Agreeing Needs, Making a Formal Record and Next Steps (Reablement)

Throughout the process of information gathering to establish needs you should talk to the person (or their representative) and others about the level of need apparent, endeavouring to reach an agreement about this as the process progresses.

See: Talking about Needs.

Whether or not an agreement about needs is reached the Local Authority is responsible for making the final decision about the level of need that a person has in each area of need identified. As such this is your responsibility as you are the Local Authority's representative.

When determining the level of need you must give regard to:

1. The views of the person about the level of need;
2. The impact of the need on the person's Wellbeing;
3. The views of any carer about the level of the person's need; and
4. The views of anyone else consulted or involved in the assessment process.

The decision that you make about the level of need must be evidence based and robust. This means you must be able to demonstrate the information that you have used to reach a decision about need 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 have given regard to the person's views, their Wellbeing and the views of others.

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

All recording should be made in line with local requirements.

The Care Act does not specify a timeframe for making a formal record of an assessment only that this should be done in a timely way.

Timely recording will:

1. Reduce the likelihood of inaccuracies;
2. Prevent any unnecessary delays for the person;
3. Optimise the benefit of the reablement intervention to be provided; and
4. Ensure that the duty to meet eligible needs outside of reablement is met as close to the need being identified as possible.

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

The following information must be clearly recorded in all cases:

1. The identified areas of need that the person has;
2. The nature of needs that the person has in each area where needs exist;
3. Which needs can be prevented, reduced or delayed (and the options explored for doing so);
4. The views of the person, any carer and any other person in relation to need (and how these have been regarded);
5. The views of the person, any carer and any other person in relation to how need impact on Wellbeing (and how these have been regarded);
6. The evidence that has been used to reach a determination about the level and nature of need;
7. How the impact of the decision on Wellbeing has been considered;
8. A proportionate record of the options explored to meet needs and achieve outcomes, clearly demonstrating a strengths based approach;
9. A proportionate record of conversations about risk, clearly demonstrating a positive approach to risk;
10. A proportionate record of any general information and advice that has been given about adult Care and Support;
11. A proportionate record of other preventive measures that have been explored; and
12. A proportionate record of any actions and next steps agreed (including whether reablement is to be provided).

The following information should also be clearly recorded where relevant:

1. The safeguarding concerns raised and action taken;
2. The Deprivation of Liberty concerns raised and action taken;
3. A proportionate record of specific information and advice given (for example around finances or Lasting Power of Attorneys);
4. The evidence that has been used to demonstrate the level of fluctuating need; and
5. Any difference in views about need that have occurred.

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

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

If the assessment 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 assessment 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 assessment has been provided to the person so that they can support them to understand it.

Where the assessment was carried out jointly with another organisation to avoid duplication (for example occupational therapy) a copy of the assessment must be made available to the other person that 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 assessment, or to share only part of the assessment. In this case you will need to discuss and agree which elements of the assessment 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).

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 assessment itself.

Concerns about a request

You must provide a copy of the assessment 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 assessment. 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 assessment 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 assessment 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.

The reablement service provides a bespoke function to directly support people with a disability, who have a mental health issue or who are recovering from illness to:

1. Learn the skills of daily living to enable them to live independently (or with as little support as possible);
2. Re-learn lost skills of daily living (either fully or to a point where independence is increased as much as it can be);
3. Learn to 'live well' with a condition and develop strategies to be as independent with daily living skills as possible for as long as possible;
4. Build confidence across any other areas of life that are important to the person so as to increase their independence (for example building social skills).

Reablement is available to everyone whose needs can be prevented, reduced or delayed by the service. This includes people who lack capacity. As such, if the assessment has identified that the person has needs that can be prevented, reduced or delayed reablement will normally be appropriate.

Reablement may not be appropriate when:

1. The person is not open to being supported in an enabling way;
2. The person's goal is not to become as independent as possible;
3. The person is not able to "carry over" what they have learned from one day to the next;
4. The person's health has changed and they are not well enough to engage with reablement.

Decisions about the appropriateness of reablement should be made in line with local processes and guidance.

When a decision is made that reablement is appropriate you should proceed to reablement planning to:

1. Identify and agree the specific outcomes that the person wants to achieve from the reablement service; and
2. Arrange to provide the reablement service.

If the person has a Care and Support Plan that is meeting all needs there is no further action required, other than notifying the allocated practitioner or service/team responsible for reviewing the plan of the assessment outcome.

If the person has a Care and Support Plan that does not appear to be meeting the person's needs a review of the plan should be requested. This should be made to the allocated practitioner or team with responsibility for reviewing the plan. You should inform the person and seek their consent to make the review request, although even if the person does not consent you should still make the request. This is because the consent of the person is not required to request the review (only to carry it out).

When requesting the review you should provide the following information:

1. Why the review is being requested and the sense of urgency;
2. Whether the person has consented to the review;
3. The information gathered during the assessment to support the request;
4. Whether there is a need to provide urgent or interim support.

If the person (or carer) is not happy about the request to review they should be advised can discuss this with the practitioner who contacts them to make review arrangements.

If the person does not have a Care and Support Plan you will need to seek their consent to transfer their case to a more appropriate service/team.

Any process for transferring the case 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.

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.