The Reablement Plan

The Reablement Plan is a plan that:

1. sets out the specific outcomes that the person wishes to meet through reablement;
2. describes how reablement will support the person to meet the identified outcomes; and
3. sets out how progress towards meeting outcomes will be reviewed and monitored.

The Reablement Plan should include the following information:

1. the needs that are being prevented, reduced or delayed by the plan;
2. the person's outcomes and any specific targets and goals they wish to achieve from the plan;
3. the frequency and duration of planned reablement visits;
4. the support that the reablement worker will provide during any visits;
5. any other support that will be provided to maximise reablement (for example, from occupational therapy or the use of Telecare or other technology); and
6. how the plan will be reviewed (frequency of review and who is responsible for reviewing).

Whenever you complete a Reablement Plan you must involve:

1. the person whose plan it is;
2. anyone else that the person has asked you to involve;
3. any carer that the person has;
4. where the person lacks capacity, anyone else that the Local Authority deems it would be in the person's best interests to involve.

This means that if the person has capacity, you cannot involve anyone else in their Reablement Plan other than their carer, without their consent to do so.

The Local Authority uses a standard format to record all Reablement Plans. This ensures a consistent approach that meets all of the requirements of the plan.

If the format of the template is accessible to the person, you can use a blank copy as a tool to support the planning process.

If the format of the template used by the Local Authority is not accessible, or will not ensure maximum involvement of the person, it is appropriate to adopt a different reablement planning style for some/all of the plan.

Examples include:

1. Picture or drawing formats;
2. Video or audio formats;
3. Alternative written formats.

Wherever possible, as long as it meets all the requirements, the Reablement Plan should be recorded in its accessible format.

If the plan format does not meet requirements, or if it is not possible to record and file it as it is (for example, the technology used by the Local Authority does not enable electronic filing of audio or video), you should explain this to the person (or their representative) and use the information to complete a final plan in a format that does meet requirements (the Local Authority single format).

The final Reablement Plan should:

1. reflect all of the things from the original plan; and
2. explain that a plan in a different format exists and where this can be located.

If it has not been possible to reflect everything in the original plan within the final plan, then a copy of the original plan should be attached to the final plan whenever it is provided.

Using a tool is not a statutory requirement but can be useful to support conversations during the process of reablement planning. However, any tool should:

1. facilitate and ensure the person's involvement;
2. support the process of exploring needs from a strengths based approach;
3. be flexible and adaptable; and
4. be appropriate and proportionate to the situation and needs of the person.

See below for details of the tools that are available for you to use as required.

Reablement planning involves having a skilled conversation about:

1. wellbeing and outcomes;
2. ways to provide reablement; and
3. risk.

From the assessment (or other process to establish needs), you should have identified how best to communicate with the person and support their engagement in care and support processes, and any tool that you subsequently use should reflect what you know about the person.

If you do not feel that the tools available to you will be appropriate, you should speak to your manager about how they can be adapted.

First and foremost you should have regard for any available practice guidance or good practice examples provided by the Local Authority.

The following are other tools available to you that may enhance any reablement planning conversations and accessibility.

tri.x has developed a range of person centred tools that can:

1. support a person to think about what matters most to them, now and in the future;
2. support a person or family member to think about wellbeing; and
3. support a person or family member to think about needs and what a good day/bad day looks like.

See: Resources for Person Centred and Strength Based Conversations

Supporting Outcomes-Focused Practice is a supplementary RiPfA website, available without normal subscription. It can support you to develop your skills, knowledge and practice in working with outcomes.

Some people will lack capacity to understand or engage in the reablement planning 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 before deciding reablement outcomes and provision;
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 reablement planning, 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 reablement planning 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.

If the person does not engage in the reablement planning process taking place, you should:

1. establish whether the reason for their disengagement is related to substantial difficulty or mental capacity, and if so, ensure they have the right support in place (an advocate or an appropriate other person);
2. provide them with information to support them to understand the purpose of a reablement plan, the process and the benefits of being involved.

If the person continues to disengage from the process, you should establish whether they still wish for the Local Authority to provide a reablement service.

If the person wishes to proceed with reablement

If the person wishes to proceed with a reablement service you should:

1. explain that a reablement plan is the method by which reablement outcomes and the reablement service is agreed; and
2. explain that without a reablement plan the reablement service cannot proceed; and
3. provide information about the reablement plan process as required encouraging the person to engage.

If the person does not wish to proceed with reablement

If the person does not wish to proceed with reablement, and has capacity to make this decision, you should not proceed with reablement planning.

You should:

1. provide them with the information and advice they request (or you feel would be beneficial) about available appropriate support to meet their needs;
2. provide them with information and advice about ways they can prevent, reduce or delay needs for care and support;
3. provide them with any other information that they request or that you feel will be beneficial;
4. explain to them what they should do if their needs or situation changes.

All of the above information should be confirmed in writing.

If reablement was requested by anyone other than the person and it has been refused, you should notify the person who requested it so that they can make any arrangements to discuss other options with the person. For example, this could be:

1. a carer;
2. a health professional;
3. a social worker or an occupational therapist;
4. a housing officer;
5. a care provider.

Sometimes another person may obstruct you from carrying out reablement planning with a person who has care and support needs. You should establish whether:

1. the person with care and support needs has asked the person to obstruct the process and, if so, whether they still wish for the Local Authority to provide a reablement service;
2. the person obstructing the process is doing so out of concern for the person with care and support needs (for example, would the process cause anxiety);
3. the person with care and support needs is at risk of abuse or neglect.

Wherever possible, you should provide information and advice relating to the reablement planning process to the person obstructing it, to support them to understand the benefits and engage in the process.

If the person continues to obstruct the process, you should discuss the situation with your line manager and agree the most appropriate course of action. This could be to delay the reablement service, to liaise with the referrer (if the referrer was not the person), or to withdraw the service.

Any decision must be made with regard for:

1. the person's views about withdrawing the service;
2. the views of any carer about withdrawing the service;
3. the impact on the person's wellbeing of withdrawing the service.

Depending on the circumstances, consideration should also be given to raising an adult safeguarding concern.

See Safeguarding Adults

If the service is withdrawn, this should be confirmed in writing to the person, and any subsequent referrals should be considered at the time they are made.

One of the main focuses of the Reablement Plan is to agree the outcomes that the person will work towards with the reablement service (reablement outcomes).

Outcomes are important because they:

1. shape how the reablement service will be provided;
2. provide a focus for reablement;
3. motivate the person; and
4. can be used as a measure of success.

Good outcomes:

1. build on the person's strengths and abilities; and
2. reflect what the person wants to achieve from reablement.

Outcomes that do not reflect what the person wants can be difficult to achieve because:

1. the person can lack incentive to engage in reablement from the beginning; or
2. the person can quickly become demoralised.

Outcomes that are not realistic to the person's strengths and abilities can also be difficult to achieve because:

1. the person can feel overwhelmed from the outset about the expectations set; or
2. the person can quickly become demoralised.

Although outcomes will likely focus on supporting the person to regain physical abilities at home, you should always explore whether the person has any social outcomes that they wish to meet (or that could be met) through reablement.

Social outcomes can be vital to a person's recovery and sustained wellness, and include things like:

1. regaining confidence to use public transport;
2. returning to a community group after a period of illness;
3. being able to use technology to contact family and friends; and
4. carrying out tasks like shopping independently.

Reablement should therefore not be restricted to providing support in the home environment and may involve:

1. supporting a person to re-integrate into their community; or
2. exploring ways to remove barriers to the person achieving their social outcomes (for example, if the person's physical access to the community requires adaptation, you may request an OT assessment).

Outcome setting involves three main steps:

• Step 1: Identifying what it is that the person wants to achieve.
• Step 2: Agreeing what steps are needed before the outcome can be achieved (for example, smaller goals and targets along the way).
• Step 3: Agreeing what support is required to achieve the outcome.

One way to set realistic outcomes can be to apply the SMART principles.

Risk is broadly defined as 'the probability that an event will occur with beneficial or harmful consequences'.

The aim of any conversation about risk is to maximise the benefits and reduce the likelihood of harm.

During the reablement planning process there will be a need to talk about risks to the person:

1. from the impact of their assessed needs (for example, from falls or medication); or
2. from the outcomes they want to achieve (where there is an element of risk taking required to achieve them).

It is vital that you demonstrate a positive approach to risk, especially when family members or the person are expressing concern about risk.

A positive approach to risk identifies all of the benefits to the person that would come from taking any risk, in terms of personal change or growth. Where the benefits outweigh the potential harm, a positive risk assessment would then develop a strategy to support the person to take the risk as safely as possible.

See: Risk Assessment

As part of the reablement planning process you must explore potential risks to the plan itself. Not doing so could:

1. increase the risk that the outcomes in the plan will not be achieved;
2. increase the risk that any positive effect of reablement will not be sustained into the future.

The kind of risks to the plan will vary depending on each person's needs and circumstances and any conversation that you have should be proportionate and appropriate.

Examples could include:

1. risks that the person will not engage in reablement;
2. risks that the person will lose motivation;
3. risks that a carer, family member or friend will not encourage or motivate the person to develop independence;
4. where applicable, risks that an external provider will not work in an enabling way;
5. risks that the outcomes in the plan may be unrealistic.

The person (or their representative) should be involved in any conversation about risk and how to manage risk. Any carer should also be involved.

You need to understand:

1. what the risk is;
2. what the impact of the risk would be to the wellbeing of the person; and
3. how likely the risk is to occur (based upon available evidence).

When risks to the plan have been identified, a contingency plan will need to be agreed with the person. A contingency plan is a proactive agreement about the steps that will be taken to mitigate and respond to the identified risk.

Examples of measures in a reablement contingency plan could include:

1. providing additional information to a carer, family member or friend about the purpose of reablement;
2. more frequent monitoring or review of reablement provision and outcomes;
3. increased feedback requests from the reablement worker/provider.

It is the responsibility of the person with CQC Registered Manager status to ensure that measures are in place to mitigate any risks to the worker before reablement commences.

Examples of risk to the worker include but are not limited to:

1. risk of falls or trips from the person's home environment;
2. risk of injury from faulty or inappropriate equipment or appliances in the person's home;
3. risk from the actions of the person (for example, if they are known to become verbally or physically aggressive);
4. risks around the need for the worker to be specifically trained or experienced in a particular area (for example, epilepsy or specialist medication).

Where the available evidence suggests that risks are present from a particular environment, a risk assessment of that environment must be carried out prior to commencing reablement.

It is important to understand any risks to the reablement worker that may exist before any reablement service is provided.

To set realistic expectations about the duration of reablement, you must explain to the person that:

1. Reablement is a time limited service that is regularly reviewed; and
2. Reablement will end no later than the time that the maximum period of reablement permitted by the Local Authority is reached (in line with local policy); but
3. Reablement could end at any point that the outcomes in the plan are achieved, or a decision to end reablement is made at review.

It is your responsibility to understand the local policy about the maximum period of Reablement permitted by the Local Authority, and the financial implications for the person of any service that is provided beyond this.

It is important that you set clear expectations about the enabling approach used by Reablement, especially if the person is already familiar with a more traditional service approach to meeting needs.

The key things that you should explain are:

1. that the focus of the whole reablement service will be on promoting and optimising independent functioning; and
2. that the reablement worker will be encouraging the person to do things for themselves at all times, and will not automatically intervene when this proves challenging for the person;
3. that the reablement worker will proactively be exploring ways to support the person to be more independent, including the use of technology and occupational therapy equipment; and
4. as the person becomes more able to do things for themselves, the reablement service will reduce accordingly.

If the assessment has identified that a person's needs fluctuate, you will need to agree with the person how they should be supported at times when their needs fluctuate.

This could mean the reablement worker providing more hands-on support on a 'bad day'. Where this is agreed, it should be clear that:

1. hands-on support is being provided to support the person to manage a fluctuation in their needs only; and
2. when their needs return to normal, a more enabling approach will resume with immediate effect.

If not already discussed as part of the assessment, the need to involve others should be explored during reablement planning and any joint referrals should be made in good time, 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.

Any decision to involve others 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 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.

It is important to identify any specific skills required of reablement workers. This should be based on:

1. the skills, knowledge and experience to meet the requirements of the specific reablement service to be provided (including working with risk and specific activities);
2. the skills, knowledge and experience to work 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.

If the person has Autism

Anyone working with a person who has a diagnosis of Autism must have received specialist training so that they understand Autism and are able to provide appropriate support to a person with Autism. This is set out in the Think Autism 2014 guidance and adopted as good practice within the Care Act statutory guidance.

If the person is deafblind

Under Care Act Regulations, deafblind is defined as having a combined sight and hearing impairment (including progressive sight and hearing loss) which causes the person difficulties with communication, access to information and mobility.

Anyone working with a person whose sensory needs meet the definition of deafblind must have specific training and expertise to work with people who are deafblind.

The frequency and duration of visits should be agreed with the person and any carer they have. Consideration should be given to:

1. the number and nature of reablement outcomes to be met;
2. the time it will take the person to physically carry out tasks in an enabling way;
3. the motivation of the person to engage in reablement;
4. whether the person has any need for rest during reablement;
5. if reablement is around particular activities, when those activities will be taking place;
6. the normal or preferred routine of the person;
7. the availability of any carer (where the carer has a direct role in reablement).

You should explain that the frequency and duration of visits is subject to ongoing review and will increase or reduce over the period of reablement in response to changes in the person's level of independence.

The timeframe for the formal scheduled review of the plan should be agreed with the person and any carer they have.

This is likely to be within three weeks of the reablement plan commencing, but may be earlier than this if:

1. the person requests a review and this is agreed;
2. anyone else requests a review and this is agreed (for example, a carer or the reablement worker/provider);
3. monitoring activity suggests the need to review earlier.

Where you are making arrangements for someone else to carry out the next review (rather than carrying it out yourself), you must make sure that you have recorded this in a way that will ensure the review takes place at the agreed time.

You must let the person know how they (or anyone else) can request an unplanned review outside of the agreed timescale if:

1. the Reablement Plan is not working as intended;
2. they no longer wish to use reablement; or
3. their needs change and they feel additional support is required.

Draft Reablement Plans 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. optimise the benefit of the reablement intervention to be provided.

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

To ensure the involvement of the person, and to ensure that the reablement planning process has been carried out in an accessible way, there will be at least one (but possibly a range) of informal records made. Examples could include:

1. a blank copy of the Local Authority template with handwritten notes;
2. a tool that has been used by the person to explore outcomes; or
3. a risk assessment.

It is important that you use all of the information gathered and record it on the Reablement Plan where it is relevant to do so.

Any informal records should then be filed, destroyed securely or returned to the person (if they have requested this) with full regard for confidentiality.

The Reablement Plan should include the following information:

1. The needs that are being prevented, reduced or delayed by the plan;
2. The person's outcomes and any specific targets and goals they wish to achieve from the plan;
3. The frequency and duration of planned reablement visits;
4. The support that the reablement worker will provide during any visits;
5. Any other support that will be provided to maximise reablement (for example, from occupational therapy or the use of Telecare); and
6. How the plan will be reviewed (frequency of review and who is responsible for reviewing).

The person must be given a written record of the Reablement Plan, and you should explain to the person that the plan should be available for the reablement worker to refer to when providing reablement.

It is important that the person understands the Reablement Plan. If you are of the view that the person will experience substantial difficulty understanding the plan, then you must make sure that appropriate support is in place, including consideration of the duty to provide an independent advocate.

If an independent advocate is already in place, they should be informed when the plan has been provided so they can support the person to understand it.

A copy of the Reablement Plan must be shared with anyone directly responsible for providing the reablement service.

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

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

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 planning process itself.

Concerns about a request

You must provide a copy of the plan 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) may ask for amendments to be made to the Reablement Plan. You should:

1. consider the request;
2. if the person whose Reablement Plan 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.

If you reach an agreement with the person about the need to amend the plan, you should do so.

The amended plan should be circulated to the same people as the original plan, unless the person requests otherwise.

If you are unable to reach an agreement with the person and you feel that an amendment is not required, you should not make the amendment. You should be clear about your reasons for not making the amendment and you must make the person aware of their right to complain about your decision.