Preparing to Carry out a Care and Support Plan Review

1. Using this Procedure

This procedure should be used by anyone preparing to carry out a Light Touch or Full Care and Support Plan Review.

Anyone preparing to carry out the review of a carers Support Plan should see: Preparing to Carry out a Support Plan Review (Carers).

Note: This procedure is used by all of the following teams and services:

1. Hospital Pathway Team;
2. First Response Teams;
3. Review Teams;
4. All Age Learning Disability.

2. Letting the Person know you will be Carrying out the Review

General Guidance

You should contact the person as soon as possible to let them know that you will be carrying out the review, even if you are not able to make the arrangements to do so yet.

You should let the person themselves know that you will be carrying out the review unless:

1. They have requested you liaise with a nominated representative (for example an advocate or family member); or
2. They lack capacity and a decision is made that it would be in their best interests to liaise with another appropriate person.

The method of communication should reflect that requested by the person and any specific communication needs they may have. For the purposes of the Care Act communication about the review is subject to the same requirements as the provision of information and advice, and the duty to make it accessible therefore applies equally.

See: How to Provide Information and Advice to read more about how to provide information in an accessible way under the Care Act.

In all cases where communication has been provided by telephone a follow up letter confirming the conversation and outcome should be sent to the person as a formal record.

Where the person lacks capacity

If the person lacks capacity you should let an appropriate person know that you will be carrying out the review. Where available this should be a person legally authorised to represent them (for example a Court appointed Deputy or the Donee of a Lasting Power of Attorney) or an independent advocate. If the person lives in a care home this could also be the manager of the home.

Arranging a review

If you are able to make arrangements for the review to be carried out you should do so. See Section 5, Arranging the Review and Preparing the Person.

If you are unable to arrange the review yet

If you are not able to arrange the review at this first contact you should:

1. Be satisfied that the delay is not going to increase the risk of deterioration in need or circumstances;
2. Be satisfied that the delay is not going to increase the risk of abuse or neglect;
3. Provide any information or advice that may be beneficial at that time;
4. Be satisfied that urgent or interim support is not required;
5. Be satisfied that the person understands the reason for the delay;
6. Agree a proposed timeframe for the review to be carried out and further contact to be made; and
7. Advise the person what to do should their situation change.

An element of monitoring should be incorporated into any delayed process to ensure that you remain aware of the person's situation and are able to respond appropriately to any changes or need to re-prioritise their review.

If the timeframe for review agreed with the person changes you should let them know as soon as possible. If you experience difficulties prioritising your own work you should seek support from your line manager.

If the person is not happy about any delays and you are satisfied that you are taking all reasonable steps to make arrangements and reduce risk you must make them aware of their right to complain.

3. Mental Capacity and Engagement Difficulties

Review when the person lacks capacity

Some people will lack capacity to understand or engage in any review process (verbally or through another means). For example, they may be too unwell to do so or have a significant learning disability. Where this is the case the duty to ensure their involvement still applies.

There are a range of ways that you can ensure the involvement of a person who lacks capacity, including but not limited to:

1. An appropriate other person or independent advocate to support the person to engage and ensure that they are represented;
2. Spending time with the person can show you what they enjoy about life and what may be most important to them (this could be a person, a place or something they do with their time);
3. Consulting with a range of people who know the person before reaching a judgement about Wellbeing, outcomes and what is working/not working (speaking to a family member, a health professional, a paid carer, a college tutor and a day services manager will give a much better picture of what appears to matter most to the person than relying on the views of one person);
4. Use other available evidence to support you to understand Wellbeing and what matters most (for example ABC charts and other records that show behaviour changes clearly linked to an event, person or place).

All information gathering and sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

Review when the person has substantial difficulty engaging

If a person does not lack capacity but does have substantial difficulty being involved in any Care and Support process you must take all reasonable steps to ensure their involvement.

You must:

1. Ensure that you have provided information in an accessible way, or that the person has an appropriate person to support them to understand it;
2. Arrange to carry out the review in an appropriate format so that it is accessible. This is likely to be face to face, unless the person's difficulty arises when engaging in face to face communication;
3. Consider whether the person has an appropriate person to support their involvement and, if not, whether the advocacy duty applies.

See: Using Independent Advocacy, which includes guidance on how to establish whether a person needs an advocate and how to make a referral.

Managing Disengagement

If the person does not engage in the review process taking place you should:

1. Establish whether the reason for their disengagement is related to substantial difficulty or mental capacity, and if so ensure they have the right support in place (an advocate or an appropriate other person);
2. Provide them with information to support them to understand the purpose of a review, the process and the benefits of being involved.

If the person continues to disengage from the process and has capacity you should:

1. Explain to them that a review is a legal requirement as part of the duty to meet their eligible needs;
2. Establish if there is anyone else that the person wants to represent them in the process; and
3. Explain that you will proceed to complete a review based on the information that is available, and that this may involve consulting with their carer and anyone else involved in the provision of Care and Support.

If the person continues to disengage you should proceed to carry out a review based upon the information available. This should be done in consultation with any carer, any service provider and, if the person lacks capacity you should involve anyone else that you feel it would be in the person's best interests to involve.

A copy of the review must be provided to the person and they should be invited to review it. If at any point the person regains capacity or changes their mind about engaging consideration should be given to the benefit of carrying out a further proportionate review to ensure their involvement.

Refused access to a person requiring a Review

Sometimes another person may obstruct you from carrying out a review with a person who has Care and Support needs. You should establish whether:

1. The person with Care and Support needs has asked the person to obstruct the process, and if so whether they understand the implications of doing so;
2. The person obstructing the process is doing so out of concern for the person with Care and Support needs (for example would the process cause anxiety);
3. The person with Care and Support needs is at risk of abuse or neglect.

Wherever possible you should provide information and advice relating to the review process to the person obstructing it, to support them to understand the benefits and engage in the process.

If the person continues to obstruct the process, and you are not able to establish from the person with Care and Support needs that this is at their request you must take action to ensure the process is carried out. By obstructing the review process the person is:

1. Possibly putting the person with Care and Support needs at risk through lack of support;
2. Preventing the person from being involved in reviewing and deciding how their Care and Support needs are met; and
3. Possibly preventing the Local Authority from fulfilling its duties under the Care Act to meet eligible needs.

A review process in this situation can be carried out based on the information available. This should be done in consultation with any carer and, if the person lacks capacity you should involve anyone else that you feel it would be in the person's best interests to involve.

The advocacy duty should be considered and it is likely that a referral would be appropriate to ensure that the person's involvement in the process is maximised.

Opportunities to carry out a further review must be considered at such time when the person is involved, and all information sharing should give regard to confidentiality.

Depending on the circumstances consideration should also be given to instigating an adult safeguarding enquiry.

4. Gathering, Understanding and Using Available Information

What the Care Act says

The Care Act is clear that you should not ask the person (or anybody that you consult with for the purpose of review) to repeat information that has already been made available to you unless there is a valid reason for doing so. For example, if you have not understood the information and want to clarify the meaning behind it then it may be appropriate to ask for it to be repeated, summarised or clarified.

Before continuing or beginning to carry out any kind of review you should take some time to read through the information that is already available for the purposes of:

1. Understanding it; and
2. Thinking about how it should inform the review process.

Sources of existing information

Existing sources of information may be available via:

1. Recordings of any contact made;
2. Letters, texts and e-mails;
3. A confidential conversation with a colleague or manager who is familiar with the person;
4. Reports from professionals (for example a Speech and Language Therapist,  Psychologist or Teacher);
5. Records relating to current or historical safeguarding enquiries or concerns;
6. Existing or historical mental capacity assessments; or
7. Existing or historical assessment reports, review reports or Care and Support Plans.

All information gathering and sharing should be carried out with regard to the Caldicott Principles, Data Protection legislation and local information sharing policies.

Other sources of information available

It may be appropriate and necessary for you to undertake an element of research in order to improve your own knowledge or awareness of a particular issue or health condition:

1. By speaking with a colleague who possesses skills and knowledge in a particular area;
2. By reading particular guidance or written resources about a particular medical condition;
3. By accessing a reputable website for information and advice (for example Parkinson's UK, the British Institute for Learning Disabilities or MIND).

See: National Organisations with Information and Advice Helplines for details of some national organisations offering a specific information and advice helpline.

See: National Contacts for Adult Care and Support for a wider range of useful national contacts for adult Care and Support.

Gathering Information and Consulting

You may need to speak to the person in advance of arranging their review in order to gather or clarify any information.

You may also identify a benefit in gathering information and consulting with others. However, under the Care Act you are only permitted to consult with those people that the person has consented to you consulting with (unless they lack capacity to provide consent when a decision can then be made in their best interests).

5. Arranging the Review and Preparing the Person

Legally you must have regard to the following when arranging a review:

1. The person's views and wishes about when and how the review is carried out, including who they would like to support them;
2. The impact of any delay in review on their individual Wellbeing; and
3. Whether any information and advice can be given to them that will prevent, delay or reduce the need for Care and Support.

When to arrange the review

The review should be carried out in a timely way, based on the needs and circumstances of the person. Because every person is different, the Care Act does not specify the frequency in which a Care and Support Plan review must take place. That said, the statutory guidance does expect the Local Authority to endeavour to carry out a Care and Support Plan review as follows:

1. A review of a new service or Care and Support Plan should be carried out within 6-8 weeks of the service/change commencing;
2. A review of an on-going stable Care and Support Plan should take place no less than 12 months after the date of the 6-8 week review, and then no less than once every 12 months after that;
3. Where the person's needs or circumstances are likely to change reviews should be arranged as required to monitor the situation and respond to changes in a timely way.

The precise timing of the review should be agreed with the person and anyone else who is to be involved in it.

You should also take into account the following:

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;
6. The potential for fluctuation;
7. Any clear indication of timeframe provided within any recorded contact; and
8. Whether the person will need the support of an independent advocate and the time it may take to arrange this.

How to arrange the review

The method of communication should reflect that requested by the person and any specific communication needs they may have. For the purposes of the Care Act communication about the review is subject to the same requirements as the provision of information and advice, and the duty to make it accessible therefore applies equally.

See: How to Provide Information and Advice to read more about how to provide information in an accessible way under the Care Act.

In all cases where communication has been provided by telephone a follow up letter confirming the conversation and outcome should be sent to the person as a formal record.

What should be considered when arranging the review

The most important thing you must consider when arranging the review is how you will ensure the involvement of the person. Some of the things you should think about include:

1. Whether the person will require independent advocacy;
2. Whether the person will find any review process to be emotionally difficult and what can be done to reduce their anxiety;
3. The information the person (and any carer) may need to prepare for the review;
4. Whether the person requires any support with communication (for example, will any review tool need to be adapted, will an interpreter be required or does a Speech and Language Therapist need to be involved);
5. Whether the person would like for anyone in particular to be involved in any review;
6. Which environment would be best to meet in (if a meeting is to be arranged); and
7. Whether the review needs to consider any physical needs the person has for medication, rest or personal care.

When arranging the review you should also identify other people who may need to be a part of it. For example, a health professional or a service provider may need to be involved.

If the person lacks capacity

If the person lacks capacity you should make arrangements with an appropriate person. Where available this should be a person legally authorised to represent them (for example a Court appointed Deputy or the Donee of a Lasting Power of Attorney) or an independent advocate. If the person lives in a care home this could also be the manager of the home.

Preparing the Person for Review

Under the Care Act you must provide information about the review process to the person (or their representative if they lack capacity) as early as possible. This will help ensure their involvement in the review and any subsequent Care and Support processes. Wherever practical this should be provided before the review process begins.

Any information should be provided in an accessible way for the person who will be receiving it. In all cases where information has been provided by telephone a follow up letter confirming the information provided should be sent to the person.

The information that should be provided is as follows:

1. Information about what can be expected during the review process;
2. The purpose of the review process;
3. The format that the review will take (e.g. telephone review, face-to-face review);
4. The indicative timeframe for review (when will it begin and how long is it likely to take);
5. The complaints process; and
6. Information about possible access to independent advocacy.

You should also provide a list of any questions that you intend to ask of the person during the review (which will be different depending on whether the review is 'light touch' or not).

Information about finances

Financial assessment is often a key point of anxiety for people and it is important that you are able to provide good information and advice (either directly or by supporting the person to access it from an appropriate person or source).

You must inform the person (or their representative if they lack capacity) that a financial assessment may need to take place following the review if:

1. The review identifies that there has been a change in the person's financial circumstance; or
2. There is a change to the Care and Support services provided by the Local Authority.

You should explain that the outcome of this will determine whether there will be any changes to their current financial contribution.

See: Specific Requirements on the Provision of the Information and Advice around Finances for guidance on the requirements of the Care Act.

See the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment.

See the Financial Assessment Procedure for further guidance.

6. Using Independent Advocacy

If the need for independent advocacy has not already been established then this should become clear when either arranging the review or providing information about it. As soon as this is established you must consider whether the duty to make independent advocacy applies and, if so make the necessary arrangements.

See: Using Independent Advocacy, which includes guidance on how to establish whether a person needs an advocate, the different advocates that are available and how to make a referral.

7. Preparing Others for Involvement

In all cases

In some cases the only person who will need to be involved in the review will be the person with Care and Support needs. In other cases more people will need to be involved because:

1. The person has a carer (carer's must be involved in the person's review);
2. The person has asked you to involve another person;
3. The person has consented to the involvement of another person;
4. The person will be using independent advocacy;
5. The person lacks capacity and a decision has been made in their best interests to involve another person; or
6. The review is being carried out because of the risk of abuse and neglect and there is a need to involve others.

It is important that everyone who is to be involved in a review is aware of:

1. The purpose of the review;
2. The process of review; and
3. Their role in any review.

The needs of others involved in a review should also be considered, but this should not be at the detriment of maximising the person's own involvement.

If a person has a role in the review process but is not able to physically attend any planned meeting it is possible under the Care Act to consult with them separately and still include their views in any review and decision making processes.

Preparing carers and family members

The Care Act is clear that a whole family approach to review should be taken wherever possible. This means that you should:

1. Establish who relevant family members are; and
2. Arrange for them to be involved in the review.

Relevant family members include anyone living with the person, including older adults and any children. It can also include family members who are not living with the person, but who are still involved or interested in the person's wellbeing.

Family members and carers may have particular questions and require additional information to the general guidance above, which could include:

1. Information relating to financial assessment;
2. Information about mental capacity and best interests;
3. Information about a Lasting Power of Attorney;
4. Information about Appointeeship;
5. Information about Deprivation of Liberty Safeguards; and
6. Information about carers review or assessment.

Where the person has not consented for a carer to be involved

Under the Care Act carers have to be a part of the cared for person's review, even if the cared for person does not want them to be.  This is because the Local Authority needs:

1. To gather further information about the Care and Support Plan in regards the way it is meeting the needs of the person;
2. To understand any risk to the carer's role in the plan;
3. To identify any needs of the carer and fulfil the duty to meet them.

When a person has not consented to the carer being a part of the review you should:

1. Advise the person that you have a duty to involve the carer;
2. Explain the benefits of the carer being involved; and
3. Agree the most appropriate way to involve the carer (for example a separate meeting with the carer).

If the person has requested particular information not relating to needs is withheld from the carer, and they have capacity to do so normal confidentiality rules apply unless doing so would put the person (or another vulnerable adult or child) at risk of abuse or neglect.

8. Deciding the Method of Review

The different methods of review available

The Care Act recognises a whole host of different methods of review, any of which could be appropriate so long as:

1. The person's involvement is maximised by the method;
2. The method is proportionate to the needs being met by the Care and Support Plan; and
3. The method enables the review to be carried out as quickly as is reasonably practical.

Possible review methods include:

1. Face to face review;
2. Telephone review;
3. Online review;
4. Combined review (with a carer or another person with Care and Support needs);
5. Joint or integrated review;
6. Supported self review; and
7. Delegated review

Combining a review with a carers review

Whenever the person with Care and Support needs has a carer with a Carers Support Plan you should consider carrying out a review of the carers Support Plan at the same time (or arranging for a carer's review to be carried out at the same time if carrying out a carer's review is not your role).

A review of a Care and Support Plan can be carried out under the Care Act as a combined review at the same time as any review of a carers Support Plan, so long as:

1. It is deemed appropriate to do so (for example both parties involvement can still be maximised and there is no conflict between the parties);
2. Both the person and the carer agree to a combined review process and the sharing of information; or
3. The person with Care and Support needs lacks capacity to agree but a best interest decision is made to carry out a combined review.

See: Carer's Procedures if you will be carrying out a carers review.

Combining a review with a Direct Payment review

Whenever a person is receiving a Direct Payment you should consider carrying out a Direct Payment review (or arranging for a Direct Payment review to be carried out at the same time if carrying out a Direct Payment review is not your role).

See: Reviewing a Direct Payment.

Combining the reviews for 2 people with Care and Support needs

Sometimes it may be beneficial to carry out a combined review process for two people with Care and Support needs. For example:

1. When 2 people share a tenancy and are supported by the same provider; or
2. When 2 people pool some or all of a Direct Payment.

A review of a Care and Support Plan can be carried out under the Care Act as a combined review at the same time as any other review of any plan, so long as:

1. It is deemed appropriate to do so (for example both parties involvement can still be maximised and there is no conflict between the parties);
2. Both people agree to a combined review process and the sharing of information; or
3. One or both people lack capacity to agree but a best interest decision is made to carry out a combined review.

To maintain confidentiality it may not be feasible to combine the reviews for recording purposes, but nonetheless, efforts should still be made to carry out a combined review process.

Delegating a review

Under the Care Act it is possible to delegate the review function to another organisation or individual, although the Local Authority remains legally responsible for the entire process, including:

1. Ensuring the review is carried out as per statutory requirements and timescales agreed in the Care and Support Plan;
2. Overall co-ordination of the review process;
3. Agreeing the outcome of the review and any next steps; and
4. Agreeing any changes to the Care and Support Plan that may arise from the review process.

Occasions when you may decide to delegate a review include:

1. If the person lives in another area of the country and the Local Authority in that area agrees to carry out the review;
2. If the person asks to carry out their own review and this is deemed appropriate;
3. If the review is a combined review and another practitioner/organisation agrees to carry out the whole review.

It is important that any person who is carrying out a review on behalf of the Local Authority is suitably skilled, knowledgeable and competent to:

1. Carry out the review; and
2. Work with the particular needs and circumstances of the person.

Depending on the person's needs and circumstances the following could all carry out a delegated review if deemed appropriate:

1. The person (with or without support);
2. A health professional;
3. A service provider;
4. Another social care practitioner, including a practitioner from another Local Authority area.

When deciding whether to delegate a review you should consider:

1. The views of the person about delegating the review;
2. The skills, knowledge and competence of the person the review is to be delegated to (and whether there is any information or advice that can be provided to them);
3. The likely outcome of the review;
4. The complexity of need or number of issues at the point of review.

If a review is to be delegated you must make sure that you provide sufficient information to enable the person carrying out the review to do so adequately. This includes information about the person's Care and Support Plan, needs and the review process itself.

How to decide the method of review

When making a decision about the method of review you must have regard to:

1. The wishes and preferences of the person;
2. The views of any carer;
3. The outcome the person seeks from the review; and
4. The severity and overall extent of the person's needs.

Some of the other factors that should be considered include:

1. Availability of a particular review method;
2. If the person has a carer, whether carrying out a combined review process would be beneficial.
3. Whether there is a concern about the person's capacity in relation to a particular decision to be made. In this situation the Care Act requires you must carry out a face to face review;
4. Whether the method of review chosen poses any challenges or risks for the person;
5. The specific communication needs of the person (specifically whether they will be able to engage in the review method);
6. The potential fluctuation of the persons needs or situation; and
7. Any need for multidisciplinary working or review.

The method of review when the person lacks capacity

9. Tools to Support Review

Using a tool to support the process of review can be useful for all involved. If you are going to use a tool you should endeavour to provide this to the person (or whoever will be supporting them) before the review is scheduled to take place.

See: Tools and Practice Guidance for Review.

10. Joint Review

Sometimes there may be a clear benefit to carry out a joint review with another service area, team or professional. For example:

1. The person is receiving support that is commissioned jointly;
2. The person has equipment provided by Occupational Therapy that is no longer working as intended;
3. The person has a complex health condition that is impacting on the effectiveness of the Care and Support Plan.

The Care Act recognises this and permits the Local Authority to make any arrangements it deems appropriate in order to facilitate joint working with others.

Where a service is commissioned jointly there is an expectation that any review is carried out jointly to prevent unnecessary duplication.

The duty to co-operate

Where the Local Authority requests another party to 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.

How to request a joint review

Any decision to request a joint review 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.

Joint review 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.

Responding to a request for a joint review

If you have been asked to carry out a joint review with a colleague in adult Care and Support or in another organisation (such as health or housing) you should contact the person you will be working jointly with to confirm your involvement and discuss the most effective way to work together. The things you should establish include:

1. 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 who will be responsible for arranging the review and recording the record);
4. What the anticipated outcome of the joint review 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 review 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.

11. Preparing in an Urgent Situation

Sometimes the timeframe within which to arrange a review is not conducive to all of the considered planning and preparation as outlined in this procedure. For example, there may not always be the time to research and make the best use of available information or to consult with others before arranging to meet with the person. However, even when the timeframe is short it is of paramount importance that you still:

1. Take all available steps to ensure the involvement of the person in any review;
2. Consider consent and mental capacity;
3. Provide independent advocacy where there is a statutory duty to do so;
4. Prepare the person as much as possible;
5. Identify what existing information is important and understand it; and
6. Know what you have not been able to do and ensure that at the earliest opportunity you make arrangements to do so (for example to consult with another professional or read a particular report).