East Bristol Reablement Service

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

People spoke positively about the first assessment of their needs. A relative said, “We had someone come around when the care first started, just to have a chat with us, it was very individualised to [Name of person]. They were lovely and explained a lot of stuff to [Name of person].” However, staff highlighted due to the limited information the organisation received initially this first assessment could take time to ensure people’s needs were fully assessed if undertaken by 1 staff member. A staff member said, “The first call is so much information to take in.” Whilst this assessment established people’s reablement goals with their involvement, it or further assessments did not gather and document information around people’s preferences or communication needs. Whilst the service only supported people for a short period of time, information learnt during the reablement process was not always added to care plan information.

People were supported with their nutrition and hydration needs if this was an identified support need. However, there was a lack of information around people’s preferences and nutrition and hydration requirements. For example, dietary needs, cultural or religious considerations or allergies.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff received training in best practice. For example, around dementia and learning disabilities awareness. This enabled staff to support people effectively. A family member said, “The carers have been extremely patient and kind with [Name of person] and they give him all the privacy he needs.”

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Systems shared updates about people with staff. A regular meeting occurred with senior staff to discuss and share information about people using the services and to take actions where these were identified. Information was shared with other teams as needed. For example, when it was identified people required equipment or aids
Staff recorded and submitted updates about people’s care and progress after each visit. This showed how people were advancing with their reablement goals. A staff member said, “We always send email updates on service users every day.” However, information recorded on people’s goal sheet was limited.
 

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service supported people for a short period of time to assist with their reablement goals. People’s support goals related to improving people’s health and independence. A person said, “They help me with my food and they give me my tablets. I’m really happy.” Staff were alert to people’s changing presentation, as many people being supported had been recently discharged from hospital. For example, recognising signs of infection. Staff were clear on procedures to escalate and manage any concerns. A staff member said, “We might have to give them more calls.”

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive andconsistent, or that they met both clinical expectations and the expectations of people themselves.

People’s reablement goals were identified and developed with them on a care plan. For example, moving around their home, getting dressed and personal care. Due to the short-term nature of the service staff were experienced in adapting to individuals, new situations and ensuring care was specific to people. A person said, “If you tell staff something new, it’s never a problem. I’m always very surprised with how they adapt to things.” However, information to support people’s reablement goals and care preferences was limited. For example, if the reablement goal was getting dressed, parts of the form were not always completed to describe people’s ability at the start of the service, how this would be achieved or how the person was progressing. A staff member said, “We do a thing called a goal sheet, that is meant to support us but I don’t think that’s very effective either. You tick next to different things, you put unassisted, independent or unseen. I don’t know what they do with the information after.” Care staff wrote detailed notes of each visit. These described how people were progressing in their reablement goals. Staff had access to this information, so they were aware of previous support given to people.

People benefited from the service and the support they received. A staff member said, “We get a lot of feedback from people once they have left saying how well they found it, and they’ve got their independence back.” At the end of the service some people could continue to live independently in their own homes. For others, further support or additional services were required. The provider made referrals for future support as necessary. A relative said, “The carers have expressed their concerns to us, they’ve spoken to social care, as have we. We are just on a waiting list now to get some additional support.”

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff received training in the Mental Capacity Act and Deprivation of Liberty Safeguards for people in community settings. Staff we spoke with demonstrated they always offered people choices and were respectful of this. A staff member said, “If they need a doctor and we were concerned, we would ask them first, always, regardless.” Staff listened to the person and their wishes. For example, about what they wanted to eat or what care they did or did not want to receive. If there were concerns about the person’s capacity to make decisions or consent to the service this was escalated and referred for a professional to undertake an assessment.