The Full Review Conversation (Carers)

1. When to use this Procedure

This procedure should be used to support a full review conversation as part of the statutory review of a Support Plan.

A full review conversation should only be carried out when a decision has been made that a light touch review conversation is not appropriate.

A light touch review is normally appropriate and proportionate whenever;

1. There are no known changes in need or circumstances; and
2. There are no changes required to a Support Plan (or minimal changes to how existing Support is provided only); and
3. There are no changes required to the personal budget.

A light touch review should be specifically considered in the following circumstances;

1. At the 6-8 week review; and
2. When there is/has been on-going monitoring of the carer's needs or circumstance.

If a light touch review is appropriate you should click here to access the procedure to support a light touch review conversation.

If you are not clear whether a light touch review is appropriate you should seek advice from your line manager.

2. Families

The Care Act is clear that a whole family approach to review should be taken wherever possible and with the carer's consent. The whole family approach in review is the same as the whole family approach in assessment.

Click here to access the procedures for ensuring a whole family approach, including who should be involved, consent and the responsibilities you have to adult and child family members.

3. Reviewing what is Working and Not Working (Full Review)

Wellbeing and the effectiveness of the Support Plan

A Support Plan that is working well is more likely to have a positive effect on the carer's Wellbeing than a plan that is not working well. The Local Authority has a duty to promote individual Wellbeing, so must ensure that everything is in place in the plan and working as intended.

A strengths based approach

Wherever possible, every conversation with a carer should be from a strengths perspective. This means that before you talk about service solutions to anything that is not working you must support the carer to explore whether there is;

1. Anything within their own power that they can do to help themselves; or
2. Anything within the power of their family, friends or community that they can use to help themselves.

Comprehensive guidance about using a strengths based approach can be found in the Strength Based Approach Practice Handbook. This is part of a larger resource published by the Department of Health and Social Care-Strengths-based approach: Practice Framework and Practice Handbook. It can be found in the Local Resource area by clicking here.

SCIE have also produced clear and practical guidance around how to use a strengths based approach in practice. See Care Act Guidance on strengths-based approaches.

Note: SCIE requires a login to access resources, but any social care practitioner can create one quickly and easily.

What the conversation about what is working and not working must establish

The conversation about what is working and not working must broadly establish whether;

1. All of the support in the plan is in place as intended;
2. All of the support in the plan is meeting the carer's needs (including the carer's need for work, education, training and recreation);
3. The plan is supporting the carer to achieve their outcomes;
4. The method of managing the personal budget is still the most effective way of meeting needs and supporting the carer to achieve outcomes;
5. Anything has changed about the carer's circumstances that may indicate a change is needed to the Support Plan;
6. There any risks to the plan's sustainability;
7. The plan is reducing any identified risk to the carer or the cared for person (including risk associated with their needs and risk relating to abuse and neglect);
8. Everybody involved in the plan is satisfied with it.

The conversation about what is working and not working

Any questions that are used to support a carer to think about what is working and not working must;

1. Be proportionate to the level of information required;
2. Be appropriate, taking into account the carer's specific needs around communication and their specific circumstances;
3. Be realistic in respect of the carers ability to be able to answer the question; and
4. Be asked in a manner that is accessible to the carer.

Powerful questions

A powerful question is a specific type of open question that;

1. Encourages a carer to reflect;
2. Is thought-provoking;
3. Supports an exploration of options; and
4. Helps the carer to gain a greater insight into their situation.

Powerful questions should be framed in a positive way to promote engagement of the carer and promote a strengths based approach.

Powerful Question	Open Question (not powerful)
Why do you think that means so much to you?	What do you think that for?
What works well about the support you have?	Who does that for you?
Why do you think that didn't quite go as expected?	Why didn't that work out?
What made you decide to take that approach?	Why did you do that?

Appreciative Enquiry

An appreciative enquiry is a conversation that is led by the carer and focuses on times of personal strength. It supports them to recognise that they do still have those strengths and abilities and to think about how they can apply them to their current situation.

The listener should invite the carer to;

1. Talk about a time or times when something has been working well in their life;
2. Explore what it was that worked well and supported them at that time;
3. Think about how that experience could support them now in making a plan for the future.

Some key questions to support an appreciative enquiry approach include;

1. Tell me about a time when things were going well for you?
2. What did you learn about your strengths at that time?
3. If you had a magic wand what would the future look like?
4. What is it that you value most in your life now?
5. What small changes would make the most difference?

The use of tools

A tool can be helpful to shape and focus a conversation about what's working and not working. Tools are also useful because they;

1. Can be completed with the carer as part of any conversation you have with them; or
2. The carer can complete them in their own time as part of their preparation for the conversation.

Click here to access the range of tools that are available and practice guidance around the use of tools.

Resolving what is not working

If the conversation about what is working and not working identifies elements of the plan that are not working 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 carer;
2. Anyone else that the carer has asked you to involve;
3. The person or organisation to which the issue relates (unless the carer has refused consent to do so); and
4. Anyone else that you feel needs to be involved (with the carer's consent).

Examples of situations that may be identified as 'not working include;

1. When formal services are not in place;
2. When needs are not adequately being met by the support in place;
3. When support is not supporting the carer to achieve their outcomes as intended;
4. When support is not managing risk to the carer or the cared for person effectively; or
5. When the support is not sustainable.

You will need to;

1. Understand the impact on the carer's Wellbeing of the issue identified;
2. Establish whether the issue is preventing an eligible need from being met;
3. Explore what has already been tried to resolve the issue and what the alternative options may be; and
4. Identify the risks to the carer, the person they care for and the Support plan if the issue is not resolved.

When exploring the range of options to resolve the issue a simple pros and cons list can be helpful to identify the most proportionate response.

The use of an action plan

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

Click here to access a tri.x tool that can be used to action plan.

Urgent and interim support

You will need to consider any requirement for urgent or interim support to ensure that the carer's eligible needs are met whilst steps are being taken to;

1. Resolve the issues with the Support Plan;
2. Agree revisions to the Support Plan; or
3. Carry out any other action (for example safeguarding or a reassessment of need).

If there is an urgent need to be met click here to access the procedures for arranging urgent and interim support.

4. Talking about Individual Wellbeing (Full Review)

You have a statutory duty to promote individual Wellbeing at all times, including at review. Conversations about Wellbeing need to be proportionate and appropriate, having regard for whether Wellbeing is likely to have changed.

Click here to access the procedure for talking about Wellbeing.

5. Reviewing Outcomes (Full Review)

Outcomes and Wellbeing

Outcomes can change when a carer's life priorities change. This can happen unexpectedly and unmet outcomes can have a dramatic impact on a carer's individual Wellbeing. The Local Authority has a duty to promote Wellbeing and to do this it must;

1. Understand what is important for a carer to achieve, change or maintain in their life at any given point in time; and
2. Take steps to support the carer to achieve these outcomes.

What the conversation about outcomes must establish

The conversation about outcomes must broadly establish whether;

1. The outcomes in the Support Plan have been achieved or not;
2. The carer has any new outcomes they want to meet; and
3. Any improvements are required to the plan to achieve better outcomes.

The conversation about outcomes

Simple questions should be used to confirm that outcomes are being met by the Support Plan, such as;

1. How have you been able to work towards the outcomes in your plan?
2. Have there been any changes to the things that are important to you to achieve, change or maintain?
3. Do you think there needs to be any changes to the plan to support you work towards your outcomes?

Specifically you should confirm whether the carer's outcomes are being met or have changed in regards to work, education, training and recreation.

You should refer to the Support Plan to confirm what the carer's outcomes were if this requires clarification.

Action when outcomes have not been achieved

If outcomes have not been achieved (or progressed) as intended by the support provided you must take steps to;

1. Establish if the outcomes are still important to the carer;
2. Where the outcomes are no longer important agree new outcomes; or
3. Where the outcomes are still important, agree how to resolve any issues in meeting them.

Click here to access the procedure for resolving issues with any element of a Support Plan.

Where there is a need to talk about new outcomes you should refer to the full procedure for talking about outcomes, which can be found by clicking here.

6. Talking about Needs (Full Review)

Review and the duty to meet eligible needs

The Local Authority has a duty to meet eligible needs on an on-going basis, not just at the point that needs are established.

Review is an important element in ensuring that the duty to meet needs is met because it;

1. Offers assurance that eligible needs are being met; or
2. Provides evidence that needs have changed so that the Local Authority can provide an appropriate response to assess any new needs, reassess any change in existing needs and meet them if they are eligible.

What the conversation about needs must establish

The conversation about needs must establish whether the carer's needs have changed since the time that they were assessed and the Support Plan agreed.

The conversation about needs

A simple question, such as 'Has there been any change to your needs' can be sufficient during a review.

You should refer to the assessment report to confirm what assessed needs were if this requires clarification.

Exploring and Managing different views about need

If, as part of a review process there is disagreement about whether a carer's needs have changed it is your responsibility to make the final decision about whether needs have changed. To do this you should;

1. Consider all of the available evidence;
2. Give regard to the views of the carer; and
3. Consider the different views expressed by others.

You must make sure that the evidence upon which you base your decision is robust and you must be open about the evidence that you have used.

If there has been no change in need

Once you have established that there has been no change in need there is no requirement to discuss needs further during the review.

If there has been a change in need

If there has been a change in need you should explore;

1. Broadly, what the changes in need are;
2. What the impact of the changes are on the carer's Wellbeing;
3. What the impact of the changes are on the cared for person's Wellbeing;
4. What the impact of the changes are on support; and
5. The impact of the changes on risk (to the carer, the cared for person and the plan).

Whenever there has been a change in need the outcome of the review must be to carry out a proportionate reassessment of need.

The reassessment must make effective use of the information gathered during the review to avoid duplication.

The procedures for carrying out a reassessment of need are the same as the procedures for carrying out any assessment of need.

Urgent and interim support

You will need to consider any requirement for urgent or interim support to ensure that the carer's eligible needs are met whilst steps are being taken to;

1. Resolve the issues with the Support Plan;
2. Agree revisions to the Support Plan; or
3. Carry out any other action (for example safeguarding or a reassessment of needs).

If there is an urgent need to be met click here to access the procedures for arranging urgent and interim support.

Short term changes in need

If a carer has experienced a change in need but this is only likely to be short term a reassessment of need may not be required, as long as;

1. The needs can be met and are being met by the existing Support Plan; and
2. It is reasonable to believe that the needs are short term only.

You will need to agree appropriate arrangements to monitor the carer's needs and circumstances. This could be through another light touch review in a shorter time frame. You will also need to ensure that the carer knows what action to take should the short term needs become more long term or the Support Plan no longer meets the needs.

7. Reviewing Risk (Full Review)

Understanding what risk is

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.

Why you must review risk

It is important to talk about risk during a review for the purpose of establishing that;

1. Risks continue to be well managed by the Support Plan;
2. There have been no changes to risk;
3. There is no risk to the carer or the cared for person from abuse or neglect; and
4. There is no risk to the Support Plan's stability or sustainability.

To establish whether there have been any changes to risk simple questions should be used in the first instance, such as;

1. Are the things in the Support Plan keeping you safe?
2. Is there a chance that your plan could stop working well?

Talking about risk to the carer

Examples of risk to a carer include;

1. Risk associated with the carers own impairment or disability (e.g. falls when carrying out caring related tasks);
2. Risk of accidental injury (e.g. from manual handling and supporting the cared for person to mobilise);
3. Risks to the carer from the person they care for (e.g. from verbal or physical abuse or from behaviour relating to the use of drugs or alcohol);
4. Risks to the carer's emotional health as a result of the caring role;
5. Risks to the carers work or family life as a result of their caring role; and
6. Risks to the carer's own network of support (e.g. is it sustainable and how likely is it to break down).

You should refer to the Support Plan to confirm the current contingency plan and what the risks are to the carer if this requires clarification.

If risks to the carer have not changed and are well managed

If the review identifies that risks to the carer have not changed and the measures in place are effectively reducing risk there is no requirement to talk about risk to the carer further during the review.

If risks to the carer have changed or are not managed

If the review identifies that there are new risks to the carer, or that risks are not well managed you will need to explore;

1. What is working and not working with the current measures;
2. What steps can be taken to resolve any issues with the current measures to reduce risk; and
3. Any new measures to manage risk.

This should be done from a strengths based and positive approach that supports the carer to;

1. Explore and understand the benefits of taking the risk;
2. Explore and understand the potential harmful consequences of taking the risk;
3. Think about the measures that can be taken to reduce the likelihood of a negative consequence; and
4. Make an informed decision about whether to take the risk.

The process of talking about risk can be very empowering for a carer and build resilience, confidence and independence.

Depending on the level of risk a formal risk assessment may need to be carried out as part of the review process. Click here to access the procedures for carrying out a risk assessment.

Talking about risk to the plan

Examples of risks to a Support Plan could include;

1. Risks that informal Support being provided to the carer will not be sustainable;
2. Risks that needs will not be met if a service provider is temporarily unavailable;
3. Risks that the support in the plan will not be as effective at meeting needs or supporting the carer to achieve outcomes as intended;
4. Risks that a regular Direct Payment will not be managed appropriately;
5. Risks due to a likely change in the needs of the cared for person.

You should refer to the Care and Support Plan to confirm the current contingency plan and what the risks are to the person if this requires clarification.

If risks to the plan have not changed and are well managed

If the review identifies that risks to the plan have not changed and the measures in place are effectively reducing risk there is no requirement to talk about risk to the plan further during the review.

If risks to the plan have changed or are not managed

If the review identifies that the plan is at risk or that the contingency plan is not adequately reducing risk to the plan you will need to explore;

1. What the risk to the current plan is;
2. What is working and not working with the current contingency measures;
3. What steps can be taken to resolve any issues with the current measures to reduce risk; and
4. Any new measures to manage risk.

The full procedure for managing risk to a plan and contingency can be accessed by clicking here.

8. Good Information and Advice and Prevention

The duty to provide good information and advice and to consider ways to prevent, reduce or delay needs for Support applies at all times.

It is vital that you understand your duties in relation to the above. Please use the links below to access further information as required.

Click here to read about the duty to prevent, reduce or delay needs.

Click here to read 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.

During the review process it is important that you;

1. Offer information and advice as appropriate, including signposting to other sources;
2. Discuss options to prevent, reduce or delay the need for Support; and
3. Give the carer and anyone else involved opportunities to ask questions or seek clarity.

Depending on the carer's situation and needs specialist information and advice that may be required could include;

1. Advice around the financial assessment process;
2. Advice about becoming a Lasting Power of Attorney or Deputy;
3. Advice about becoming an Appointee;
4. Advice about making a complaint about the Local Authority;
5. Information about the local market place for Care and Support or health services.

Click here to access the general information and advice procedures, including access to local and national information and advice resources (general and specialist).

9. Safeguarding and Deprivation of Liberty

Safeguarding

If, as part of any conversation you have with a carer 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.

1. Click here to access the adult safeguarding procedures, including how to recognise abuse and neglect, how to raise a concern, how to record safeguarding information;
2. Click here to access the Local Safeguarding Adults Board Multi-Agency Safeguarding Procedures; or
3. Click here to access the Local Safeguarding Children's Board Multi-Agency Procedures.

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 and seek immediate medical support if necessary.

Where the safeguarding is in respect of the carer whose Support Plan is being reviewed (for example if the cared for person is causing harm to the carer) a decision will need to be made about the need to pause the review process to allow a safeguarding enquiry to take place.

There are 3 possible options;

1. The review process continues alongside any safeguarding process;
2. The review is paused with no on-going intervention by the person carrying out the review whilst a safeguarding process takes place; or
3. The review is paused but urgent interim support is arranged to ensure needs are met whilst a safeguarding process takes place.

Any decision should involve the person carrying out the review, the person who will be carrying out any safeguarding process and the carer.

Deprivation of Liberty

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

1. The person being cared for 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.

Click here to access the Recognising and Responding to Deprivations of Liberty Procedure for further practice guidance.

10. Making a Record of the Conversation

During the conversation

It is quite appropriate to take notes during a skilled conversation to ensure that you are able to satisfactorily recall and capture what has been discussed and agreed in the formal record. However, there are some general good practice rules to follow when doing so;

1. Think beforehand about the level of note-taking that may be required-ensure you have to right tools and that they are proportionate;
2. Explain to the carer and anyone else present that you will be taking some notes and why;
3. Reassure the carer and anyone else present that you will still be listening to them even when you are making notes;
4. Don't record everything that is said. This will prevent you from engaging in the conversation and cause distraction-you need to pick out what is relevant and important;
5. Make sure you record everything that the carer says is important to them, even if it does not appear to be relevant to you or others;
6. If the carer uses a certain phrase that is powerful or indicative to the context you should record this word for word;
7. Sometimes information is detailed or complex and taking notes could take a little longer than expected. If this is the case you should consider making a polite request for a brief pause to allow for notes to be made
8. Sometimes people provide a lot of information without a pause-perhaps they are anxious or simply have a lot to say. Trying to keep up can lead to you over-recording (recording everything regardless of relevance); missing key points, failing to understand what is being said or appearing disengaged from the conversation. If this is the case you should consider politely requesting a pause to allow for clarity and notes to be made;
9. Refer to your notes to summarise what has been said during the conversation, reflect and seek clarity about what has been agreed and next steps;
10. Try to make notes in a legible way and take care to use appropriate language-the carer may request to see the notes or be provided with a copy;
11. Confidentiality must be maintained at all times. Make sure that the notes are kept securely and only available to people authorised to see them;
12. Always file or dispose of any notes securely when a formal record of the conversation has been made.

After the conversation

Click here to access the procedure for making a formal record of the conversation.