The Full Review Conversation

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 Care and Support Plan.

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

1. First Point of Contact;
2. Reablement;
3. Hospital Discharge;
4. Older Adults;
5. Learning Disability;
6. Mental Health.

If you are carrying out the review of a carer's Support Plan you should see: The Full Review Conversation (Carers).

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

Light touch reviews

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 Care and Support Plan (or minimal changes to how existing Care and 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 person's needs or circumstance.

If a light touch review is appropriate, see: The 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. The Full Review Conversation and Mental Capacity

When a person with Care and Support needs lacks capacity the duty to ensure their involvement in the review process still applies. As such, any review should always be face to face and not held remotely.

The person with Care and Support needs should be supported to communicate their views during the review, either by an independent advocate (where the duty applies) or another appropriate person.

The views of any carer should also be sought, as should the views of anybody else that you deem it in the person's best interests to consult with.

You can also gather information by:

1. Spending time with the person to make your own observations about risk, outcomes, Wellbeing and needs; or
2. Using other available evidence to support you to understand what is working and not working with the Care and Support Plan, and what things may need to change (for example carer's notes and other records).

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

3. Carers and Families

Carers

Where the person is known to have a carer there is a requirement under the Care Act for the carer to be involved in the review process.

The purpose of doing so is:

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.

Families

The Care Act is clear that a whole family approach to review should be taken wherever possible. The whole family approach in review is the same as the whole family approach in assessment.

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

The impact on Wellbeing

A Care and Support Plan that is working well is more likely to have a positive effect on the person'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 person 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 person 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.

SCIE have 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 must establish

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

1. All of the services and support in the plan are in place as intended;
2. All of the services and support in the plan are meeting the person's needs;
3. The plan is supporting the person to achieve their outcomes;
4. The method of managing the personal budget is still the most effective way of meeting needs and supporting the person to achieve outcomes;
5. Anything has changed about the person's circumstances that may indicate a change is needed to the Care and Support Plan;
6. There any risks to the plan's sustainability;
7. The plan is reducing any identified risk to the 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 person 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 person's specific needs around communication and their specific circumstances;
3. Be realistic in respect of the persons mental capacity and ability to be able to answer the question; and
4. Be asked in a manner that is accessible to the person.

Powerful questions

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

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

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

Appreciative Enquiry

An appreciative enquiry is a conversation that is led by the person 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 person 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 person as part of any conversation you have with them; or
2. The person can complete them in their own time as part of their preparation for the conversation.

See: Tools and Practice Guidance for Review.

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 person with Care and Support needs (or their representative if they lack capacity);
2. Any carer;
3. The person or organisation to which the issue relates (unless doing so will put the person with Care and Support needs at risk of abuse or neglect).
4. Anyone else that the person asks you to involve; and
5. Anyone else that you feel needs to be involved (with the person's consent or in their best interests if they lack capacity).

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

1. When a carer has not been able to provide the support intended;
2. When formal services are not in place;
3. When needs are not adequately being met by the support and services in place;
4. When support and services are not supporting the person to achieve their outcomes as intended;
5. When support and services are not managing risk effectively; or
6. When the support and services are not sustainable.

You will need to:

1. Understand the impact on the person'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 person, the Care and Support plan and others 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 the purpose of recording and monitoring what has been agreed, and the steps that different people will be taking to resolve what is not working.

tri.x has developed a tool that can be used as required to action plan.

See: Action Planning Tool.

Urgent and interim support

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

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

5. 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.

6. Reviewing Outcomes (Full Review)

Outcomes and Wellbeing

Outcomes can change when a person's life priorities change. This can happen unexpectedly and unmet outcomes can have a dramatic impact on a person'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 person to achieve, change or maintain in their life at any given point in time; and;
2. Take steps to support the person to achieve these outcomes.

What the conversation about outcomes must establish

The conversation about outcomes must broadly establish whether:

1. The outcomes in the Care and Support Plan have been achieved or not;
2. The person 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 Care and 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 to work towards your outcomes?

You should refer to the Care and Support Plan to confirm what the person's outcomes were.

Action when outcomes have not been achieved

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

1. Establish if the outcomes are still important to the person;
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 (see 'Resolving what is Working and Not Working' above for guidance).

Where there is a need to talk about new outcomes you should refer to The Skilled Conversation: Outcomes.

7. 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 person's needs have changed since the time that they were assessed and the Care and 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.

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 you should explore:

1. Broadly, what the changes in need are;
2. What the impact of the changes are on the person's Wellbeing;
3. What the impact of the changes are on any carer and formal services; and
4. The impact of the changes on risk (to the 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.

Exploring and Managing different views

If, as part of a review process there is disagreement about whether a person'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 person; 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.

Urgent and interim support

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

1. Resolve the issues with the Care and Support Plan;
2. Agree revisions to the Care and 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, see: Urgent or Interim Support.

Short term changes in need

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

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

8. 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 Care and Support Plan;
2. There have been no changes to risk;
3. There is no risk to the person from abuse or neglect; and
4. There is no risk to the Care and 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 Care and Support Plan keeping you safe?
2. Is there a chance that your plan could stop working well?

Talking about risk to the person

Examples of risk to a person include:

1. Risk of fall, accident or injury carrying out an activity or function;
2. Risk of harm from abuse or neglect; and
3. Risk to Wellbeing from not being able to do something (for example go to work or take part in a social activity).

You should refer to the Care and Support Plan to confirm the current contingency plan and risks being managed.

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

If the review identifies that there are new risks to the person, 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 person (and others) 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 person 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.

See: Risk Assessment.

Talking about risk to the plan

Examples of risks to a Care and Support Plan could include:

1. Risks that informal care will not be sustainable;
2. Risks that needs will not be met if a service provider is temporarily unavailable;
3. Risks that the support or services in the plan will not be as effective at meeting needs or supporting the person to achieve outcomes as intended;
4. Risks that a Direct Payment will not be managed appropriately.

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 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 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.

9. 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 Care and 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.

• Preventing Needs for Care and Support for information about the duty to prevent, reduce or delay needs;
• Providing Information and Advice for information 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 Care and Support; and
3. Give the person and anyone else involved opportunities to ask questions or seek clarity.

Depending on the person'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.

See: Providing Information and Advice, which includes access to local and national information and advice resources (general and specialist).

10. Safeguarding and Deprivation of Liberty

Safeguarding

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

See Safeguarding Adults, which also includes information about how to raise a concern about a person under the age of 18.

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 dialing 999.

Where the safeguarding is in respect of the person whose Care and Support Plan is being reviewed 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, the person with Care and Support needs (or their representative) and any carer.

Deprivation of Liberty

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

1. The person 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 any reassessment to take place is likely to deprive them of their liberty.

See: Recognising and Responding to Deprivations of Liberty.

11. Making Notes

It is quite appropriate to take notes during a review 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 person and anyone else present that you will be taking some notes and why;
3. Reassure the person 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 person says is important to them, even if it does not appear to be relevant to you or others;
6. If the person 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 person 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.