Deciding the Outcome of a Care and Support Plan Review and Making a Formal Record

1. Using this Procedure

This procedure should be used when deciding the outcome of a Care and Support Plan Review.

If you are deciding the outcome of a carer's Support Plan Review you should refer to the bespoke carers procedure by clicking here.

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

  • Initial Contact;
  • Community Led Support;
  • Learning Disability;
  • Mental Health;
  • Community Response Hub; and
  • Reablement (ongoing needs only).

2. Deciding the Outcome of a Care and Support Plan Review

Possible outcomes of a review

Broadly there are 3 possible outcomes following review:

  1. No changes required to the Care and Support Plan or personal budget; or
  2. Changes to one or more element of the Care and Support Plan required but not to the personal budget (including changes to outcomes and the contingency plan); or
  3. Changes to the Care and Support Plan and personal budget required due to a change in circumstance or need.

Deciding the outcome through the skilled conversation

Throughout the process of review you should talk to the person (or their representative) and others about the likely outcome of the review, endeavouring to reach an agreement about this as the process progresses.

The responsibility for deciding the outcome

The Local Authority is responsible for making the final decision about the outcome of the review. As such this is your responsibility as you are the Local Authority's representative.

Considerations when deciding the outcome of the review

When determining the outcome of the review you must give regard to:

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

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

Example:
Ahmed is of the view that his mother is not able to safely support him with transfers. There have been no changes in Ahmed's needs and his mother has always managed his transfers in the past. Ahmed's mother explains that she has injured her shoulder and, while she can still support Ahmed to stand it can sometimes be painful to do so. Ahmed wants an increase in his personal budget so that he can arrange homecare. However, you know that there is currently no moving and handling equipment in place so you discuss the possibility of equipment to support with transfers and arrange to make a referral to Occupational Therapy. This is not the outcome that Ahmed wanted but the evidence suggests that the provision of equipment is the most proportionate response to try and resolve the current risk to Ahmed's mother.
Example:
Peter has a degenerative health condition. He tells you that everything in his Care and Support Plan is working well and there is no need to change anything. He currently receives support from a provider twice a week to carry out household tasks. Peter's daughter is part of the review and says that on several occasions she has been to visit Peter and been concerned about his appearance. She also produces a report from Peter's Neurologist that indicates Peter's mobility has deteriorated recently, which is reiterated by the manager of the service provider. From the evidence available you decide that the outcome of the review should be a proportionate reassessment to establish what has changed and what additional support Peter may need.

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

3. Managing Disagreement about the Outcome

There may be times when the person, their representative or another person disagrees with the decision you have made about the outcome of the review.

In this situation you should be open to reviewing the available evidence and your rationale to ensure that the decision you have made is robust. You should be open and transparent about the evidence sources you have used and take steps to try and support the person to understand the decision you have made.

Where ongoing disagreement persists you should:

  1. Seek the support and advice of your line manager as required;
  2. Make a record of any difference of opinion in the formal record of the review;
  3. Ensure the evidence upon which you have based your decision is robust;
  4. Make sure that the regard you have given to the views of the person (and others) and the impact on their Wellbeing is clear; and
  5. Make proportionate records of any conversations you have had to try and resolve the differences.

You must also make the person (or their representative) aware of their right to complain about the decision that has been made.

4. Making a Formal Record of the Review

You are responsible for establishing the current review framework used by the service for recording purposes. If you are unclear you should speak to your line manager before proceeding to make a formal record of the review.

The timeframe for making a record

Reviews should be recorded in a timely way and in line with local requirements.

Timely recording will:

  1. Reduce the likelihood of inaccuracies;
  2. Prevent any unnecessary delays for the person; and
  3. Ensure that any reassessment of need can make effective use of the information gathered at review.

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

What should be included in the record

The following information must be clearly but proportionately recorded in all cases:

  1. Whether the different elements of the Care and Support Plan are in place and working as intended;
  2. Whether the person's circumstances or needs have changed (and the evidence used to determine this);
  3. The person's views about any changes to their needs or circumstance;
  4. Any carer's views about changes to needs or circumstance;
  5. Whether the outcomes in the plan have been achieved and whether the person has new outcomes they want to meet;
  6. Whether the plan is effectively reducing risk to the person and whether there are new risks to the person (for example from a change in need or from abuse or neglect);
  7. Whether the contingency plan in place is working;
  8. Whether the personal budget is still sufficient and enabling the person to meet their needs and the outcomes identified in the plan;
  9. Whether the current method of managing the personal budget is working and still represents the best method for achieving outcomes (for example, should a Direct Payment be considered)?
  10. Whether there have been any changes to informal support that have impacted the plan (for example, can informal support be sustained, can informal support be used instead of formal support);
  11. What information and advice has been given to prevent, reduce or delay the need for further adult Care and Support; and
  12. The overall outcome of the review and next steps agreed (including the rationale for the outcome decision and the proposed timeframe for the next review).

The following information should be clearly recorded where relevant:

  1. Where the person's needs or circumstance have changed; what the changes are and what the impact is on Wellbeing (including the person's views and the views of any carer);
  2. Where elements of the plan are not working what steps have been agreed to resolve any issues (from a strengths based approach);
  3. Where outcomes have not been achieved, steps that are to be taken to support the person to achieve them (including any changes required to the plan);
  4. If the person has new outcomes, how the plan will support them to be achieved;
  5. If the plan is not reducing risk, what changes are required to the plan to reduce risk;
  6. If the contingency plan is not working, what changes are needed to it;
  7. Where the person's needs have changed; whether urgent or interim support needs to be provided;
  8. Any safeguarding concerns that have been raised and action taken;
  9. Any Deprivation of Liberty concerns raised and action taken;
  10. Any difference in views about the outcome of the review.

Providing a copy to the person

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

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

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

Providing a copy to others

Where the review was carried out jointly with another organisation to avoid duplication (for example housing or health) a copy of the review 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 review, or to share only part of the review. In this case you will need to discuss and agree which elements of the review 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).

If the person consents (or lacks capacity and a best interest decision is made) a copy of the review should be shared with any service provider who was involved in the review and is responsible for providing Care and Support to the person.

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 review itself.

Concerns about a request

You must provide a copy of the review 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).

Amending a review record

Sometimes the person (or their representative if they lack capacity) or anyone else that was involved in the review may ask for amendments to be made to the record. 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 review 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 review 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.