Choices for Living Well (Reablement)

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.

This is the first assessment for this registered service. This key question has been rated 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 plans had the detail required to deliver effective care. Though they did check and discuss people’s health, care, wellbeing and communication needs with them this was not clearly documented.

Assessments were received from hospitals and other social care professionals as part of the referral process. These helped when determining whether a person was eligible for reablement support.

Upon review of a sample of care plans, we noted they did not consistently contain all the person-centred information gathered during initial assessments, meaning care plans were not tailored to people's individual preferences. As staff knew people well and asked about their preferences during visits person centred care was still able to be provided.

The provider had identified the need for care plans to be strengthened and planned to achieve this with the support of the new tailored electronic care planning system, which was due to be reimplemented the following month.

The provider had redeveloped their catheter training to ensure staff were competent and confident in providing appropriate support and planned to amend any future care plans with links to best practice guidance. This was due to be rolled out to staff and would include a practical component to assess competency and ensure the sessions remained engaging.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

Assessments took place in people's homes, with individuals involved in developing their care plans. Family members or representatives were also involved where appropriate.

Following an initial assessment, the provider offered weekly care plan reviews, tracking people's progress and making onward referrals when required. One staff member told us, “When we go into a home we will risk assess, will make the environment safe. Monitor their wellbeing in the home. “There were instances in which people did not receive these reviews; however, this was often for reasons beyond the provider's control. For example, people's chosen representatives were not present.

There was a waiting list for the service. At the time of the inspection, reduced staffing levels meant the provider was unable to accept a greater number of referrals. Recruitment was taking place to increase the number of care staff, which would, in turn, enable a greater number of people to access reablement support.

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.

Managers and staff told us they worked closely with various external health and social care agencies and sought advice regarding best practice and referred for equipment required. One person stated, “I have loads of aids (fractured shoulder), trolley, bars on my bed all provided to make life easier.” As a result of this multidisciplinary approach, all the people we spoke to stated they felt well cared for and safe.

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 provider supported people in a strengths-based way that enabled them to maximise their independence, choice, and control. One person said, “I am getting what I need. They encourage independence but help me with what I can’t do at the minute.”

The provider shared case studies with us which tracked people's journeys through reablement. One demonstrated how the provider's approach enabled a person to be discharged from the service and remain in their own home, having regained their independence with their care teams support and multidisciplinary strengths-based approach.

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.

Weekly care plan reviews were completed by co-ordinators in conjunction with people and their families. A review of the goals set was completed at each of these meetings, enabling people's progress and further reablement potential to be tracked.

Systems were in place for monitoring accidents and incidents, helping to identify areas for improvement. Records were kept under review, and actions were identified where necessary through discussions at management meetings. Learning was shared with staff through team meetings or individual discussions, ensuring lessons learned were consistently embedded.

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

People said they were asked how and when they wanted to receive care and support. Staff had also completed training in the Mental Capacity Act and understood the importance of seeking consent from people when offering support. A staff member provided an example and said, “If [people] needed to take meds, we would speak to them, explain reasons, give all information needed and allow them time to process and encourage to make decision, if refused would document in notes and tell manager. Would keep trying while on visit.”