Contact and Referral Adult Care and Support Procedures (Mental Health Services)

1. Consent

Referrals

Referrals for adult Care and Support interventions cannot be taken unless:

1. The person or carer the referral relates to is making the referral;
2. The person or carer the referral relates to has given their consent to the referral; or
3. The person that the referral relates to lacks mental capacity to make a referral and a decision has been made under Best Interests that a referral should be made; or
4. The person that the referral relates to is at risk of harm from abuse or neglect.

Review

Requests for a review of an existing Care and Support/Support Plan can be made by anyone who has a concern that a plan may not be working as intended or a person's needs have changed. However, the person or carer whose plan it is must be consulted when deciding how to respond to the request, so it is important that wherever possible they know the request is being made from the outset.

2. Mental Capacity

If there are concerns that the person may lack capacity to consent to your support then a proportionate mental capacity assessment must be carried out to determine whether this is the case. This can be carried out anyone with the necessary skills to do so.

If the person has capacity to consent following the mental capacity assessment their consent must be obtained before support can be provided.

If the person lacks capacity to consent following the mental capacity assessment then a Best Interest Decision must be made to confirm that accessing the service will be in their Best Interests.

3. Legal Requirements of all Decision Making

The Care Act places certain duties on the Local Authority whenever it is making any decision about a person with (or who may have) Care and Support needs. These are things that you absolutely must consider and are:

1. The impact on the person's individual wellbeing;
2. Whether any other prevention service can be provided that will delay, reduce or prevent the need for Care and Support;
3. Whether information or advice can be provided to support the person to find their own solution, or to delay, reduce or prevent the need for Care and Support.

It is vital that you understand your duties in relation to the above. Please use the links below to access further information as required.

Click here to access information about the duty to promote individual wellbeing.

Click here to access information about the duty to prevent, reduce or delay needs.

Click here to access information about the duty to provide good information and advice.

If the person is not happy with any decision that is made about them then you must make them aware of their right to complain about it.

4. A Strengths Based Approach

The Care Act statutory guidance states that, wherever possible, every conversation with a person should be from a strengths perspective. This means that before you talk about service solutions to any presenting issue 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.

A strengths based approach is empowering for the person and gives them more control over their situation and how best to resolve any issues in the best way for them. The end result may still be that the Local Area Co-ordination service intervenes with support, but this decision will have been reached knowing that it is the most proportionate response available.

Adopting a strengths based approach involves:

1. Taking a holistic view of the person or carers needs in the context of their wider support network;
2. Helping the person to understand their strengths and capabilities within the context of their situation;
3. Helping the person to understand and explore the support available to them in the community;
4. Helping the person to understand and explore the support available to them through other networks or services (e.g. health);
5. Exploring some of the less intrusive/intensive ways the Local Authority may be able to help (such as through prevention services or signposting.

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.

5. Providing General Information and Advice

Providing Information and Advice

The duty to provide good general information and advice about adult Care and Support applies at all times.

Click here to see what the Care Act says 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.

General Information and advice about adult Care and Support can be accessed in a number of ways:

In person:

• Chingford Library Plus - The Green, Chingford, E4 7EN;
• Leyton Library Plus - High Road, Leyton, E10 5QH;
• Leytonstone Library Plus - 6 Church Lane, Leytonstone, E11 1HG;
• Walthamstow Library Plus - High Street, Walthamstow, E17 7JN.

Online:

Click here to access the Adult Social Care information and advice pages of our website.

Sometimes it is helpful to contact a well known national organisation with a dedicated information and advice service or help-line. Click here 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. Click here for a wider range of useful national contacts for adult Care and Support.

Financial Assessment FAQ's

Click here to see the answers to some frequently asked questions around financial assessment, including questions relating to Disabled Facilities Grants.

Note: This FAQ is based on statutory duties and powers and does not reflect Waltham Forest’s policy to provide all carers services on a non-chargeable basis.

Information and Advice about Equipment and Adaptations

The Waltham Forest Equipment and Living Aids Online Marketplace is where you can browse and purchase a range of products that can assist in all areas of the home.

Click here to access the marketplace.

Making Information and Advice Accessible

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.

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 make 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 be agreed with the person to whom the information and advice was given and 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.

6. Accessing a Prevention Service

Under Section 2 of the Care Act the Local Authority has a duty to prevent needs for Care and Support/Support.

Click here 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.

There are many kinds of prevention service available. Some are provided by the Local Authority and some are provided by the community or partner organisations, such as health. All available prevention services in the local area should be explored before undertaking a longer term intervention.

7. Raising a Safeguarding Concern

If you become aware that any adult or child is experiencing or at risk of abuse or neglect you must raise a concern under safeguarding:

Adults

Click here to access the safeguarding adults procedures. They explain how to recognise abuse or neglect and how to raise a concern.

Children

To raise a concern about a child call:

1. 020 8496 2310 (Monday-Thursday 9am-5.15, Friday 9am-5pm); or
2. 020 8496 3000 (out of hours).

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.

8. 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 any 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.

Click here to access a tri.x tool that can support effective and consistent decision making about when/which advocacy support should be made available.

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.

Click here for information about how to determine substantial difficulty.

Click here to access 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.

Click here 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 click here.

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.

Use the tri.x Resource tab to access information about the role of an Independent Mental Health Advocate (IMHA) in the glossary.

Click here to access a tri.x tool that can support effective and consistent decision making about when/which advocacy support should be made available.

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.

Use the tri.x Resource tab to access information about the role of an Independent Mental Health Advocate (IMHA) in the glossary.

Click here to access a tri.x tool that can support effective and consistent decision making about when/which advocacy support should be made available.

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. The Care and Support process requiring advocacy support cannot begin until it is in place.

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 not proceed to carry out any Care and Support process 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.

Click here to see the procedures for providing urgent support, including access to a tool to support consistent decision making in determining urgent needs.

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.

9. Gathering Information and Consulting with Others

The power to gather information and consult with others

With the person's consent, the Care Act permits the Local Authority to consult with anyone it deems relevant to consult with.

You should proactively identify anybody that it may be appropriate to speak with in order to gather comprehensive information upon which to decide the most appropriate outcome for a person. This could be a family member, a health professional, another Local Authority or an organisation (such as a Care and Support provider). Under the Care Act anybody contacted by the Local Authority has a duty to co-operate with any requests for information or support.

Click here to read more about the duty to co-operate under the Care Act.

The purpose of gathering information from others

The purpose of consultation and information gathering is to ensure that the response of the Local Authority is a proportionate and appropriate one to the person's situation and level of need. Only information relevant to this purpose should be gathered during consultation.

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

Use the tri.x Resources tab to access further information about the Caldicott Principles in the glossary.

Methods of consultation

The method of consultation and information gathering used should reflect the individual circumstances of the case. Depending on the level of urgency, risk and need consultation and information gathering can be formal or informal in nature.

For example:

1. A telephone conversation;
2. An email or letter; or
3. A face to face meeting.

Where the method of consultation is not face to face you should be satisfied that the information you share will only be seen by the person to whom it is intended to be seen.

Where the Person has requested the Local Authority Gather Information or Consult

The Care Act is clear: Apart from cases where the level of risk is paramount you must consult with anyone that the person has asked you to consult with before making any outcome decision.

Examples of paramount risk could include:

1. Where urgent action is required, that if delayed to allow consultation would place the person at imminent risk of abuse or neglect leading to serious harm;
2. Where the person to be consulted is deemed to be the perpetrator of abuse and neglect and consulting with them at that time would place the person at imminent risk leading to serious harm;
3. Where urgent Care and Support provision is required, that if delayed to allow consultation would place the person at imminent risk of harm through the non-meeting of essential needs.

The person should be told why consultation has not occurred, and long term decision making should be avoided until such time when consultation is possible.

Consulting with carers

Where the person is known to have a carer the Care Act expects you to consult with them before making any decision regarding Care and Support for the person.

The purpose of doing so is:

1. To gather further information about the needs and situation of the person; and
2. To understand the needs of the carer and fulfil the duty to meet them.

Where the person with Care and Support needs has not consented to you consulting with their carer you must still do so for the purpose of understanding the needs of the carer. This will no doubt involve some discussion about the person with Care and Support needs but the Local Authority has a duty to support the needs of any carer it identifies and the person they care for cannot override this duty.

The procedures for assessing and meeting the needs of carers can be found in Carers Procedures.

Consulting with Others

You should proactively identify anybody else that it may be appropriate to speak with in order to gather comprehensive information upon which to decide the most appropriate outcome. This could be a family member, a health professional, another Local Authority or an organisation (such as a Care and Support provider). Under the Care Act anybody contacted by the Local Authority has a duty to co-operate with any requests for information or support.

Click here to read more about the duty to co-operate under the Care Act.

Consent to Consult and Mental Capacity

With the person’s consent, the Care Act permits the Local Authority to consult with anyone it deems relevant to consult with.

If there are concerns that the person may lack capacity to consent to you gathering information from or consulting with others then a mental capacity assessment must be carried out to determine whether this is the case. This should be carried out by the Local Authority because it is the Local Authority who wishes to consult.

If the person has capacity to consent following the mental capacity assessment their consent must be obtained before consulting others.

If the person lacks capacity to consent following the mental capacity assessment then a Best Interest Decision must be made to confirm that consulting with others will be in their Best Interests. This decision should be made by the Local Authority because it is they who will be consulting.

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

10. 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

11. Acting on Information about Risk

Information that a person may be at risk

If you have received information that indicates a person may be at risk of abuse or neglect you will need to consider the measures that you (or others) can take to protect them.

Where a safeguarding concern has not been raised already you should raise a concern without delay.

Click here to access the safeguarding adults procedures, including how to recognise abuse and neglect, how to raise a concern, how to record safeguarding information or adult safeguarding.

Information that a person may be risky

If you have received information that indicates that a person may pose a risk to others you will need to consider the measures that you (or others) can take to reduce the risk and protect others.

Click here to access the procedure for carrying out a risk assessment.

If the risk assessment indicates that a vulnerable adult or child may be at risk of abuse and neglect you must ensure that you raise a safeguarding concern without delay.

Click here to access the safeguarding adults procedures, including how to recognise abuse and neglect, how to raise a concern, how to record safeguarding information or adult safeguarding.

12. Urgent or Interim Support

When urgent or interim support can be provided

Not everyone contacts the Local Authority in a timely way so as to allow for an assessment and exploration of options to take place prior to any initial decisions being made about the need for Care and Support.

For example, some people only approach the Local Authority when they are in a time of crisis, high risk or when there is a sudden or unexpected change in their Wellbeing.

In these cases there may appear to be an urgent need for support that cannot wait for an assessment or review process to be carried out.

The Care Act recognises this occurrence and gives the Local Authority powers to meet such needs without having carried out a formal assessment process.

Click here to see what the Care Act says about meeting urgent needs without an assessment or review.

Having the power to meet needs without an assessment or review means that the Local Authority can decide whether or not to do so, based on the available information and specific circumstances of the person and their situation.

Deciding how to meet interim needs

Under the Care Act, the Local Authority can put any interim or urgent measures in place that it deems appropriate to meet the needs of the person and manage the situation. This can range from a small number of domiciliary care visits to a stay in residential accommodation.

The same legal considerations apply when meeting urgent needs as they do when meeting non-urgent needs:

1. The impact on the person’s individual wellbeing;
2. Whether any preventative service can be provided that will delay, reduce or prevent the need for Care and Support;
3. Whether information and advice can be provided to support the person to find their own solution, or to delay, reduce or prevent the need for Care and Support.

It is vital that you understand your duties in relation to the above. Please use the links below to access further information as required.

Click here to access information about the duty to promote individual wellbeing.

Click here to access information about the duty to prevent, reduce or delay needs.

Click here to access information about the duty to provide good information and advice.

In addition, you should be mindful that nobody has yet assessed (or reassessed) the needs of the person and you may be relying on historical information or information from sources currently under significant strain or pressure to act. As such the information presented may or may not be an accurate reflection of the person’s needs following an assessment.

Interim support should therefore only be seen as a temporary measure to reduce risk of harm and support the person to a place in time where a needs assessment can be carried out and long term options explored and agreed with them. As such, you should be cautious about providing interim Care and Support that may be problematic to cease following assessment.

Click here to access a tri.x tool to support consistent decision making about the provision of urgent or interim support.

Requesting Funding for Urgent or Interim Support

All funding requests for urgent and interim support should be made in line with available local processes and guidance.

Funding Decisions for Urgent or Interim Support

It is difficult to make a decision about the level of funding required to meet the urgent or interim Care and Support needs because:

1. There will be no personal budget allocated to the person; or
2. There will be a personal budget but this will not be based on their current needs.

The Care Act does not discuss or set funding limitations in relation to the provision of any Care and Support. This includes urgent and interim Care and Support. Instead, the golden rule of the Care Act when making any funding decision is that ‘the amount of funding agreed must be sufficient to meet the needs that are to be met at that time’. Decisions must also be made in a way to ensure that the person will be satisfied the process was fair and robust.

Factors other than sufficiency that must be considered when making funding decisions are:

1. The views and wishes of the person about how their needs should be met;
2. The availability of other potential options in the marketplace; and
3. The cost of available suitable services in the marketplace.

Other factors that should be considered are:

1. The complexity of the person’s needs;
2. The level of risk/sense of urgency; and
3. Whether the practitioner requesting the funding has provided relevant information and advice, whether they have explored prevention services that may be appropriate and whether they have explored how the person’s own networks of support could help; and
4. Where the person is not ordinarily resident; if they receive Care and Support already in another Authority the nature of the Care and Support they receive.

When making a funding decision the Local Authority is also permitted under the Care Act to consider how to balance its legal requirement to maintain universal services to the entire local population with the power to meet the urgent needs of a person or carer. In doing so it must:

1. Not base it’s decision on finances alone;
2. Consider things on a case-by-case basis; and
3. Not set arbitrary limits (fixed amounts for a particular type of need or service).

Communicating the outcome

The outcome of the funding decision should be communicated to the person at the earliest opportunity. 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 outcome of a funding decision is subject to the same requirements as the provision of information and advice, and the duty to make it accessible therefore applies equally.

Where communication is provided by telephone a follow up letter confirming the conversation and the funding decision should be sent to the person as a formal record.

When communicating the outcome you should include the following information:

1. The funding decision itself;
2. The rationale for the decision;
3. Any information and advice relating to adult Care and Support, and the prevention, delay or reduction of needs;
4. What will happen next and the timeframes involved;
5. How to complain about any aspect of the decision or proposed outcome.

Recording Urgent and Interim Support

Any funding decision rationale should be clearly recorded in line with local recoding requirements.

The Local Authority is not required to record urgent and interim support on a Care and Support Plan because:

1. The support is being provided under the Local Authority’s powers (as opposed to duties);
2. The person has not yet been assessed (or reassessed); and
3. There has been no decision about eligible needs.

However, the following must be clearly recorded:

1. The urgent or interim support being provided;
2. The contribution to the cost of the support being made by the Local Authority;
3. The contribution being made by the person;
4. The duration of the support;
5. How the support will be reviewed;
6. What outcomes the support aims to achieve; and
7. The next steps, including timeframes for any assessment.

Arranging Interim or Urgent Support

Under the Care Act the process of arranging to meet urgent and interim Care and Support needs is the same as arranging to meet needs agreed through a non-urgent Care and Support Planning process.

The Commissioning and Brokerage Procedures include the processes for using any brokerage service to commission a service, commissioning Care and Support services directly, and how to record the services that are being provided on the system.

Charging for Care and Support

The Local Authority is permitted under the Care Act to charge any person for Care and Support (including Care and Support provided on an urgent basis) unless:

1. It chooses not to; or
2. The person has been financially assessed as having insufficient funds to contribute; or
3. The support being provided is reablement (up to 6 weeks is non-chargeable); or
4. The support being provided is equipment (up to the cost of £1000 is non-chargeable).

Click here for further information about charging for all services under the Care Act.

Click here to see the answers to some frequently asked questions around financial assessment.

Click here to access the procedures relating to financial assessment, which include links to any local policy and financial assessment process.

Urgent Support for people who are not ordinarily resident

Where urgent support is provided to a person who is not ordinarily resident contact should be made at the earliest opportunity to the Local Authority in which they live to inform them of the intention to meet an urgent need.

Where the person is already in support of a service from the other Local Authority information should be gathered to support any decisions made about which support should be provided.

Agreement should be reached with the other Local Authority about how any urgent Care and Support services will be monitored, when they intend to assess for eligible needs and how reimbursement of costs incurred can be sought.

Click here to access a tri.x tool to help determine whether a person is ordinarily resident in the area.

Click here to see the ordinary residence procedures, which include how to seek reimbursement for urgent needs met and any supporting documentation.

13. Revising a Care and Support Plan

When a Care and Support Plan can be revised

Under the Care Act, when a person is already receiving Care and Support from the Local Authority they may request a change to their Care and Support Plan at any time and the Local Authority must consider the request. Where the request is deemed reasonable the Local Authority has a duty to review the plan.

The review is the mechanism by which the need for a revision is determined. As such, under the Care Act a Care and Support Plan can only be revised following a review.

Where a change is requested to a plan and there is no planned review scheduled consideration should be given to arranging an unplanned review. Any review must be proportionate to the needs of the person and undertaken in a timely way so as to reduce the risk of a crisis developing and needs not being met.

Click here to access a tri.x tool to support consistent decision making around the response to a review request.

When the person requiring a review has an allocated worker

If the person has an allocated worker this person should carry out the review, unless the review is urgent and the worker in unavailable.

Before transferring the review request you should confirm that the practitioner the review request is being transferred to is available.

If the practitioner is not available you should speak with a manager to establish whether:

1. The request should still be transferred to the allocated worker to action when they become available;
2. The request should instead be transferred to another practitioner to carry out the review.

If there is no allocated worker

Where the information gathered at contact suggests there has been no change in the person’s needs, and that a change to the personal budget amount is not required may be possible to complete a ‘light touch’ review without further allocation.

Click here for information about the methods of light touch review that should be made available under the Care Act.

When the information gathered at contact suggests there has been a change in need or circumstance, and that a change in the personal budget amount is required any review carried out is likely to lead to a proportionate reassessment of need. Because this is a longer term intervention allocation for this should be considered.

Carrying out the review

Please refer to the Reviewing Support and Services procedures from the team or service homepage.

14. Recording Decision Making

Recording of decision making should be clear and comprehensive yet proportionate. Anyone reading the recordings should be able to (as quickly and easily as possible) understand what has happened and why a particular decision has been made.

When available it is important to capture in recordings:

1. The views of the person with Care and Support needs in regard to;
   • Their needs and what they would/would not like to happen;
   • The information and advice that has been given to them;
   • Any verbal consent given to gather information or consult with others; and
   • The possible outcomes that have been explored with them.
2. The views of any carer in regard to;
   • The needs of the person;
   • Their needs and what they would/would not like to happen;
   • The information and advice that has been given to them;
   • Any verbal consent given to gather information or consult with others; and
   • The possible outcomes that have been explored with them.
3. The details of and views of any other person or organisation consulted with as part of the decision making process;
4. Details of any manager or peer supervision discussions that have influenced the outcome decision;
5. Any actions agreed with anyone, including how any follow up will take place;
6. Where there have been concerns about the person’s mental capacity to consent to the contact or referral, to consent to consultation with others or to be part of the decision making; a record of how mental capacity has been assessed and how any best interest decisions have been made;
7. How the outcome has been decided, particularly how regard has been shown for individual Wellbeing, and how the decision prevents, delays or reduces the needs for Care and Support;
8. How the outcome has been communicated and how it was received; and
9. How the situation will be monitored for changes.

Recording should take place as near to the time that the actual event being recorded took place and in line with local recording requirements.