Choices for Living Well (Reablement)

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• 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.

This is the first assessment for this registered service. This key question has been rated Good.

This meant people’s needs were met through good organisation and delivery.

This service scored 75 (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 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.

Although not recorded in care plans, we found staff clearly understood people's individual needs and preferences based on the feedback received. One person told us carers were, “Fantastic. Very knowledgeable and so caring and considerate. The care I have had is exceptional.” The service did need to improve their records to include people’s individual needs and preferences as this should be recorded in care plans. Management were informed of this and planned to make improvements to strengthen care plans.

Feedback from external professionals reflected on how the team provided a personalised service for people, assessing all their needs holistically. One professional said, “The Reablement Team are a very caring and compassionate team who are working hard to re-able people to remain independent in their own homes with the least restrictive options, for example, tech or equipment.” This could have been better recorded and captured within care plans.

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

Staff told us they worked closely with other professionals within health and social care to ensure people's needs were met. The provider also helped people plan for the future. A family member told us of their relative's experience, in which staff responded promptly: “On the day she said she wanted to go into a home a meeting was arranged to discuss the future.”

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

Management explained that where required, people had access to information in alternative formats, including larger print and coloured overlays. They also explained that service information and care plans could also be provided to people in easy-read formats to support accessibility and understanding.

Care plans did not consistently record people's communication needs, which meant staff may not have had sufficient guidance to ensure these needs were fully understood and met. However, we did not receive any concerns regarding this from people using the service. An electronic care planning system was due to be implemented, which would strengthen the information held regarding communication needs.

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 were provided with an information leaflet and contact details. This explained the nature of the service and the support it could offer. It also contained contact details in case people had any questions or wished to raise concerns.

Following discharge from the service, people were always asked to provide feedback. Comments were overwhelmingly positive. However, some people reported they would have preferred set times for visits, as opposed to time frames. Managers demonstrated they had reflected on this; however, due to the short-term nature of the service, management stated this was not possible.

The provider made sure that people could access the care, support and treatment they needed when they needed it.

The provider ensured that people had access to the care, support, and equipment they required, which resulted in better outcomes for people. A professional told us, “They also work very closely with third sector agencies to ensure a strengths-based approach when looking at long-term needs. All of this supports the person to remain at home and avoid admission or longer-term services, which is a better outcome for the person”.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Service management and professionals told us that the service took part in a pilot scheme. This was a collaboration between the hospital and the reablement service, enabling faster discharges for people living with dementia. This promoted equity and gave people greater choice and control over their care, preventing longer stays in hospital or the need for residential care, which were noted as common outcomes.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The provider's goal was to support people to regain as much of their independence as possible. Over the short time people were supported by the service, many were able to remain in their own homes without the need for ongoing support. For those who were identified as requiring ongoing support, the provider spoke with people and their families, arranging the appropriate assessments.

The provider holistically considered the person's needs and those of their family and supported them to make decisions about their future care. A family member told us, “They have looked at the family as a whole. We haven’t been pushed to make future decisions.’