Warwickshire Reablement Service

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant services were tailored to meet the needs of individuals and delivered to ensure flexibility, choice and continuity of care.

This service scored 89 (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 was exceptional at making sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

People felt their care was focussed on them, their needs and goals. Relatives said the care provided was exceptional. Relatives said staff provided constant help to their family member with encouraging their confidence, maintaining their independence and their aspirations. In some cases, people’s rehabilitation was completed before the specified period.The registered manager and staff repeatedly told us throughout the inspection, ‘we place people at the heart of what we do’. They achieved this by being outcome focussed, and regular reviews helped shape how the care benefitted people in an individual way. The registered manager said, “People don’t like to be rushed. We give people time and respect everyone.” This approach was embedded through all aspects of the service people received that made it person centred.

The providers systems and approach supported this. This was because care was bespoke to each person, based on comprehensive and accurate assessments. Those assessments formed care plans that guided staff on how to support each person in a way that helped them to become more confident and enabled. Staff found the care plans easy to navigate around and any updates or important messages were communicated to them.

We found people’s planned care calls were not time limited. The registered manager said, “We are flexible and we can increase time, whatever the reason. The supervisor can move other care calls so we can provide that support they need to help their independence - we can adapt.” The registered manager explained the personalised initial assessments were 2 hours but sometimes it took 4 hours. “They are in depth, but we learn about the person, their hobbies, histories and family. We also want to know their goals; we take a holistic approach.”Further assessments were completed 3 days later so people got a better understanding of what reablement staff do, and vice versa. The registered manager said, “By going back we see any barriers and work with them. It’s a constant assessment we look at.”

The staff worked collaboratively with other partners and stakeholders which benefitted those people they supported. Positive feedback from other stakeholders showed how well staff acted as advocates for people in meetings, with sound knowledge that achieved the best outcomes for them.

The provider had an exceptional understanding of the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Relatives told us their family member received continuity of care from a consistent staff team who knew people well. People’s care calls were organised around their needs and commitments. People said if they needed additional time, this was provided or if they wanted less calls, this was arranged. Relatives felt valued as a partner in their family members reablement journey.

Managers and staff had built effective partnership working with external healthcare professionals so people could be confident of joined up care pathways. One healthcare professional told us, “The reablement team are very approachable. Their response is very prompt, usually same day/next day depending on the time of referral.”

Staff told us how they helped people and their relatives to receive all the funding they were entitled to and signposted them to other agencies for guidance and support. One staff member said, “In their reablement journey someone will be looked after to empower and promote independence. We find their baseline; we discuss in our peer group meetings and then I go and do a care act assessment. It puts their voice into their care plan and goals.” This staff member said they helped people with supporting them to look at financial support once their care package concluded. They said this gave them an immediate response with an accurate amount, so they could consider their options, rather than waiting weeks which reduces any potential stress.

The provider supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The provider was committed to ensuring that every person they supported was heard, understood, and empowered to participate fully in their care, recovery and reablement journey. The staff team met people’s diverse communication needs. During the initial assessment, staff identified people’s preferred method of communication such as verbal, written, visual aids, sign language and with support from family. Individual communication needs were recorded and regularly reviewed. Family members and other professionals were consulted where appropriate to support understanding and consistency. Staff said they considered a variety of communication aids such as speaking more clearly to people, using large print, easy-read materials or audio. People’s sensory and communication needs were assessed and care plans informed staff about the most effective way of ensuring people had the information they needed in an accessible format. Person-centred communication was tailored to each person's needs, preferences, and pace. Staff used active listening, open-ended questions, and nonverbal cues to build trust and understanding. One staff member told us they could tell from a person’s face or eye movement if there was something they needed or if they were experiencing some discomfort. People confirmed to us they were encouraged to work towards goal setting and have opportunities to be involved throughout their reablement which created additional opportunities to share important information.

The provider made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

People and relatives were listened to which was evident when people told us how their care calls were adjusted overtime. One person told us about the difference this made to them. They said, “The difference that it made, it sort of makes me happier knowing there is somebody going to come who I can talk to and discuss things with, just a shoulder to learn on. It’s reassuring.”Feedback from people we spoke with, evidenced they were involved and listened to, at every stage of their care journey. What people said was heard, respected and followed. No one we spoke with had any reason to raise any concerns. Where people had asked for help or had discussions about pieces of equipment or where they wanted to reduce their calls, they were heard.

Staff told us they followed people’s wishes and if there was anything they were asked to do within reason, this was completed. Staff understood they were there to support and listen to people. In some cases, staff listened to how people were feeling and, in some cases, identified where people may need extra support, for example with a particular task. The registered manager emphasised the importance of empowering people to take ownership of the service through their feedback and ensuring they always felt listened to.

The provider was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

We have highlighted the lengths to which the provider has made sure, people could and did access the health and support they needed, alongside other partners who helped come together to support positive outcomes. The provider was a strong voice to advocate everyone had equity in access to services. From referral, the staff team worked responsively to ensure people had access to everything they needed. In some cases, this was equipment. Staff contacted and arranged for this, instead of leaving this to the person or their family. Staff recognised if they called equipment suppliers, they had faster response times than if people themselves did this.

The provider had built strong professional relationships with various specialist services to support an outcome focussed service. Strong links included tissue viability nurses, speech and language therapy, dieticians, and dementia specialists. In some cases, health colleagues guided staff to ensure the person received the best care. Staff attended regular multi-disciplinary meetings with external professionals that included hospital and community teams along with housing, ensuring a shared and co-ordinated journey for the person needing support. The registered manager said they had access to people’s ‘Integrated Care Record’, which provided information that supported staff to reflect on a holistic and tailored approach to a person's needs.

The provider promoted community assets for people to be aware of, including services available in each of the localities within Warwickshire. In 1 example, the provider said they had an excellent working relationship with all local food banks. This meant they could make referrals on a person's behalf and support with collecting the voucher and food where needed. Staff had access to a designated worker in Warwickshire’s Safeguarding Team meaning they had a direct referral pathway to make cross team referrals. There was an internal directory within the service of the most known services within Warwickshire. This meant staff could quickly access the right services for people, including mental health support, and make referrals where necessary.

All people receiving a service, were discussed at a peer group meeting overseen by a manager. Those conversations promoted open communication channels between staff, where knowledge and experiences of people they supported were shared. These meetings spoke about people with dignity and they evaluated the levels of support required. The registered manager said, “This ensures the support people receive is tailored to them, rather than a one size fits all.”

The assessment process promotes and embeds the FREDA principles (Fairness, Respect, Equality, Dignity, and Autonomy) which is a framework for applying human rights in health and social care. The provider ensured all staff respected individual beliefs, culture, values, and preferences. Staff conversations with us showed they gained the trust and respect of the person to engage effectively with the service, and achieve their aspirations, outcomes and goals. External factors were also considered that may influence their recovery and reablement journey. For example, those people important to the person, whether the person lived alone and their home environment.

People’s care plans reflected their needs and preferences giving staff clear, detailed, person-centred records which demonstrated appropriate communication and action when changes to people’s needs, health or wellbeing were identified. Following completion of a reablement package, the provider completed a therapy outcome measure. This assessed impairment, wellbeing and participation at the start and end of a person’s reablement journey to assess how well they had done. Outcomes were measured from the ‘initial level to a realistic end’. In all of the examples we saw, positive improvements had been made.

Staff and leaders were innovative in how they listened to information about people who are most likely to experience inequality in experience or outcomes. Staff and leaders actively used this information to provide exceptionally tailored care, support and treatment in response to this.

We have described how people told us their care and support was co-ordinated, and everyone worked well together, for them. We found people were in control of planning their care and support and people told us they were actively encouraged and enabled to feedback. Where people had fed back, they were respected and listened to. The provider kept many examples of people, relatives and external compliments to demonstrate the quality of the service provided.

We found there was a whole team commitment to ensuring everyone was treated fairly and their protected characteristics were respected. This approach was from staff who were dedicated, trained and equipped to recognise what individual people needed and to act promptly. In the provider information return sent to us by the provider, they said they can refer individuals to local food banks across Warwickshire, ensuring that those in need can access essential support.

Staff supported people who may often be marginalised owing to their existing physical health diagnosis, anxiety or addictions. They did this by embracing people’s unique needs and by adapting and tailoring initial assessment processes, so people had the best opportunity to make key decisions about their lives. In two examples, staff told us how they helped people with addictive personalities to help reduce risks to them and their environment, suggesting ways they could adapt their living space to support positive outcomes.

People were supported to plan in enough detail for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. At the time of our inspection, no one received end of life care.

The nature of reablement is that care packages were for people who were not at end of life. Occasionally, people referred to the reablement service experienced a decline in their health and well-being. Staff from the service told us they had worked with health and social care professionals to source the support and care for the person and their families. The registered manager told us they had recently contacted local hospice providers to look at providing training sessions for their staff to ensure staff’s knowledge and skills continue to remain current.

As part of the initial assessment, information was shared relating to known wishes expressed by the person regarding treatment in the event their health deteriorated. Their wishes were recorded on a ReSPECT document or DNACPR (a document which records people’s advanced wishes should they stop breathing).