London Borough of Merton - 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 83 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Reablement officers told us that they assessed people’s care needs during the settling in visit, this included any recommendations from the Hospital prior to discharge. They told us, “We assess function, mobility, stairs, also assess Activities of Daily Living, we discuss any needs with them.” ADL include things like washing, dressing, meal preps, toileting.

Reablement officers were clear about the assessment process for newly referred people. This included vetting new referrals, carrying out the assessments through a settling in visit once a referral had been accepted and developing reablement assessment care records from the initial settling in visit.

The provider had a culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had systems in place to record any incidents and accidents. The registered manager told us, “We have an incidents and accidents log that we monitor.” Support workers explained the process they used when reporting any incidents.

We reviewed the incidents log with the registered manager, which showed the incidents that had taken place, any action taken and lessons learnt.

Any lessons learnt or themes were discussed in Multi-Disciplinary Team (MDT) meetings which helped to ensure these were embedded in future practice.

The provider worked exceptionally well across teams and services to support people.

People told us staff worked with external health and social care professionals in their overall care needs.

Managers and staff told us they worked very closely with various external health and social care bodies and professionals. For example, the reablement team consisted of reablement officers and occupational therapist but they also liaised with other teams to provide support where needed. The registered manager told us that they worked in close collaboration with healthcare partners who were based at the same physical location as them which meant they were able to share information quickly and effectively.

The provider worked closely with the hospital discharge team when accepting new referrals and also with social care organisations once a package of care had finished after 6 weeks. This involved referring people to either a private or local authority funded. There was daily liaison with the hospital to home team to monitor number of referrals, delayed discharges and what can be done to support the hospitals to free up bed capacity. Once a referral is accepted from the hospital the care was in place within 24 hours.

We received positive feedback from healthcare professionals. Comments included, “The team works collaboratively across disciplines and maintains clear, timely communication with health and social care professionals.”

A daily tracker was used to used to review the existing caseload of work, demonstrating close working relationship with healthcare professionals in prioritising 'Discharge to assess' service users and ensuring all the necessary staff were in place to support them.

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.

People using the service told us the provider helped to get them back on their feet after a hospital stay. They said the provider supported them with their independence.

Reablement officers completed reports following each visit which included details of how they supported people in relation to their health care needs.

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

The whole premise of the service was short term reablement, up to a period of 6 weeks to support people with their independent living skills and improve their outcomes.

People told us that staff supported them to achieve their goals. Comments included, “Rehabilitation Team provided support for my father. Avoided him settling in a care home”, “I have received more quality than anticipated from a hip fracture and two rib fractures. Your team is always positive and encouraging.”

Care plan summaries were completed which showed the support provided and the goals that had been achieved to successfully reable people. Peoples planned goals/outcomes were clearly recorded and were SMART. SMART goals are a framework for setting effective objectives, ensuring they are Specific, Measurable, Achievable, Relevant, and Time-bound. This method helps in creating clear, actionable, and attainable goals, increasing the likelihood of success.

Examples of goals that had been made for people included being able to ‘Shower independently in 1 week’, ‘Be able to get dressed independently in 5 days’, ‘Be able to prep and cook a microwave meal or oven in 1 week.’

Reablement officers and Occupational Therapists (OT) recorded people’s progress against goals on which were monitored by the managers to ensure they were being supported in the best way possible.

Some people had specialist OT assessments which included their views, wishes and desired outcomes. These also included an OT action plan for reablement officers to adhere to ensure people achieved the best outcomes possible.

The provider told us that reablement focuses on strength based approach and their success rate of people not needing ongoing care after the 6 week reablement period was currently at 86 percent.

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

People using the service told us that care workers respected their wishes and supported them according to their needs. They said, “They ask our permission before they start doing anything.”

People had agreed to the reablement package of care during both the referral stage and when reablement officers carried out their settling in or initial visit. This visit was used to work out people’s support package including any tasks they needed help with. Reablement assessments were developed with people’s consent and included their wishes and desired outcomes. One person said, “Her care plan was all discussed with the co-ordinator of reablement and as far as I know it was all followed correctly.”

A staff member told us, “We assume people have capacity unless otherwise indicated or documented, then their next of kin can help with decision. We get consent by asking suitable questions.” Another said, “We have an authorisation for that they consent to, they sign in at the initial visit.”