Actions and Next Steps (Reablement)

The Local Authority (and anyone representing the Local Authority) has a duty under Section 4 of the Care Act to either provide directly, or provide access to a range of information and advice relating to adult Care and Support, including financial advice. This duty applies equally in respect of all local residents regardless of whether the person with Care and Support needs is known to, lives in, or is already receiving services from the Local Authority.

See: Providing Information and Advice to read more about the duty to provide information and advice, including how information and advice should be provided and the specific information and advice requirements around finances.

In addition to our own services, information and advice is available from community and partner organisations. Information about these can be found in the Adult Services section of the Council website which also contains the Adult Social Care Directory.

See: Adult Social Care Hub.

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.

NOTE: This FAQ is based on statutory duties and powers and does not represent Milton Keynes local policy.

When providing information and advice on local charging policy, always refer to the relevant policy.

This will be found in the Local Resources section.

There is also information about charging on our Council website.

See: Paying for your Care and Support.

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.

Under the Care Act the Local Authority has a duty to not only provide information and advice where it is needed, but to ensure that the information and advice it provides has been effective.

Therefore, when information and advice has been provided you should agree appropriate arrangements to follow up with the person to whom it was given in order to review how effective it has been.

The timescales for this follow up should reflect the individual circumstances and level of risk.

Where you are making arrangements for someone else to follow up on the information and advice you have given (rather than following up on it yourself) you must make sure that you have recorded this in a way that will ensure the person follows up on it at the agreed time.

Maintaining confidentiality

The Local Authority has a common law and legal duty to safeguard the confidentiality of all personal information. As an employee of the Local Authority you are bound contractually to respect the confidentiality of any information that you may come into contact with. Under no circumstances should such information be divulged or passed to any persons or organisation in any form unless you have authorisation to do so.

All information sharing that takes place must be in line with data protection regulations and local policy.

Any unauthorised disclosure of confidential information may result in disciplinary action of individual prosecution under the Data Protection Act 2018.

Protecting information

You should take necessary steps to protect the information that you hold and have access to. For example:

  1. You should ensure that nobody else has access to your electronic information systems (e-mail and IT system);
  2. You should send electronic communication by secure channels (having verified the detail of the recipient);
  3. You should keep records made by hand in a secure place (e.g. notebooks);
  4. You should only discuss information with appropriate people in safe environments.

The rights of the data subject

Under Data Protection legislation (namely the Data Protection Act 2018 and the UK General Data Protection Regulations (UK GDPR) any person (known legally as the data subject) that the Local Authority holds information about is legally entitled to access the information held about them (known legally as the right of access) unless an exemption to do so applies (see below).

This includes both paper/hard copy information and information held electronically.

If the person lacks capacity

If the data subject lacks capacity to make a request for information under Data Protection legislation and they have a legally authorised representative who deems it in their best interests to request the information it can also be requested by that legally authorised representative and the request should be treated as if it had been made by the data subject.

The rights of other people

The rights of other people to access information about a data subject are limited. Information can only be provided if:

  1. The data subject provides consent for it to be shared; or
  2. The data subject lacks capacity to consent but has a legally authorised representative who has consented; or
  3. The data subject lacks capacity to consent, does not have a legally authorised representative but it is the view of the Local Authority that sharing the information would be in their best interests (e.g. to support an assessment by another professional);
  4. None of the exemptions set out in the Data Protection Act apply; or
  5. The information is requested under safeguarding and is integral to protecting the person, a child or other vulnerable adult from abuse or neglect.

As permitted under the UK GDPR, the UK Data Protection Act sets out some exemptions to the right of access. These exemptions apply to every information request, with one exception; if disclosure of the information is required by a court order or is necessary for the purpose of or in connection with any legal proceedings it should be provided.

The exemptions are:

  1. If providing the information requested will place the data subject, a child or other adult in (or at risk of) serious harm to their mental or physical health;
  2. If the information is child abuse data, it would not be in the best interests of the data subject;
  3. If a court has ordered the information not to be disclosed;
  4. Where a person with capacity provided the information to you with the expectation it would not be disclosed, or if they expressly indicated this (i.e. they did not consent);
  5. Where the information contains the identity or personal information of another data subject, that other person has capacity and has not consented to their information being shared, and it would not be possible to remove or disguise their data from the information (e.g. by blocking out or removing those details);
  6. Where the information contains the identity or personal information of another data subject, that other person lacks capacity to consent to their information being shared, it is not deemed in their best interests to do so and it would not be possible to remove or disguise their data from the information (e.g. by blocking out or removing those details);
  7. Where disclosure would prevent the detection or investigation of a crime or pose a risk to national security;
  8. The request is deemed 'manifestly unfounded or excessive' (e.g. an identical request has already been received and information has already been provided or denied).

If you are unsure whether an exemption applies you should seek support from a manager, who in turn should seek legal advice as required.

Data subjects should be told what information is collected about them, why and how long it will be kept for.

You should routinely share the following information with the person it is about (the data subject), whether or not they have requested it:

  1. Copies of any assessment or review reports (including risk assessments, mental capacity assessments and safeguarding reports);
  2. Copies of any Care and Support or other Plans; and
  3. Copies of any meeting minutes in which the person was present.

Where the person has capacity and requests that this information is also shared with another person you should honour this request unless doing so would place the person, a child or other vulnerable adult at risk of harm from abuse or neglect by that person. Where a request to share information is not honoured you should explain to the person why the information has not been provided.

If you feel that the information should be shared with another person or organisation in order to benefit the person (for example a health professional completing an assessment) you should obtain consent to do so.

Where the person lacks capacity a decision can be made that it is in their best interests for this information to be shared, so long as no exemptions apply.

In all cases

Whenever you are unclear about whether or not to share information you should seek support from a manager, who in turn should seek legal advice as required.

Informal requests by the data subject

If the person (data subject) has requested information informally relating to them or their case you must decide whether the information can be provided under Data Protection legislation.

It is the expectation in the legislation that wherever possible information is provided to a data subject following an informal request.

Some of the things that should be considered are:

  1. Is the information something that should be shared with the person as a matter of course?
  2. Would providing the information be a breach of someone else's confidentiality?
  3. Would sharing the information put the person at risk of harm from abuse or neglect?
  4. Would sharing the information put another adult or child at risk of harm from abuse or neglect?
  5. Do any of the exemptions in the Data Protection Act apply?

Informal requests by others

If the request is being made by a person who is legally authorised to request the information (a Court of Protection appointed Deputy for welfare or someone with Lasting Power of Attorney) the request should be treated as if it had been made by the data subject.

The rights of other people to access information about a data subject are limited. Information can only be provided if:

  1. The data subject provides consent for it to be shared; or
  2. The data subject lacks capacity to consent but has a legally authorised representative who has consented; or
  3. The data subject lacks capacity to consent, does not have a legally authorised representative but it is the view of the Local Authority that sharing the information would be in their best interests (e.g. to support an assessment by another professional); or
  4. The information is requested under safeguarding and is integral to protecting the person, a child or other vulnerable adult from abuse or neglect.

The person making the request can still make a formal request for the information if an informal request is denied.

Formal requests for information about a data subject

A formal request is a request made in writing. They can be made by anyone.

The outcome of a formal information request should be made within 1 month of the date it was made. Notification in writing should be provided to the person making the request.

If information is to be shared this should also take place within that timeframe, even if the amount of information is significant (e.g. a case file).

Under the Freedom of Information Act anybody may make a formal request in writing (including e-mail) for non-personal information from a public body. This is information that does not relate to a particular person (data subject).

The Freedom of Information Act specifies that any formal request for information made under the Act must be responded to within 20 days of receipt. The response should confirm:

  1. Whether the information is held by the Local Authority; and
  2. If so, provide the information requested.

Where information about a person (data subject) is  requested as part of a safeguarding enquiry in order to protect the person, or another vulnerable adult or child from abuse or neglect (or the risk of abuse or neglect) it should be provided.

This should be provided securely to the person leading the safeguarding enquiry and any concerns that you have about the implications for other vulnerable adults or children as a result of providing the information should be shared and considered by the safeguarding enquiry.

If it is possible to seek consent from the data subject before providing the information you should do so, although information can be provided without consent for the purpose of protecting them (or another adult or child) from abuse or neglect. If the person does not give consent the information should still be shared if doing so would serve to protect them (or another adult or child) from the risk of abuse and neglect.

You should notify the person that their information has been shared for the purposes of protecting them (or under safeguarding) from harm unless doing so would place them (or another adult or child) at further risk of harm. In this case you should notify them when it is deemed safe to do so.

You should be clear with the person from the beginning that in the event of safeguarding information about them may be provided without their consent or immediate knowledge.

It is important that the person making contact speaks to the right practitioner at the right time. Sometimes you may find that you are not the most appropriate practitioner to manage the contact.

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 the written communication is being transferred to 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.

Reablement is just one of a range of local services available where the focus is on the prevention, delay or reduction of needs. 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.

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.

When considering, seeking, or arranging preventative services, this should be:

  • Personalised, responsive and flexible depending on the needs of the person;
  • Creative and focussed on what people want to achieve in their lives;
  • Strengths based- building on what people and their communities can do and promoting new ideas.

Information about preventative services provided by our Adult Services can be found in the Local Resources section.

This includes, but is not limited to:

  • Community Alarm;
  • Community Occupational Therapy;
  • Rehabilitation.

In addition to our own services, preventative support is also available from community and partner organisations. Information about these can be found in the Adult Services section of the Council website.

See: Adult Social Care Hub.

If, as part of any conversation or information gathering you become concerned that a vulnerable adult or child is experiencing, or at risk of abuse or neglect you must respond appropriately by raising a concern.

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 dialing 999.

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 maximise 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 2 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 2 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.

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.

Regular monitoring of the reablement plan should be incorporated into any reablement service provided. This is essential to ensure that the service is working as intended, and to make changes required quickly to promote and optimise independent functioning.

The monitoring mechanism in reablement must be responsive and consider any need to hold a review of the plan outside of any scheduled review:

  1. Whenever the person whose plan it is requests it;
  2. Whenever a carer of the person whose plan it is requests it;
  3. Whenever the service providing the reablement requests it; and
  4. Whenever new information is provided that indicates a review would be beneficial in optimising reablement.
Need to know

If the person, carer or anyone else request a review of the reablement plan this must be considered. The Care Act permits anyone to make a request for any type of review and places a duty on the Local Authority to carry out a review whenever it is deemed reasonable to do so.

See: Revising a Reablement Plan.

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 action plan.

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 teams 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 would best support them must be regarded;
  2. The service/team must possess the skills, knowledge and competence to carry out the anticipated Care and Support functions; and
  3. The service/team must possess the skills, knowledge and competence to work with the particular person in question.

tri.x as 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.

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.

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 assistive technology 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, on-going joint-work to monitor);
  5. What does the person with care and support needs 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.

Last Updated: May 31, 2022

v40