Care and support - Monitoring and review of care and support plans

What are the outcomes we want to achieve?

• The individual is able to reflect on how things are working
• All parties agree any changes needed at this time
• The person identifies the key outcomes and goals for the coming period
• The person understands how well they are doing in meeting the original outcomes as set out in the assessment
• Further or alternative means of increasing the individuals independence and control over the way support is arranged including consideration of direct payments are fully explored
• Improved resilience and enhanced informal networks and opportunities to contribute

What tools and resources do we need to do a good job? What are the steps we have to go through?

• A simple form sent out in advance to the person. It should be remembered that when a self-assessment is returned, it cannot be simply 'rubber-stamped' as this would not constitute a 'statutory review'. There has to be considered professional input - and for individuals who lack mental capacity a self-assessment will never be sufficient.
• Consideration of the advocacy obligations afresh, on the triggering of a review
• A light touch and proportionate approach, sensitive to individual circumstances
• Most recently updated care and support plan
• Individual records of how the personal budget has been spent
• Direct payment statements - prepay card statements where applicable prepared by finance
• Information and advice on preventative services where new ones have come on stream
• Online portal with review tools and support planning tools to enable a person to update their own plan and self-review

What are the products we will have at the end of this process?

• An understanding of any changes in circumstances including the individuals informal support network
• Identification of any new outcomes the person aims to achieve
• A record of what has worked well and what has not worked well from what the person has tried so far and what they want to change for the future
• Enabling a decision on any revisions needed to the support plan and if desired, a separate summary support plan which people are willing to share; alternatively a decision to do a proportionate re-assessment where circumstances such as abilities/inabilities, impact or extent of informal support available appear to have changed

When does this process start and end and within what timescales should this process be completed?

• Annually or more frequently where appropriate or where circumstances require - The Care Act gives the right to make a reasonable request and reasons must be given if one is refused
• The likelihood of the person lacking mental capacity to request a review themselves should be taken into account in deciding how frequently to review
• Proportionate to need and previous reviews
• Gives sufficient time for the individual to reflect on how things have gone so far and to plan for the coming year

Who needs to be involved and what is their role? Who is taking the lead?

• Person receiving service or a carer
• Family, carer or other who the person chooses to be involved
• Independent advocate or chosen representative
• Interpreter
• Care coordinator
• Relevant professionals with specialist knowledge, e.g. OT, nurse, housing staff
• Staff from another organization with delegated authority