Monitoring Reablement (Reablement)

1. The Importance of Monitoring

Monitoring is a vital role in reablement and crucial in ensuring that:

1. The Reablement Plan is working as intended;
2. Progress is being made towards outcomes;
3. Issues and risks to the plan are identified at an early stage; and
4. The benefit of any equipment or assistive technology is being maximised.

2. The Responsibility of Monitoring

It is the responsibility of the Local Authority to monitor progress of the reablement service being provided. To do this you should arrange to work closely with:

1. The reablement worker/s or provider (agreeing how they will provide you with progress updates and any concerns they have);
2. Any Occupational Therapists involved in providing equipment as part of reablement;
3. Anyone else involved in the plan; and
4. The person and any carer (through telephone contact at agreed times and frequency).

When reablement is being provided by an external provider the provider is responsible for:

1. Gathering regular progress updates from the workers providing reablement support;
2. Providing the Local Authority with regular updates through an agreed medium; and
3. Notifying the Local Authority at an early stage of any issues with reablement or need to make changes to the plan.

3. Agreeing Monitoring Arrangements

How to agree monitoring arrangements

Monitoring arrangements should be:

1. Agreed with the person and any carer; and
2. Explained to anyone with a role in monitoring.

Monitoring arrangements should be proportionate and take into consideration:

1. How the person is likely to engage with reablement;
2. Whether there have been any risks to the success of reablement identified by the Reablement Plan;
3. The complexity or challenge of the reablement outcomes to be met;
4. Whether equipment or any assistive technology is to be provided as part of reablement.

Arrangements should clearly explain:

1. How frequently the reablement worker/provider will provide information;
2. The nature of any information to be provided (is this general or specific?);
3. Whether anyone else will be involved in monitoring (for example an occupational therapy practitioner);
4. How monitoring will be carried out (for example verbal feedback, the provision of a written record, e-mail or through a MDT meeting).

Changing monitoring arrangements

If there is a need to change the monitoring arrangements at any point during reablement this can be done in agreement with the person and any carer. The rationale for any changes should be clear and could include a reduction or an increase in monitoring activity.

4. The Role of the Reablement Worker

The reablement worker has a crucial role in ensuring monitoring is effective. To this end you must make sure that each individual worker understands (either directly or through the assurances given by an external provider):

1. The importance of monitoring;
2. The monitoring arrangements that have been agreed;
3. When and how to provide scheduled updates;
4. When and how to provide unscheduled updates;
5. How to record monitoring activity;
6. How to manage non-complex issues with the plan;
7. How to request and make changes to the Reablement Plan;
8. When and how to request a review of reablement;
9. How to report a concern about any other Care and Support service being provided to the person; and
10. How to report a safeguarding concern.

5. The Role of a MDT

Effective reablement often involves an element of joint working with other professionals. For example:

1. Occupational Therapy;
2. Social Work;
3. A health practitioner.

Where a range of people are involved in reablement this is known as an MDT (multi-disciplinary team). Everyone involved in the MDT must work together to maximise the effectiveness of reablement and achieve better outcomes for the person.

Each member of the multidisciplinary team must understand:

1. The outcomes in the Reablement Plan;
2. The strengths and abilities of the person;
3. Who else is involved in reablement, the role that they have and the actions they intend to take during reablement;
4. The monitoring arrangements and their role in this;
5. How the plan is progressing over time, the progress made and any issues that arise.

For the purpose of monitoring each member of the MDT must:

1. Provide information as per agreed monitoring arrangements;
2. Provide unscheduled information as and when it is appropriate to do so (for example if they are concerned about any aspect of the plan).

The MDT can provide this information virtually or through a physical meeting. If the latter takes place you should:

1. Where applicable, encourage any external provider of reablement to attend the meetings (or provide specific information to inform the meeting);
2. Notify the person and any carer that the MDT is taking place, why it is taking place and obtain their views to share at the MDT;
3. Consider the benefit and appropriateness of supporting the person or a carer to attend the MDT meeting;
4. Wherever possible, support the person or a carer to be involved in the MDT when they request this (for example in person, on the telephone or via a medium such as Skype).

6. Recording Monitoring Information

When monitoring reablement you will receive information from a range of sources including:

1. The reablement worker/provider;
2. The person or carer;
3. Others involved in reablement (for example an occupational therapy practitioner); and
4. Anyone else involved with the person for another purpose (for example a social worker or a health professional).

It is important that all information gathered is recorded in a timely way and acted upon when it indicates that a change to the plan or an unscheduled review is required.