Reviewing a Best Interests Decision

1. The Importance of Review

What is in a person’s Best Interests may change over time. This means that a decision that was made and implemented at the time that it was originally needed may not always remain in their Best Interests.

For example there may be changes in;

  1. The relevant circumstances;
  2. The person’s present wishes and feelings; or
  3. The risks and benefits of the preferred option.

It is important to make sure that;

  1. Any decision remains in the person’s Best Interests for as long as it is being implemented: and
  2. The way that the decision is being implemented remains the least restrictive way of achieving the desired outcome.

2. Initial Reviews

Decisions with a single act of implementation

Examples of decisions with a single act of implementation include;

  1. The provision of life saving treatment;
  2. The provision of any one-off medical treatment or procedure;
  3. A decision to allow a person to take part in a specific activity; and
  4. A decision to allow the person’s money to be used to make a particular purchase.

Shortly after the decision has been implemented you should review the impact of the decision upon the person and if;

  1. The anticipated benefits have not arisen; or
  2. There have been negative impacts that were not anticipated; or
  3. The impact has been more negative than anticipated; you should
  4. Explore what can be done to minimise the negative impact on the person.

Decisions with on-going acts of implementation

On-going acts of implementation are acts that are required to take place routinely, or on more than one occasion. They include any act that;

  1. Deprives a person of their liberty in a care home or hospital; or
  2. Results in a choice being made on the person’s behalf about, for example what to eat, what clothes to wear or how to spend their time;
  3. Imposes a particular care regime on the person, for example personal care routines, how medication is provided or how transfers are carried out; and
  4. Acts to provide routine treatment, such as visits to the GP or dentist.

Shortly after the decision has been implemented you should review the impact of the decision upon the person and if;

  1. The anticipated benefits have not arisen; or
  2. There have been negative impacts that were not anticipated; or
  3. The impact has been more negative than anticipated; you should;
  4. Explore what can be done to minimise the negative impact on the person; and
  5. Review the manner in which the acts implementing the decision are being carried out to make sure that this remains the least restrictive way to achieve the desired outcome; and
  6. Consider reviewing the original Best Interests decision that was made.

3. General Reviews of Decisions and Acts

Acts related to everyday decisions about routine care or treatment

Acts related to everyday routine care or treatment are acts that are required to take place routinely, or on more than one occasion in order to implement the Best Interests decision.

Examples of acts relating to everyday decisions include;

  1. Personal care tasks;
  2. Providing medication;
  3. Using equipment for transfers;
  4. Making food or clothing choices;
  5. Visits to the GP or dentist; and
  6. Making choices about how a person spends their time.

The process for carrying out these on-going acts of implementation should be;

  1. Agreed through applying the Best Interests principle; and
  2. Clearly set out in the person’s Care and Support Plan, Care Plan or Support Plan.

Carers should follow the process set out each time that they are required to carry out the act. However, on each occasion they must reasonably believe that there have been no changes to;

  1. The relevant circumstances; or
  2. The person’s wishes and feelings; and
  3. That the decision that was made is still in the person’s Best Interests; and
  4. That the act being carried out to implement the decision is still the least restrictive way of doing so.

Where changes to the above have occurred, or may have occurred steps should be taken to;

  1. Formally review the original decision by applying the Best Interests principle; or
  2. Review the manner in which the acts implementing the decision are being carried out to make sure that this remains the least restrictive way to achieve the desired outcome.
Case Example

Mohammed used to enjoy having a bath, but changes in his mobility following a stroke led to a decision being made in his Best Interests that he should instead use a walk in shower.

Mohammed remained unhappy at not being able to have a bath and regularly expressed this view to carers.

Over time Mohammed’s mobility improved and his carers decided that the original Best Interests decision that was made should be reviewed.

Major decisions and acts to implement them

Major decisions include those about;

  1. Accommodation;
  2. Medical treatment;
  3. Restricting human rights;
  4. The sale or purchase of a significant item.

To implement a major decision may require;

  1. A single act; or
  2. On-going acts.

Major decisions requiring a single act of implementation

Examples of major decisions with a single act of implementation include;

  1. The provision of life saving treatment;
  2. The provision of any one-off medical treatment or procedure; and
  3. A decision to allow the person’s money to be used to make a particular purchase.

Where a decision requires a single act of implementation you should review the impact of the decision upon the person shortly after the act has been carried out and if;

  1. The anticipated benefits have not arisen; or
  2. There have been negative impacts that were not anticipated; or
  3. The impact has been more negative than anticipated; you should
  4. Explore what can be done to minimise the negative impact on the person.

Major decisions with on-going acts of implementation

Examples of major decisions that require on-going acts of implementation include;

  1. Continued accommodation in a specific setting;
  2. A course of medical treatment;
  3. A Deprivation of Liberty;
  4. A restriction on contact with others.

Those persons responsible for carrying out any on-going acts to ensure that major decisions are implemented on a day to day basis should follow the process set out in any Care and Support Plan, Support Plan or Care Plan of the person. However, on each occasion that they carry out an act they must reasonably believe that there have been no changes to;

  1. The relevant circumstances; or
  2. The person’s wishes and feelings; and
  3. That the decision that was made is still in the person’s Best Interests; and
  4. That the act being carried out to implement the decision is still the least restrictive way of doing so.

Where changes to the above have occurred, or may have occurred the person carrying out the act should;

  1. Notify the person (or organisation) who made the original Best Interests decision; who
  2. Should take steps to formally review the original decision by applying the Best Interests principle; or 
  3. Review the manner in which the acts implementing the decision are being carried out to make sure that this remains the least restrictive way to achieve the desired outcome.

Major decisions and the manner in which they are being implemented should also be reviewed;

  1. Whenever a Care and Support Plan (or health plan) is reviewed; or
  2. Whenever a Education, Health and Care Plan is reviewed (if the person has an EHC Plan); or
  3. During any other Care and Support process, including safeguarding.
Case Example

2 years ago a Best Interests decision was made to accommodate Edith in a care home 50 miles from her family because there no available local options to meet her specialist needs. Edith has always been upset by the fact that she does not see her children as often as she would like.

Edith’s son becomes aware that a suitable placement has become available just 3 miles from his home. He contacts the Local Authority to ask that a review of the original Best Interests decision is carried out on the basis that;

  1. The relevant circumstances have changed (because there is a now an option available locally);
  2. Edith’s views have not changed; and
  3. He feels that the current placement is no longer in her Best Interests.

4. Reviewing a Short Term Decision

When a short term decision is made it is done so because there is a possibility that the person;

  1. Will regain mental capacity to make the decision for themselves; or
  2. Can be supported to be more involved in the decision.

A short term decision should always specify a timeframe within which it must be reviewed.

The review of a short term decision should take place;

  1. Within the agreed timeframe; or
  2. As soon as possible if the person’s capacity or ability to be involved in the decision improves; or
  3. When there is evidence that the person’s capacity is no longer likely to improve.

The review should also take place if those persons responsible for carrying out any on-going acts of implementation believe that there have been changes to;

  1. The relevant circumstances; or
  2. The person’s wishes and feelings; and
  3. That the decision that was made is no longer in the person’s Best Interests; or
  4. That the act being carried out to implement the decision is no longer the least restrictive way of doing so.

5. Keeping a Record of Review

Whenever a review is carried out you should clearly record all of the following on the person’s file;

  1. The Best Interest decision that has been reviewed; or
  2. The acts of implementation that have been reviewed; and
  3. The reason for the review (e.g. a general review or because there has been a change); and
  4. The outcome of the review; and
  5. The rationale for the outcome.

tri.x procedures