Reablement Monitoring Actions (ICS)

1. Changes to Monitoring Arrangements

If there is a need to change the monitoring arrangements at any point during reablement this can be done in agreement with the person and any carer. If the person or carer is not in agreement with the change you can still make the change so long as you have given regard to:

  1. The views of the person and carer; and
  2. The impact on the person's Wellbeing of the change.

The rationale for any changes should be clearly recorded and could include a reduction or an increase in monitoring activity.

When changes are made to monitoring arrangements you must explain the changes to:

  1. The person and any carer;
  2. The support worker;
  3. Anyone else involved in the plan (for example a Therapy colleague).

2. Revising a Reablement Plan

When to revise the plan

Changes can and should be made to the plan whenever:

  1. There is evidence that a change is required; and
  2. The person and any carer is in agreement with the change; and
  3. Other people involved in the plan agree with the change.

For example, when:

  1. Progress is being made toward outcomes;
  2. Increased support is required (for example during a period of fluctuating needs);
  3. There are changes in the person's circumstances; or
  4. There is increased independence as a result of equipment or assistive technology.

The changes could include:

  1. Changes to the day, time or duration of support;
  2. Reduction in the number of visits per day;
  3. A temporary increase in the support provided to manage a fluctuation of need; and
  4. Changes to the way that support is provided (for example if equipment is installed).

The process of revising the plan

All changes should be evidence based. Evidence could include:

  1. Observations of a support worker;
  2. Information from another person involved in the plan (for example a Therapy colleague); or
  3. Information from anyone involved with person for another reason (for example a social worker on a long term team or another health professional).

After receiving evidence a decision to revise the plan should be made in a timely way to avoid unnecessary delays and optimise windows of opportunity to promote independence.

The Reablement Plan is a working document and should be in a format that allows for regular and frequent revisions to be made quickly and easily.

It is appropriate for a support worker to amend a Reablement Plan by hand once changes have been formally agreed and for the formal record to be amended as soon as possible after this.

Whenever a change has been made to the plan you should:

  1. Communicate the changes to everyone involved in reablement; and
  2. Explain that until a revised copy of the plan is provided to them they should refer to the plan in the person's home.

Unless there have been changes to consent or to the people who are involved in the reablement, a copy of the revised plan should be made available to the same people as the original. Where a copy is provided electronically this must be provided securely.

If the person or carer is not in agreement with the change you can still make the change so long as you have given regard to:

  1. The views of the person and carer; and
  2. The impact on the person's Wellbeing of the change.

3. Managing Issues with the Plan

Examples of possible issues with a Reablement Plan include:

  1. The person is not engaging in reablement;
  2. The person is losing motivation;
  3. A carer, family member or friend is not encouraging or motivating the person to develop independence or engage in reablement;
  4. The outcomes in the plan appear unrealistic.

Resolving what is not working

In order to try and resolve the issues in the plan you will need to:

  1. Explore the issues;
  2. Explore the options to resolve the issues (from a strengths based approach); and
  3. Wherever possible reach an agreement about how best to resolve them.

This should be done in an open way and should involve:

  1. The person (or their representative if they lack capacity);
  2. Any carer;
  3. The person or organisation to which the issue relates (unless doing so will put the person at risk of abuse or neglect).
  4. Anyone else that the person asks you to involve; and
  5. Anyone else that you feel needs to be involved (with the person's consent or in their best interests if they lack capacity).

The following are just some of steps that may be appropriate to resolve the issues with the plan:

  1. Increased monitoring of the plan;
  2. Having a conversation with the person, a carer, family member or friend about the purpose of the reablement service, risk or enablement;
  3. Breaking down the outcomes into more achievable steps;
  4. Changing the frequency or duration of reablement visits;
  5. Holding a formal review of the plan where it is felt that the reablement service may no longer be appropriate.

It may be useful to prepare a simple written action plan for the purpose of recording and monitoring what has been agreed, and the steps that different people will be taking to resolve what is not working.

tri.x has developed a tool that can be used as required to action plan.

See: Action Planning Tool.

4. Reviewing Reablement

You should consider carrying out an unscheduled review of reablement if:

  1. Monitoring identifies that reablement may no longer be appropriate; or
  2. There are issues in the plan that have not been resolved through monitoring and they are reducing the benefit of reablement; or
  3. The person has achieved all of the reablement outcomes; or
  4. The person, carer or anyone else has requested a review.
See: The Reablement Review.

5. Providing Information and Advice

The duty to provide good information and advice about Care and Support applies at all times.

See: Providing Information and Advice (which is part of the Care Act 2014) to read more about the duty to provide good information and advice, including the duty to make sure that information and advice is accessible to the person receiving it.

See also: Providing Information and Advice, which includes access to local and national information and advice resources (general and specialist).

6. Accessing another Prevention Service

Reablement is one of a range of services available where the focus is on the prevention, delay or reduction of needs. However other prevention services may also be beneficial alongside reablement and should also be explored. These could include health services or Telecare.

Under Section 2 of the Care Act the Local Authority has a duty to prevent needs for Care and Support/Support whenever it identifies an opportunity to do so.

See: Preventing Needs for Care and Support to read more about the duty to prevent needs for Care and Support, including the types of prevention services recognised by the Care Act, when to provide prevention services and how to charge for prevention services.

7. Safeguarding and Deprivation of Liberty

Safeguarding

If, as part of any conversation you have with a person or their family you become concerned that a vulnerable adult or a child is experiencing, or at risk of abuse or neglect you must respond appropriately.

See Safeguarding Adults, which also includes information about how to raise a children's safeguarding concern.

If you are concerned that an adult or child is in imminent danger from abuse or neglect, or that a criminal act has taken place you should contact the police by dialling 999.

Where the safeguarding is in respect of the person receiving reablement a decision will need to be made about the need to pause the reablement process to allow a safeguarding enquiry to take place.

There are 2 possible options:

  1. The reablement process continues alongside any safeguarding process; or
  2. Reablement is paused with no on-going intervention by the person whilst a safeguarding process takes place.

Any decision should involve the reablement service, the person who will be carrying out any safeguarding process, the person with Care and Support needs (or their representative) and any carer.

Deprivation of Liberty

You must consider any appropriate action required to authorise deprivations of liberty whenever:

  1. The person lacks capacity to make decisions about the Care and Support provided to them; and
  2. You feel the level of restriction being imposed on the person is depriving them of their liberty; or
  3. You feel the level of restriction required to meet their care and support needs following assessment is likely to deprive them of their liberty.

See: Recognising and Responding to Deprivations of Liberty.

8. Whistleblowing

When to raise concerns

The Local Authority values openness, transparency and candour and encourages you to raise concerns as soon as possible about the practice of any individuals (whether they are employed by the Local Authority or not) that you feel:

  1. Compromises the safety or Wellbeing of a person with Care and Support needs; and/or
  2. Compromises the safety or Wellbeing of a carer with support needs; and/or
  3. Compromises the safety of a child.

Examples of individuals employed by the Local Authority include:

  1. A social worker;
  2. An occupational therapist;
  3. Unqualified workers in social work or occupational therapy services;
  4. Support workers in Local Authority day or provider services;
  5. Individuals employed in other areas of the organisation (such as housing officers and teachers in Local Authority schools or colleges).

Examples of individuals employed by other organisations include:

  1. Health professionals (for example a community or district nurse, a GP, a Psychiatrist or Psychologist, a Speech and Language Therapist. An Optician or a Dentist);
  2. Police Officers;
  3. A support worker in a charitable organisation;
  4. An advocate.

The legal context for Whistleblowing

Whistleblowing is part of the Public Interest Disclosure Act 1998 (PIDA). Under the Act you:

  1. Must be provided with a safe space in which to raise the concerns;
  2. Must be taken seriously;
  3. Cannot be subjected to any detrimental or unfavourable treatment and victimisation by the Local Authority or individuals as a result of making a disclosure.
Need to Know
If you are a student you are not protected by the Public Interest Disclosure Act. Prior to raising a concern you should seek advice from your University tutor, lecturer or mentor, a trade union or the Whistleblowing Helpline (details below).

Providing evidence of concerns

Legally you do not have to provide any hard evidence to support a whistleblowing disclosure, but if you have any evidence you should always provide it. This could be:

  1. Details of when a specific incident occurred;
  2. A witness statement written by you or that has been provided to you;
  3. Other documentary evidence (for example an e-mail or letter).

Further advice

If you require further advice about whistleblowing before making a disclosure you can contact the Whistleblowing Helpline:

  1. By telephone on 08000 724 725;
  2. by e-mail at enquiries@wbhelpline.org.uk.

Raising a concern

Concerns should be raised in line with local whistleblowing policy and process.