Monitoring Actions (Reablement)

Changes can and should be made to the plan whenever:

1. There is evidence that a change is required; and
2. The person and any carer is in agreement with the change; and
3. Other people involved in the plan agree with the change.

For example, when:

1. Progress is being made toward outcomes;
2. Increased support is required (for example during a period of fluctuating needs);
3. There are changes in the person's circumstances; or
4. There is increased independence as a result of equipment or assistive technology.

The changes could include:

1. Changes to the day, time or duration of support;
2. Reduction in the number of visits per day;
3. A temporary increase in the support provided to manage a fluctuation of need; and
4. Changes to the way that support is provided (for example if equipment is installed).

All changes should be evidence based. Evidence could include:

1. Observations of a reablement worker/provider;
2. Information from another person involved in the plan (for example an occupational therapy practitioner); or
3. Information from anyone involved with person for another reason (for example a social worker or a health professional).

After receiving evidence a decision to revise the plan should be made in a timely way to avoid unnecessary delays and optimise windows of opportunity to promote independence.

The Reablement Plan is a working document and should be in a format that allows for regular and frequent revisions to be made quickly and easily.

It is appropriate for a reablement worker/provider to amend a Reablement Plan by hand once changes have been formally agreed and for the Local Authority to then amend the formal record as soon as possible after this.

Whenever a change has been made to the plan you should:

1. Communicate the changes to everyone involved in reablement; and
2. Explain that until a revised copy of the plan is provided to them they should refer to the plan in the person's home.

Unless there have been changes to consent or to the people who are involved in the reablement, a copy of the revised plan should be made available to the same people as the original. Where a copy is provided electronically this must be provided securely.

If the person or carer is not in agreement with the change you can still make the change so long as you have given regard to:

1. The views of the person and carer; and
2. The impact on the person's Wellbeing of the change.

In order to try and resolve the issues in the plan 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 (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 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).

The following are just some of steps that may be appropriate to resolve the issues with the plan:

1. Increased monitoring of the plan;
2. Having a conversation with the person, a carer, family member or friend about the purpose of the reablement service, risk or enablement;
3. Breaking down the outcomes into more achievable steps;
4. Changing the frequency or duration of reablement visits;
5. Having a conversation with the external reablement provider about the purpose of the reablement service and enablement;
6. Changing the reablement service provision;
7. Holding a formal review of the plan where it is felt that the reablement service may no longer be appropriate.

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.

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 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.

Where the safeguarding is in respect of the person receiving reablement a decision will need to be made about the need to pause the reablement process to allow a safeguarding enquiry to take place.

There are 2 possible options:

1. The reablement process continues alongside any safeguarding process; or
2. Reablement is paused with no on-going intervention by the person whilst a safeguarding process takes place.

Any decision should involve the reablement service, the person who will be carrying out any safeguarding process, the person with Care and Support needs (or their representative) and any carer.

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 assessment is likely to deprive them of their liberty.

See: Recognising and Responding to Deprivations of Liberty.

Under section 5 of the Care Act the Local Authority has a duty to maintain an effective and efficient market of services for meeting Care and Support needs in the local area. A key part of maintaining a market place is understanding what is working and not working about the marketplace. It is therefore important that you report any concerns you have about any organisation providing any kind of Care or Support.

The local marketplace includes:

1. Services that are commissioned by the Local Authority;
2. Services that are provided by the Local Authority;
3. Services used by self funders and people who have a Direct Payment;
4. Universal services available to all residents; and
5. Services provided by partner agencies (for example health or voluntary services).

In all cases, you must take appropriate steps to manage the risk to an individual posed by the poor practices of a service provider. Effective ways of managing the risk could be:

1. Raising a Safeguarding concern;
2. Arranging an alternative provider (there is a duty to do this when a regulated provider fails);
3. Agreeing monitoring arrangements.

The commissioning service are responsible for ensuring that regulated Care and Support services are safe and of a high standard when:

1. They are commissioned by the Local Authority (services provided in the Local Authority area or outside of it); or
2. They are being used by people who have a Direct Payment (services in the Local Authority area); or
3. They are available to people who self fund or use a Direct Payment (services in the Local Authority area only).

You should notify the commissioning service if you have general concerns about any of the following:

1. Domiciliary Care Providers commissioned by the Local Authority (either in the local area or outside of it);
2. Domiciliary Care Providers available in the local area but not commissioned (used by people with a Direct Payment or self-funders);
3. Reablement services provided or commissioned by the Local Authority;
4. Regulated day services (those providing personal care) commissioned by the Local Authority or available in the local area;
5. Any other regulated Care and Support provision.

Where you are providing details about a particular incident involving a person with Care and Support needs you should:

1. Make the person aware that you are raising the concern and why; and
2. Establish whether they consent to be contacted as part of any further information gathering if required.

The commissioning service will determine the most appropriate response to the concern that has been raised, which could include:

1. Contract renegotiation with a commissioned provider;
2. Agreeing and monitoring an action plan with the provider;
3. A temporary stop on the use of a provider;
4. A large scale safeguarding response;
5. Joint work with another Local Authority (when the provider is not local);
6. A recommendation to information and advice services not to signpost to a provider;
7. Notification of concerns to the Care Quality Commission;
8. A letter to people who use a service.

You may be asked to support the commissioning service by providing additional information or assisting in any investigation process they undertake. You are required to co-operate with any request under the Care Act unless doing so will:

1. Prevent you from effectively carrying out other duties under the Care Act; or
2. Prevent you from effectively carrying out duties under any other legislation.

Unregulated Care and Support services are generally services that do not provide personal care, and so do not have to be registered with the Care Quality Commission. They include:

1. Some day services;
2. Prevention services provided by housing;
3. Health services;
4. Colleges and training centres;
5. Advocacy services;
6. Voluntary and charitable services.

If the services are commissioned by the Local Authority you should report concerns to the commissioning service in the same way that you would report a concern about a regulated Care and Support service.

If the services are provided by a partner organisation (such as health, housing or education) there will be local arrangements in place to report concerns. If you do not know what these arrangements are you should:

1. Speak to your line manager; or
2. Speak to the commissioning service.

Where you are providing details about a particular incident involving a person with Care and Support needs you should:

1. Make the person aware that you are raising the concern and why; and
2. Establish whether they consent to be contacted as part of any further information gathering if required.

When concerns arise about the practice of a personal assistant you should discuss your concerns with the relevant social work team. They should take the necessary actions to address the concerns.

Concerns about a personal assistant providing support to others

If you know that the personal assistant is providing Care and Support to other individuals in the local area you must consider any further action required. This could be:

1. Notifying the team responsible for managing Direct Payments of the concerns so they can take appropriate action to notify others;
2. Raising a safeguarding concern in respect of another individual being supported by the personal assistant.

Concerns about a personal assistant who is part of a local register

When a personal assistant is part of a local register of PA's it is important that any unresolved or on-going concerns are reported to the organisation or person responsible for managing the register.

This will allow for the register to be updated and consideration given to the on-going suitability of the PA to be included on it.

The Local Authority values openness, transparency and candour and encourages you to raise concerns as soon as possible about the practice of any individuals (whether they are employed by the Local Authority or not) that you feel:

1. Compromises the safety or Wellbeing of a person with Care and Support needs; and/or
2. Compromises the safety or Wellbeing of a carer with support needs; and/or
3. Compromises the safety of a child.

Examples of individuals employed by the Local Authority include:

1. A social worker;
2. An occupational therapist;
3. Unqualified workers in social work or occupational therapy services;
4. Support workers in Local Authority day or provider services;
5. Individuals employed in other areas of the organisation (such as housing officers and teachers in Local Authority schools or colleges).

Examples of individuals employed by other organisations include:

1. Health professionals (for example a community or district nurse, a GP, a Psychiatrist or Psychologist, a Speech and Language Therapist. An Optician or a Dentist);
2. Police Officers;
3. A support worker in a charitable organisation;
4. An advocate.

Whistleblowing is part of the Public Interest Disclosure Act 1998 (PIDA). Under the Act you:

1. Must be provided with a safe space in which to raise the concerns;
2. Must be taken seriously;
3. Cannot be subjected to any detrimental or unfavourable treatment and victimisation by the Local Authority or individuals as a result of making a disclosure.

Legally you do not have to provide any hard evidence to support a whistleblowing disclosure, but if you have any evidence you should always provide it. This could be:

1. Details of when a specific incident occurred;
2. A witness statement written by you or that has been provided to you;
3. Other documentary evidence (for example an e-mail or letter).

If you require further advice about whistleblowing before making a disclosure you can contact the Whistleblowing Helpline:

1. By telephone on 08000 724 725;
2. by e-mail at enquiries@wbhelpline.org.uk.

Concerns should be raised in line with local whistleblowing policy and process.