Short Term Assessment and Re-ablement 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 as good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.
People and their families were actively involved in the assessment process and were confident that staff fully understood and their care and support needs. One person told us, “STARS arrived as soon as I got home, they did an assessment and asked me what I wanted and what help I needed.”
Assessments included information about their physical and emotional needs as well as any specific communication requirements. A person said, “I had an initial assessment on the day I came out of hospital. STARS explained who they were and what they would do – it was a 2 way conversation and I explained what I needed and wanted from the service too”
Each person was continually reviewed at each contact to ensure that support was appropriate to their needs and to plan for their future care needs.

The provider 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 current evidence-based good practice and standards.
Care and treatment were delivered in line with the recognised standards and current guidance. The manager explained how they kept themselves informed of legislation and current practice through various methods including training and forums. The manager had recently organised meetings with other managers of re-ablement services to share learning and information on best practice.
People using the service reported receiving care that was specific to them and had a positive impact on their lives. One person said, “They helped me feel better and recover as well as I could, made a big difference.”
 

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.
Staff worked collaboratively to deliver safe care that was specific to each person’s needs and circumstance. Staff used their training and knowledge to ensure people received the right level of support and could demonstrate how they would assess for changes, such as an infection. Where changes or health concerns arose, staff escalated these promptly and helped to ensure people received timely support, involving external professionals when needed. One staff member said, “Health concerns are communicated via the triage team, with information recorded on (in house system) and incorporated into (staff) programmes. Service users are assessed daily, and any emerging health concerns are promptly addressed. For example, if a pressure sore is identified, we contact the District Nurse without delay.”
 

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.
Staff supported people to live healthier lives by promoting both physical and emotional well being, building confidence and helping them to regain skills. The service focused on what each individual person wanted to achieve and how they wanted to achieve it. Care plans contained personalised support that reflected these goals and guided staff on how this could be achieved. One person said, “They helped me feel better and recover as well as I could, made a big difference”
 

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 monitored the effectiveness of the care through regular audits, spot checks, supervisions and feedback from people using the service and their families.
Due to the nature of the service, monitoring of clinical expectations was imperative in order to ensure that the correct support was provided in the future. There was a structured approach to this ensuring people felt informed and in control of their care. One person said, “I’m going to not have carers anymore, they really helped me and now I think I can manage. They did a finishing assessment and ticked off all the things I can do so it’s all OK.”
 

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.
The provider ensured people’s consent to care and treatment was obtained. Staff received training in the Mental Capacity Act (MCA) and understood the importance of this. One member of staff said, “We work within the framework of the Mental Capacity Act, ensuring decisions are made lawfully and in the best interests of individuals who may lack capacity.”
People confirmed that staff were respectful and gained their consent when providing care and support. One person told us, “They always ask my consent, they never just ‘do’ anything. I’m involved all the time”.
People’s care files contained signed documents giving consent in different areas of support, for example, medication administration.