Warwickshire 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 changed to outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional.

This service scored 96 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

The provider operated a thorough and beneficial assessment process to ensure people’s needs were met from the start. Everyone we spoke with felt included in how their care was bespoke to them. One relative said, “On the day of discharge the reablement team were organised and attending to her needs immediately. The reablement team assessed [Person] that day and spoke to us and our relative about the plans for care and outcomes, everything was discussed and agreed.” In addition, this relative said, “What I thought was very good was the team spoke to [Person] directly; she was very included in the planning of her care and rehabilitation. The whole package gave the family and [Person] confidence about meeting her needs as well as getting her on a positive road to recovery.”

Another relative told us of their positive experience, saying, “The assessors (staff) were very good and ordered equipment for them. They needed an outdoor walker as well as indoor and organised a perching stool for the bathroom as well as a shower chair.” They told us this equipment was requested and delivered promptly which had made such a positive difference to them. This relative said, “[Relative] is more mobile now as she has had a lot of support in getting stronger which has been great and the physiotherapy sessions organised for her by the reablement team, and the exercises have really helped.” Staff completed assessments, often in hospital settings before the person returned to their home. These assessments were used to determine the level of care and support required, including any equipment to facilitate safe care. Seventy-two hours after the first care calls, staff undertook a ‘functional assessment’. These assessments provided a deeper understanding of each person’s capabilities and needs. They allowed for the person to settle back into their home environment with the support of staff for a few days before another assessment was completed.

The functional assessments gathered more information on the person’s washing and dressing needs, how they managed this in real time and how staff could best support them with the use of equipment, suggested techniques and confidence building. Positive feedback on these additional assessments highlighted how this approach supported a stronger rapport between the person and staff. Management completed ‘activity analysis’ that studied individual tasks and how small changes can improve and support how the task is completed. This meant better outcomes were fulfilled. Staff said functional assessments often revealed hidden strengths, enabling them to reduce unneeded visits, as well as a reduction in hospital admissions. This approach empowered individuals to manage independently in shorter timeframes.

The provider always 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 correct evidence based good practice and standards

The provider felt they had made significant strides in enhancing the quality, responsiveness, and effectiveness of their support. Improvements were directly benefiting the people who used the service, enabling them to regain or improve their independence and confidence in their daily lives. The registered manager believed a key area of improved success had been the implementation of ‘functional assessments’. These assessments provided a thorough understanding of each person’s capabilities and requirements once care had commenced.

People’s feedback showed they welcomed the whole assessment process and it was clear people had adjusted well to the support they received. One relative told us their story and how staff had been vital in providing support. This relative said, “[Relative] has had a walking trolley at home but because they had a stroke the care team have been reviewing their ability to manage placing things on the trolley and move to another room. They are encouraging and helping them as they were concerned about the trolley due to the stroke affecting their left side. Physiotherapy sessions have been organised for them to improve their movement.” This relative said, “I’m proud of the service that has meant they can stay at home.”

Staff told us they researched evidence-based aids that supported positive care outcomes meaning people could stay at their own home if this was their choice. Regarding the example above, staff showed us a suction cup that people could place on a walking frame, with drinks inside and the cup remained stable, without falling over. A staff member said this cup made a difference to people, meaning they can continue to make drinks for themselves, their independence was maintained and they were not reliant on staff. In some cases, this reduced people’s need for additional care calls.

Some people were supported to wash and dress themselves, where their assessment identified this as a goal and aspiration to help with their rehabilitation. Relatives spoke highly of staff in how they did this, whilst offering gentle encouragement and persuasion. The use of certain aids helped reduce people’s reliance on staff. Staff told us how they encouraged people based on their needs and preferences. One staff member said, “I do this by sitting on my hands and letting them do what they can for themselves. Of course, we don’t let them struggle but we always try and get them to do what they can.” Another staff member said, “We would suggest ideas so if we can see they struggle to put their socks on, we would get them a sock aid or if it was shoes, we would get them a shoehorn, anything to help them.” All staff said the persons reablement assessment and care plan directed them what to do and those documents were always updated.

Staff told us they completed records that showed what people had done over a period of time so they could see their rehabilitation journey. Regular reviews with staff and other multi-disciplinary teams made sure, people received the right levels of support based on sound and recorded evidence. The registered manager was confident from their analysis; a high percentage of people benefitted from the service. A large contributor to this was having the right staff, accessing the right teams and making the right decisions with the person’s best interests at heart.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

People benefitted from smooth transitions between services. People and relatives felt the staff team who supported them, knew what and how to care for them, working closely with each other and external partners. A health professional told us, “It is very easy to refer into reablement services. Delays don’t usually occur from the reablement side, it is usually the hospital that have to delay the start time /date.”

Without exception, everyone was proud of the service they received. People and relatives praised the staff, their commitment and attention to detail. One relative said, “Every member of the team has been absolutely fantastic, absolutely consistent, just brilliant.” Another relative shared their experiences with us. They said, “I think it’s a wonderful thing to actually encourage people to get themselves better, rather than saying to somebody you sit there and we’ll do this. It’s come on then show me what you can do, what would you like to do, what do you think you can do. A brilliant way to do it, to keep somebody able and their body working and moving, it’s a much better way rather than being left to deskill everything, if you can do it you need to keep doing it.” In another example, the provider shared they had received from a relative. It read, “I would like to add that the care my [Relative] received from the reablement team was absolutely outstanding and I would like the social workers to feed that back to their team.”

It was clear from conversations we had and records we saw, key partner agencies worked cohesively, sharing vital information about the person so they had all of the information to make the right decisions for that person. People’s initial assessment contained all relevant information, including the reason for referral and any health and social care professionals’ involvement. In some cases, medicines were arranged or specialist equipment was requested. Health professionals praised Warwickshire reablement staff undertaking assessments prior to discharge, so they were organised and ready.

A multi-agency approach of key partner agencies included district nurse teams, occupational therapists, mental health teams, social workers, equipment suppliers and support from external care technology companies. This joined up working meant all services, facilitated by the provider, worked together to benefit positive outcomes for those they supported. This meant people received co-ordinated and timely care. In one example, a staff member told us if they made calls to get support or equipment it was usually triaged and dealt with more quickly than if the person or their family member had made the request. This was recognised by staff to promote positive care outcomes. Staff gave us examples when they had done this.

In the event a person requiring ongoing support needs, a staff member told us they completed a referral under the Care Act Assessment. Staff also used a finance tool that accurately assessed what care packages a person may have access to and the associated costs. This tool showed an estimate of care costs which saved the person time doing this themselves so they could make an informed choice. One person said staff remained willing to help when it came towards the end of their agreed care package. This person said, “Staff helped me fill in forms to apply for attendance allowance and they have really helped me to understand what financial support there is that I could be eligible for.”

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

People and relatives described to us how the service made a real difference to them. One person said, “It made a big difference to me because when I first came out, I relied on them a lot. Over the weeks they were there and supported me, I was gradually getting more independent which they encouraged me to do, every one of them that came did what I wanted them to do. It was all led by me and they encouraged me as I got better.” A second person said, “It was reassuring because living on your own as well and just coming out of hospital, but I knew they were coming, and if I didn’t need any help we could sit and have a chat, which was really nice, and off they would go and say see you tomorrow, it was nice to know they were there.” A third person described staff as, “They (staff) are all special, they all make me feel special, I can’t separate them to be, they’re all so special and lovely.”

People and relatives were confident, staff knew them well and the whole staff team knew what they needed to help them get back to being confident to live in their own home following injury or illness. One relative was extremely satisfied with the service and we asked them, if the service had made a difference to them. This relative said, “Oh my goodness absolutely [when asked about progress/improvement], if she hadn’t had this level of help, she’d still be as she was in week 1. Her confidence, her outlook, her positivity, she looks forward to the 3 visits a day now, it’s part of her structure. My family can’t believe the difference, having people to make you feel human again, it’s given her the confidence, I don’t think she would be in the same position without them, it’s an absolute must, a lot of people her age may not have the family so for them, it’s an absolute must.”

Staff conversations showed us they knew people well. Staff said they felt they had the right information about people; their support networks and the help they needed to regain confidence and to be able to live their life to the best. One staff member told us they tried to imagine what it would be like returning from hospital, back to your own home. The staff member explained, “Some people were in hospital and it’s daunting thinking when you get home you can’t cope. When they get home, we encourage little bits at a time. They are surprised they can cope.”

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The provider utilised assistive technologies to support and promote positive outcomes for people and their families. The use of smart sensors and smart plugs helped monitor certain situations, without restriction or impacting on people’s privacy. This technology helped evidence how a person’s care remained effective or if changes were required. In 1 example, an occupational therapist told us a sensor was put on a person’s bedroom door and the data showed, they did not sleep in their bedroom. The person slept in a chair and with this information, the occupational therapist arranged for the person to have a suitable chair and the required pressure relieving equipment to support a positive outcome for that person.

In another example, a relative told us how this gave them confidence their relative’s welfare remained positive and how that reduced their anxieties. The relative told us, “[Relative] was desperate to get home, and this arrangement made it possible. They have wonderful technology that helps people live independently and safely. The Tec me system was installed to monitor [Relative’s] movements in a very unintrusive way. Monitors were placed on kitchen, bathroom, lounge and bedroom doors ,which enabled us to access the app and we could see they had managed to get up, go to the bathroom and walk into lounge …..it was wonderful as if [Relative] had fallen we would be able to tell that they hadn’t gone from room to room.” In some cases, once reablement had finished, families were offered the chance to purchase this system.

The provider co-produced the design and implementation of their care call allocation system which meant they had control over what and how care calls were planned and completed. This system allocated care staff and care call times that was focussed on people’s individual requirements. Staff routinely monitored when staff had left for a call or returned from a call to ensure all calls were completed. If people needed more time, staff reallocated calls to ensure that person had the time they needed. The management team also had oversight to ensure it was managed efficiently and effectively.

Seventy-two hour assessments reinforced the initial assessment process to make sure the reablement package continued to meet people’s requirements. Further assessments and reviews were completed. Regular multi-disciplinary meetings and staff meetings reviewed people’s care needs and if any further input was required, this was organised. For example, additional and important equipment was arranged and put in place. Following completion of a person’s reablement journey, the registered manager reviewed the success of the support. Positive results showed hospital admission prevention remained an important goal. Occupational therapy triage and the relaunch of the Tec Me Home initiative, helped people remain safe at home. This not only improved their quality of life but also reduced pressure on acute services. The registered manager shared with us, over 72% of individuals required no ongoing services when their reablement support ended. This demonstrated the providers effectiveness of promoting independence and their commitment to monitoring and improving lives.

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

People felt in control of the care they received. This was because they were included and consulted from the start, sometimes before the care package commenced. Consent was sought during the pre-assessment stage, and people and relatives were informed and aware of how their reablement package would work for them. Consultation, communication and consent formed an integral part of people’s support needs. One person said, “It was all led by me. It was when I said I thought I could do something myself now, staff understood. Sometimes I was downstairs before they were able to get to me. I can’t faut any of them.”

Staff told us they always sought consent before they did anything. Staff understood the importance of consent and making sure people agreed to something. Staff gave us an example where they wished to use assistive technology to support ongoing care. Staff explained to the person how the technology worked, and once consent was given, staff installed a monitoring application that recorded movement through an electronic system. Once explained, consent was given and staff installed a monitoring application that recorded movement on an app (electronic based application to record data). This data gave a family member confidence their relative was safe whilst they were away, alongside regular updates from staff.