Actions and Next Steps (Reablement)

1. Providing Information and Advice

The Local Authority (and anyone representing the Local Authority) has a duty under Section 4 of the Care Act to either provide directly, or provide access to a range of information and advice relating to adult Care and Support, including financial advice. This duty applies equally in respect of all local residents regardless of whether the person with Care and Support needs is known to, lives in, or is already receiving services from the Local Authority.

See: Providing Information and Advice to read more about the duty to provide information and advice, including how information and advice should be provided and the specific information and advice requirements around finances.

Local Information and Advice Resources

Customer to develop this section.

Examples of resources you may wish to include are online resources, drop-in face to face resources, telephone resources, equipment and adaptation information and advice, general and specialist resources (e.g. for mental health or learning disability).

Examples can be provided upon request.

National Information and Advice Resources

Sometimes it is helpful to contact a well known national organisation with a dedicated information and advice service or help-line. See: National Organisations with Information and Advice Helplines for details of some national organisations offering this service.

Some national organisations do not have dedicated information and advice services but can still provide such support upon request. See: National Contacts for Adult Care and Support for a wider range of useful national contacts for adult Care and Support.

You can also see the Financial Assessment and Charging FAQ Response Support Tool for the answers to some frequently asked questions around financial assessment, including questions relating to Disabled Facilities Grants.

Understanding Information and Advice

Information and advice must be provided in an accessible way so that the person for whom it is intended can best understand and make use of it.

If you feel the person for whom the information and advice is intended will need support to understand it then you should:

1. Consider whether the person has anyone appropriate who can help them to understand it;
2. Consider any steps that you can take to support them to understand it (for example talking through the information over the telephone or summarising it in a simpler format); and
3. Consider the benefit of independent advocacy.

2. Following Up on Information and Advice

Under the Care Act the Local Authority has a duty to not only provide information and advice where it is needed, but to ensure that the information and advice it provides has been effective.

Therefore, when information and advice has been provided you should agree appropriate arrangements to follow up with the person to whom it was given in order to review how effective it has been.

The timescales for this follow up should reflect the individual circumstances and level of risk.

Where you are making arrangements for someone else to follow up on the information and advice you have given (rather than following up on it yourself) you must make sure that you have recorded this in a way that will ensure the person follows up on it at the agreed time.

3. Providing Information about a Person

The Local Authority has a common law and legal duty to safeguard the confidentiality of all personal information. As an employee of the Local Authority you are bound contractually to respect the confidentiality of any information that you may come into contact with. Under no circumstances should such information be divulged or passed to any persons or organisation in any form unless you have authorisation to do so.

All information sharing that takes place must be in line with data protection legislation (namely the UK General Data Protection Regulation and the Data Protection Act 2018) and local policy.

The Caldicott Principles must also be regarded. The Caldicott Principles are a set of principles that apply to the use of confidential information within health and social care organisations and when such information is shared with other organisations and between individuals, both for individual care and for other purposes. For further information, see: The Caldicott Principles.

Any unauthorised disclosure of confidential information may result in disciplinary action of individual prosecution under the Data Protection Act 2018.

For further information and guidance see: Providing Information about a Person or Carer

4. Transferring a Contact

It is important that the person making contact speaks to the right practitioner at the right time. Sometimes you may find that you are not the most appropriate practitioner to manage the contact.

Transferring a telephone contact

When the person making the contact requests specifically to speak to or be contacted by a particular person you should establish as quickly as possible whether the contact should be forwarded to that practitioner.

You should check available systems to establish whether the person is allocated to the practitioner they have requested to speak to.

You should not transfer a telephone call to a named worker if it is clear that the worker is not allocated to the person. This will not be helpful to the worker or to the person as they will not be speaking to the right person to resolve the contact.

If the practitioner is not available

If the practitioner is not available you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a colleague or manager who may know.

If you know when the practitioner is likely to become available you should:

1. Inform the person of this;
2. Leave the practitioner a message alerting them to the contact, any action undertaken and confirming the information given to the person about when to expect a call back;
3. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required should the practitioner be unavailable for more than a few hours;
4. Agree with the person what they should do if the practitioner does not make contact at the expected time; and
5. Make a proportionate record of all the above.

If it is not clear when the practitioner will become available you should:

1. Inform the person of this;
2. Leave the practitioner a message alerting them to the contact, any action undertaken and what information has been given to the person;
3. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required; and
4. Agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
5. Make a proportionate record of all the above.

Transferring a written, e-mail or text contact

When a written contact is addressed to a named worker you should establish as quickly as possible whether the contact should be forwarded to that practitioner.

You should check available systems to establish whether the person is allocated to the practitioner that the written contact is addressed to.

You should not transfer a written contact to a named worker if it is clear that the worker is not allocated to the person. This will not be helpful to the worker or to the person as they will not be dealing with the right person to resolve the contact.

Before transferring the contact you should:

1. Confirm that the practitioner the written communication is being transferred to is available within a reasonable timeframe for the action indicated by the contact, or that you have agreed with a manager how the contact will be managed;
2. Where the communication is a letter or an e-mail, whether the practitioner wishes to receive the original contact (if not this should be filed securely); and
3. Where a written response confirming the contact has been received is required or requested, agree who will provide this.

The most secure way to transfer a written contact is to send a message to the practitioner alerting them to the contact and where it can be found on the recording system.

Any original copies of e-mails must be sent via internal secure e-mail systems only and any original letters must be sent via internal postal services or secure delivery only.

If the practitioner is not available

If the practitioner is not available you should try and establish when they may become available by looking at any electronic calendars they use or speaking with a colleague or manager who may know.

If the practitioner is not available within a reasonable timeframe for the action indicated by the contact you should:

1. Leave the practitioner a message alerting them to the contact, where it can be found on the recording system and any action undertaken, including what has been agreed with the person if contact has been made with them;
2. Undertake any actions that you are able to in order to resolve some or part of the contact, including any urgent actions that may be required and writing any acknowledgement letter to confirm arrival of the contact;
3. When the practitioner is not available within any timeframes indicted in the written contact or for more than a few days inform the person making the contact of this;
4. Agree with the person what they should do if the practitioner does not make contact within an agreed timeframe; and
5. Make a proportionate record of all the above.

5. Accessing another Prevention Service

Reablement is one of a range of services available where the focus is on the prevention, delay or reduction of needs. However other prevention services may also be beneficial alongside reablement and should also be explored. These could include health services, Occupational Therapy or Telecare.

Under Section 2 of the Care Act the Local Authority has a duty to prevent needs for Care and Support/Support whenever it identifies an opportunity to do so.

See: Preventing Needs for Care and Support to read more about the duty to prevent needs for Care and Support, including the types of prevention services recognised by the Care Act, when to provide prevention services and how to charge for prevention services.

6. Safeguarding Concern

If, as part of any conversation or information gathering you become concerned that a vulnerable adult or child is experiencing, or at risk of abuse or neglect you must respond appropriately by raising a concern.

See Safeguarding Adults, which also includes information about how to raise a children's safeguarding concern.

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.

7. Using Independent Advocacy

The Advocacy Duty

Whenever the outcome of a contact or referral is that the person will be involved in any adult Care and Support process (including a reablement assessment or safeguarding) the Local Authority has a duty under the Care Act to make an independent advocate available to the person when:

1. There is no appropriate other person to support and represent them; and
2. They feel that the person would experience substantial difficulty being fully involved in the Care and Support process without support.

tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.

See: Advocacy Decision Support Tool.

The Local Authority also has a power (but not a duty) to make advocacy available in other situations on a case by case basis if it deems this appropriate and is able to do so. This could include advocacy to support a person to understand information and advice, or advocacy to support a person to explore possible options available to them.

The Difference between substantial difficulty and lacking mental capacity

Having substantial difficulty is not the same as lacking mental capacity.

See: Determining Substantial Difficulty for information about how to determine substantial difficulty.

See the Mental Capacity Act 2005 Resource and Practice Toolkit, with guidance about assessing capacity and making best interest decisions.

An appropriate person

An appropriate person for general representation purposes is not the same as an appropriate person for independent advocacy under the Care Act.

See: An Appropriate Other Person for information about the difference and how to establish whether there is already an appropriate person.

The role of the Independent Advocate

The role of an independent advocate appointed under the Care Act is not the same as the role of a general advocate or any other type of advocate (for example an Independent Mental Capacity Advocate or an Independent Mental Health Advocate).

An independent advocate appointed under the Care Act must both facilitate and ensure the involvement of the person with substantial difficulty in the Care and Support process that is taking place.

For information about the ways in which an independent advocate should fulfil their role, see: The Role of an Independent Advocate.

Advocacy for people who lack Capacity

People who lack capacity will likely be legally entitled to advocacy under both the Care Act and the Mental Capacity Act 2005.

The Care Act statutory guidance recognises that it would not normally be appropriate or practical for a person to have 2 advocates and gives the Local Authority the responsibility to make a decision about the best type of advocacy support.

There are various factors that should influence this decision (such as existing rapport with an advocate or whether any important decisions are likely to be the outcome of the Care and Support process) and the Local Authority must ensure that whatever it decides, it does not deny the person any of the specialist advocacy skills they need or are entitled to.

tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.

See: Advocacy Decision Support Tool.

Advocacy for people subject to the Mental Health Act

People eligible for an Independent Mental Health Advocate (IMHA) under the Mental Health Act 1983 will likely be entitled to advocacy under the Care Act.

The Care Act statutory guidance recognises that it would not normally be appropriate or practical for a person to have 2 advocates and gives the Local Authority the responsibility to make a decision about the best type of advocacy support.

There are various factors that should influence this decision (such as existing rapport with an advocate or the likely outcome of the Care and Support process) and the Local Authority must ensure that whatever it decides, it does not deny the person any of the specialist advocacy skills they need or are entitled to.

tri.x has developed a tool that can be used as required to support effective and consistent decision making about when/which advocacy support should be made available.

See: Advocacy Decision Support Tool.

Making a Referral for Independent Advocacy

The advocacy referral can be made at any time and should be made without delay as soon as the duty applies.

What to do if Independent Advocacy is not available or delayed

Regardless of whether or not independent advocacy is available in the local area the duty to provide it still applies. A failure to do so is a breach of this duty and of the law. It is the role of commissioners to ensure that advocacy services are in place and available when required, and it is the role of practitioners to make timely referrals to advocates to prevent unnecessary delays in the meeting of its duty.

If you are aware that advocacy support is required and is not yet available you must notproceed to carry out any Care and Support process (including a reablement assessment) until it is in place.

In some circumstances urgent interim measures may need to be agreed without an advocate in place in order to reduce immediate risk to the person from inaction. However, Care and Support processes that will decide long term and important decisions must not be carried out without advocacy support.

What to do if the person does not want to use advocacy

The duty upon the Local Authority is to make independent advocacy support available to any person who requires it. Once made available the duty is met.

If a person decides that they do not wish to engage in the advocacy support that has been made available to them they do not have to do so, but the Local Authority must still provide it.

The Local Authority is expected under the Care Act to support the person to understand the role of an advocate and promote its benefit to them so as to reduce the likelihood that they will not engage.

8. Revising a Reablement Plan

Regular monitoring of the reablement plan should be incorporated into any reablement service provided. This is essential to ensure that the service is working as intended, and to make changes required quickly to promote and optimise independent functioning.

The monitoring mechanism in reablement must be responsive and consider any need to hold a review of the plan outside of any scheduled review:

1. Whenever the person whose plan it is requests it;
2. Whenever a carer of the person whose plan it is requests it;
3. Whenever the service providing the reablement requests it; and
4. Whenever new information is provided that indicates a review would be beneficial in optimising reablement.

See: Revising a Reablement Plan.

9. Allocation to Establish Reablement Needs

When to allocate

Where the outcome decision is for the person's case to be allocated to an individual worker to establish reablement needs this allocation should take place in a timely way so as to:

1. Avoid any unnecessary delays to the person;
2. Reduce the risk of a deterioration in the situation; and
3. Optimise the benefit of the reablement intervention.

Where there is a significant number of people awaiting allocation there should be a fair and consistent prioritisation process in place that takes into account:

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; and
6. The potential for fluctuation.

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

How to allocate

The Care Act recognises that each worker (regardless of whether or not they have a professional qualification) will possess specific skills, knowledge and experience that will enable them to carry out different Care and Support functions or work with particular people well.

Because of this there is no expectation that a particular role should carry out a particular function; instead the Local Authority should allocate tasks to the most appropriate person for the job.

Allocation decisions should take into account:

1. The skills, knowledge and experience of the worker in carrying out the function or process required;
2. The skills, knowledge and experience of the worker in working with the particular needs of the person (for example health needs or communication needs); and
3. The views and wishes of the person themselves in relation to the skills required of the worker and who they feel would best support them.

tri.x has developed a tool that can be used as required to support allocation decisions.

See: Allocation Support Tool.

10. Transferring a Case

If it becomes clear that a reablement assessment or service may not be the most appropriate and proportionate way of establishing or preventing, reducing or delaying needs the case will need to be transferred.

For example:

1. The person's needs have changed since the time of referral and they may no longer be well enough to engage with reablement at that time;
2. From the information gathered it is clear that the person would not be able to engage with a reablement service;
3. The person is not ordinarily resident in the Local Authority area (so not eligible for reablement); or
4. The person no longer consents to reablement.

Any process for transferring the referral to another service area or teams should be as simple and seamless as possible. It should involve the person and the potential services with the aim of reaching a shared agreement. Any transfer should not negatively impact the person or put them at risk through the delay of any Care and Support needs being met.

Though not a requirement, it would be prudent to apply the same criteria that the Care Act requires to be applied when deciding the most appropriate worker:

1. The views and wishes of the person about which service/team would best support them must be regarded;
2. The service/team must possess the skills, knowledge and competence to carry out the anticipated Care and Support functions; and
3. The service/team must possess the skills, knowledge and competence to work with the particular person in question.

tri.x as developed a tool that can be used a required to support consistent decision making about team suitability.

See: Team Suitability Decision Support Tool.

11. Joint Work

Joint work and reablement

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

1. Occupational Therapy;
2. Social Work;
3. A health professional;
4. A service provider.

The Care Act encourages joint working within organisations and across organisations, permitting anyone carrying out a Care and Support process to make any arrangements it deems necessary in order to facilitate joint working.

The duty to co-operate

Where the Local Authority requests another party 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 joint work or assessment

Any decision to request joint work 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.

The need to involve others should be identified at an early stage, preferably before the reablement service begins. This will allow:

1. Any equipment or assistive technology to be in place at the time reablement starts; so that
2. Reablement workers can support the person (and their carer) to use the equipment safely and with optimum effect during reablement; and
3. The risks to reablement from complexities in the person's situation or additional needs to be reduced.

The process of requesting joint work during reablement should be as simple as possible to allow for a swift response.

Joint work 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 joint work

When you have been asked to work jointly with another service, team or professional you should contact them to confirm your involvement and discuss the most effective way to work together. The things you should establish include:

1. The work they are doing/will be doing/have done and 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 will you be expected to carry out a joint assessment, meet with the person together, produce joint records or just consult and share information);
4. What the anticipated outcome of the joint work 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-work 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.

See: Joint Work for further practice guidance about effective joint working.