Reablement Provider 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 changed to outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 92 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them.

People spoke positively of the assessment process which began whilst in hospital for some. A person told us, “I was referred to the reablement service by the doctors and nurses. They [Staff from the Reablement Provider Service] came and asked me what I needed. They told me the support was to help me recover until I was better from my operation.”

People were at the heart of the assessment process. Staff worked collaboratively with people, assessing their needs based on their home environment, their individual needs and their goals and aspirations. A person told us, “At the assessment I was asked what I wanted, they checked what I could do and what help I needed. Staff watched me and my spouse to see what both of us could do. It was excellent.”

The assessment process was comprehensive and considered protected characteristics as defined by the Equality Act. All aspects of people’s needs were assessed, including general health, communication needs, age, race, religion and ethnicity. External factors were also included that may influence their recovery and reablement journey. For example, the role of family and friends in their lives, whether the person lived alone, and considered their housing and accommodation.

Staff invested significantly in keeping people’s needs under continuous review to enable them to make changes to the support provided in response to people’s progress. For example, by reducing the number of care call visits. A person told us, “I was absolutely involved in what I wanted from the beginning. Not only was recovery discussed but it has been regularly reviewed as my confidence improved.”

People’s care records comprehensively detailed their progress. A day-by-day account was documented and included information as to the involvement of any key partner agencies who had been contacted, and the action and response.

Staff escalated information in a timely manner with a member of the management team when they noted changes in people’s needs. Any changes which identified the need for key partner agencies to be involved, for example, occupational therapist support, a housing need or additional equipment, the individual requirements of the person would be discussed at the daily meeting, which health and social care partners attended. A member of staff told us, “There are weekly multi-disciplinary team meetings, that involves the reablement team, supporting a joint review approach.” The proactive and collaborate approach prioritised people, ensuring an effective response to their changing 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.

People were supported to prepare and cook meals, where their assessment had identified this was an area where they required support as part of their recovery, rehabilitation and reablement journey. A family member told us, “The staff encourage [person] with making themselves a cup of tea or a sandwich.” People’s dietary requirements were documented with consideration to their religious and cultural needs, and health needs such as diabetes.

Where people did not require support from the reablement service with regards to meals, their records detailed others, such as family or friends who were supporting with grocery shopping and meals, this evidenced a robust approach to ensure all needs were both considered and met.

The provider used recognised tools in line with legislation and current evidence based good practice and standards. Staff from the reablement service would undertake joint visits to people’s home with a speech and language therapy when it has been identified a person would benefit from an assessment, where people had trouble with swallowing, eating and drinking.

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

People benefited from robust systems and processes where information was shared by everyone involved in their care, with key partner agencies working collaboratively to achieve effective care for people.

Key partner agencies worked collaboratively at all levels, sharing information about the person so they only had to share it once. For example, people’s initial referral to the reablement service contained all relevant information, including the background to the referral, health and social care professionals involved in their care, information relating to health and wellbeing, and details as to any prescribed medicines.

A multi-agency approach of key partner agencies, including community nursing therapy, care technology, mental health services, social workers, housing and care technology meant all services, facilitated by the Provider Reablement Service, worked collaboratively. This meant people received co-ordinated and timely care as they did not have to liaise with numerous agencies to secure the support and help, they required.

A key partner stakeholder told us, “The reablement service is embedded within the ‘home first’ model, ensuring seamless transition between hospital, community health services and adult social care in reablement, without unnecessary delay or duplication.”

In the event a person required ongoing support, the reablement service forwarded to the relevant agency the Care Act Assessment they have completed. This is another example of how the Reablement Provider Service shares information, so as a person only had to share their story once.

The provider always supported people to manage their health and wellbeing to fully 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 benefited from the purpose of the service which was to facilitate, enable and encourage them to remain in their own homes. This was achieved by providing rehabilitation, reablement and recovery support, with a view to preventing people’s transfer to long term care services or hospital; or by supporting people following an illness or stay in hospital. People and family members spoke of the positive impact the service had. A family member told us, “The impact of the service has been excellent, and [person] is very happy. It has given them independence, and a return of mobility.”

People’s care records provided a comprehensive account as to why the person had been referred to the service. There was an ongoing collaboration between people using the service and staff, to keep under review their recovery, reablement and rehabilitation journey, and setting of goals to maximise independence. A person told us, “When I had a fall and returned home from hospital, I had a lot of support. They have been amazing. I now need slightly less help, and I’m being reassessed next week, to decide what areas we will be focusing on next.”

A collaborative approach with key partner agencies maximised people’s opportunity to attain maximum independence, improving their quality of life, health and well-being. This included working with a range of health and social care professionals. A key partner stakeholder told us, “The reablement service is co-located with nursing and therapy staff, meaning the reablement service has access to clinical staff. People who are supported via the service typically regain a high level of independence, if not full independence, which reduces or eliminates care needs in the long term.”

People’s care plans explained the support people required to enable them to stay well and access healthcare services, where necessary. People with specific medical conditions, had detailed information within their care records which provided guidance for staff as to how this affected the person and how best to support them.

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.

People were equivocal in their praise of the service and its impact on them. A person told us, “Staff made a very difficult situation better for me. It was a traumatic and emotional time, that they made easier.” People consistently experienced positive outcomes and worked collaboratively with staff to achieve these. A person told us, “The objective has been for me to get as much independence as possible, and it is progressing well. The next assessment will focus on bathing and washing, and how best to enable me to improve my abilities.”

The provider’s analysis of data demonstrated the positive impact of the service, which found 83% of people remained living at home at the end of their reablement, recovery and rehabilitation journey.

People’s care records detailed their progress throughout their recovery, reablement and rehabilitation journey, with information as to the role of other health and social care professionals clearly documented, to ensure effective and co-ordinated care and support.

The collaborative approach between the reablement service, health and social care professionals, and key stakeholder meant outcomes were monitored, both at an individual level but also within the wider context of the health and social care system. A key stakeholder told us, “The reablement service works cohesively with health and social care through integrated pathways, a shared objective and coordinated multi-disciplinary working, ensuring people’s care and support needs are met holistically within their community.”

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

People were fully involved in all decisions relating to their care and support. Assessments of people’s needs considered people’s capacity to make informed decisions and noted in some instances people may experience fluctuating capacity. For example, people living with dementia.

The provider understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires, that, as far as possible, people make their own decisions and are helped to do so when needed. Where people lack mental capacity to make particular decisions, any made on their behalf must be in their best interests, and as least restrictive as possible.

Staff had undertaken training on the MCA and were aware that all care interactions required the consent of the person.