such this is your responsibility as you are the Local Authority's representative.

When determining the outcome of the review you must give regard to:

1. the views of the person about the outcome;
2. the impact of the outcome on the person's wellbeing;
3. the views of any carer about the outcome; and
4. the views of anyone else consulted or involved in the review process.

The decision that you make about the outcome of the review must be evidence-based and robust. This means you must be able to demonstrate the information that you have used to reach a decision if challenged.

The decision you reach may be in line with the views of the person (and others) but equally it may not be if the evidence does not support that judgement. This is appropriate as long as you have a clear rationale for your decision and can demonstrate that you have given regard to the person's views, their wellbeing and the views of others.

If you are unclear about the outcome of the review, you should consider the benefit in gathering any additional information or consulting with any other person. If you remain unclear about the outcome you should seek advice from your line manager about how best to proceed.

Reviews should be recorded in a timely way and in line with local requirements.

Timely recording will:

1. reduce the likelihood of inaccuracies;
2. prevent any unnecessary delays for the person; and
3. ensure that any reassessment of need can make effective use of the information gathered at review.

If the timeframe for review that you use leads to inaccuracies or a delay in meeting needs, then it is not timely.

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 services 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 ongoing 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.

Following the review process the person must be given a written record of their review.

It is important that the person understands their review and the outcome of it. To this end it should be provided in a format that is accessible to them.

If the review record has been provided in a format that you know or suspect the person will not be able to understand you should:

1. consider any steps that you can take to support them to understand it (for example, talking through the review over the telephone or summarising it in a simpler format); and
2. consider the duty to make an independent advocate available.

If an advocate is already involved they should be informed when the review has been provided to the person so that they can support them to understand it.

Where the review was carried out jointly with another organisation to avoid duplication (for example, occupational therapy), a copy of the review must be made available to the other person who carried it out with you.

A copy should normally be shared in full with any carer unless the person has capacity and has asked you not to share the review, or to share only part of the review. In this case you will need to discuss and agree which elements of the review are to be shared having regard for confidentiality.

In all other cases a copy of the record can only be shared with the person's consent (or in their best interests if they lack capacity to consent).

If the person consents (or lacks capacity and a best interest decision is made) a copy of the review should be shared with any external service provider who was involved in the review and is responsible for providing reablement to the person.

A copy must also be shared with anyone that the person requests you share a copy with, even if they were not involved in the review itself.

Concerns about a request

You must provide a copy of the review to anyone that the person requests you to unless:

1. they lack capacity and you make a decision that sharing would not be in their best interests; or
2. you are concerned that doing so could put the person (or another vulnerable adult or child) at risk of abuse or neglect.

If this situation arises you should seek advice from your line manager and decide whether:

1. to share the record in full as requested;
2. to share the record partially, omitting sections where information could put the person at risk; or
3. to decline to provide a copy of the record (although the person can, of course, still choose to make a copy available from their own record).

Sometimes the person (or their representative if they lack capacity) or anyone else that was involved in the review, may ask for amendments to be made to the record. For example:

1. They feel that there is information missing; or
2. They feel that the record is a misinterpretation of something that was said or agreed.

In this case you should:

1. consider the request;
2. if the person whose review it is has not made the request, consult with them (or their representative if they lack capacity); and
3. review any evidence or information you have which may support or refute the request.

You should not make the amendment regardless of the existence of evidence and a rationale for doing so. If you reach a decision not to amend the record you should be clear about your reasons for not doing so, and you should make the person aware of their right to complain about your decision.

If a decision is made to make the amendments, you should proceed to do so. Where doing so results in 2 versions of the same review being available on the system it must be clear which the amended version is.

The amended record should be circulated to the same people as the original record, unless the person requests otherwise or there is evidence that doing so would put the person (or another vulnerable adult or child) at risk of harm or abuse.