Reablement Provider Service

On this page

• 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant services were tailored to meet the needs of individuals and delivered to ensure flexibility, choice and continuity of care.

This service scored 89 (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 was exceptional at making 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.

People were at the heart of all decisions and were involved throughout their recovery, rehabilitation and reablement journey, and fully understood the service was short term. People’s involvement started with the initial referral to the service, the assessment of their needs within their home, the identifying of goals, and the ongoing review as to their progress. A person told us, “I have been fully involved from the beginning and continue to make decisions around my progress.” People’s recovery pathway in some instances required them to agree to changes in how they lived. For example, moving their sleeping arrangements to the ground floor. A person told us, “I was asked about moving downstairs, which I agreed to as I knew it would be safer for me and help in my recovery, and I was provided with a hospital bed.”

People told us the service was responsive to requests they made regarding the timing of their care calls in response to changes in their circumstances, which demonstrated a person-centred approach to care. A person told us, “There was an appointment with the G.P. so, the office rearranged to come later, they were easy to get through to.”

People’s care records included information as to their social history, including their living arrangements, and how this related to their recovery, rehabilitation and reablement journey. People’s care records provided clear and detailed information as to people’s progress and their involvement in all decisions, which included the cessation of the service once the person had attained their goals. In some circumstances people required ongoing support with their day-to-day life, or staff had identified they may benefit from the involvement of other agencies. People’s records evidenced their consent in such circumstances.

The provider’s processes facilitated and encouraged an inclusive and person-centred approach to care, underpinned by collaborative working with key stakeholders and partner organisations, which placed people at the heart of the service. A key stakeholder partner told us, “Having a reablement, rehabilitation and recovery approach aligns both the social and medical models of social work, recognising the impact of a fall, change in health need or crisis, can have on a person and allowing them time, space and support to return to their baseline abilities via a multi-agency, person-centred approach to care.”

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

People received support from staff who had a good understanding of their local community, which included supporting people with protected characteristics as defined by the Equality Act. Staff fully understood people’s cultural and religious needs and had the necessary training and skills to understand and support people’s health care needs. For example, staff’s understanding of people’s culture and the considerations required when supporting with personal care.

Staff liaised with health and social care professionals as part of people’s recovery journey, to achieve the best outcomes for people. A key stakeholder partner told us, “Having a co-ordinated approach avoids duplication for the person and their family, is an opportunity to ensure holistic needs are met and ensures people receive responsive and effective support from both health and social care services.”

The registered manager facilitated weekly meetings with key stakeholders and partner agencies, which included sharing information as to the individual pressures specific to each partner and service type, and how they were to be individually managed. The reablement service was able to respond to these changes in the wider health and social care landscape, as the registered manager and management team through robust planning and managerial oversight fully understood the resources available to ensure the service was able to respond effectively.

People benefited from a service which fully understood the wider landscape of health and social care services. The registered manager, management team and staff facilitated and worked collaboratively with key partners and agencies from both health and social care services to meet the diverse health and care needs of people within their community. A key stakeholder partner told us, “The service works in a joined-up way with partners to align development activity with wider system priorities, including ‘home first’, neighbourhood working, frailty and prevention, ensuring reablement remains a core enabler within the integrated care system.”

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

People’s care records, including information as to their progress were accessible to the person and others involved in their care, including their family members. A family member told us, “I have power of attorney, the staff write things down in [person’s] file about their progress.”

People had access to key information in formats which met their communication needs, which included protected characteristics as defined by the Equality Act. For example, information about the service, including contact details, details about social care fees, and surveys requesting people’s evaluation of the service they were available in a range of languages, along with an easy read and large print version. The colour contrast, layout and font were also considered to support people with dyslexia or visual impairments.

People were supported by staff who were able to communicate effectively with them in their preferred language. However, in unexpected or unplanned situations, staff had access to an on-line translate and text-to-speech tool. Flashcards, pictorial guides and communication boards were available to support people with cognitive or speech challenges. Tactile stickers and visual cues were sometimes added to items such as kettles or microwaves to support safe use.

All information generated by the Reablement Provider Service, which was accessible to people using the service, was reviewed by an independent group of people, who looked at the quality of the information, whether the information was easy to understand and was free from jargon. This independent review helped the provider meet the accessible information standard. The accessible information standards ensure people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand with support so they can communicate effectively with services.

The registered manager informed us staff had received training on communication best practices, particularly in relation to non-verbal communication and working with people who were neurodivergent or had fluctuating capacity. They advised every interaction was treated as an opportunity to revisit people’s communication needs, with staff being encouraged to adapt not only the material they used, but also their tone, pace and language based on people’s engagement with them.

The provider and staff worked with health and social care providers and shared necessary information in support of people’s health and welfare. All personal information was managed consistent with the General Data Protection Regulation (GDBR) and Data Protection Act 2018.

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 and family members were knowledgeable as to how they could provide feedback about their experiences or the care and support they received, including how to raise concerns. A family member told us, “I have no complaints whatsoever. I’d have addressed them directly if there were any, I have a direct line to them.” A person told us, “I have a phone number to contact the office on the front of the folder.”

People and family members were provided with the opportunity to provide feedback throughout their recovery journey and at the time the service was ended. This was facilitated through regular phone calls, and a survey upon completion of their recovery journey. A person told us, “The staff from the office call, to check everything is okay.” The provider’s analysis of surveys found 97% of people were positive about the service.

Staff ensured people were listened to by involving them in decisions, and the setting and reviewing of their goals throughout their recovery journey. A person told us, “I’ve always been asked for my input about my care.” People told us the service listened and acted upon their requests for changes in their care visits. A person told us, “I called the office to cancel a weekend call and to stop evening calls. Staff were nicely spoken and helpful, and they did what we asked.”

The provider had a robust complaint policy and procedure. Records showed where concerns had been raised, these had been investigated and responded to, which included the adherence to other policies relating to staff, including disciplinary concerns. Duty of Candour requirements were met, with letters of apology being sent where appropriate when something went wrong during care. The outcome of complaints or concerns were used to support the learning culture of the service.

The provider was exceptional at ensuring people could access the care, support and treatment they needed when they needed it.

The provider recognised and understood the potential barriers which some people may face in accessing services. The collaborative approach of the reablement service in working with and alongside key stakeholders and partners, reduced those barriers, by facilitating people’s access to services.

The reablement service facilitated daily meetings throughout the working week, involving health and social care professionals from a range of disciplines and specialist areas. This meant any requests for the involvement of other services were discussed and agreed, without delay to the person, by removing lengthy referral processes. A key stakeholder told us, “Attending multi-disciplinary meetings means we can discuss people and find a solution.”

The timely referral and involvement of other services and agencies had a positive impact on people’s day to day lives. A key stakeholder told us, “The reablement service is a key component of the local integrated care system, playing a critical role in supporting people to regain independence and avoid unnecessary long-term care or hospital use.”

People’s care records provided clear evidence of the involvement of health and social care professionals in their recovery journey and its positive impact on the individual. The multi-agency approach, co-ordinated by the Reablement Provider Service, ensured referrals to other services such as technology, housing, occupational therapy or nursing were made in a timely manner to ensure the reablement service was able to effectively respond in support of people’s recovery, rehabilitation and reablement journey. For example, people who experienced domestic abuse or who lived within temporary housing had referrals made, with their consent to other services, and staff from the reablement service liaised and worked with staff from those other services in a joined-up way, to enable a positive outcome in an individual’s recovery.

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.

People benefited from the approach of the registered manager, management team and staff in their understanding of the services key role within the wider landscape of health and social care services, in achieving good outcomes, whilst recognising the potential barriers faced by some who used the service.

The registered manager facilitated weekly meetings with key stakeholders and partner agencies across the health and social care landscape. Challenges to all key stakeholder and partner agencies were discussed, and responses to system challenges were shared. A key stakeholder told us, “Our inclusive approach has remained consistent, welcoming people regardless of disability, cultural background, mental health history, or any other protected characteristic. The referral process avoids unnecessary thresholds and instead focuses on strengths and outcomes: ensuring that people aren’t excluded due to medical labels or assumptions about potential.”

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.

Occasionally, people referred to the reablement service experienced a decline in their health and well-being. Staff from the service liaised with health and social care professionals to source the best support and care for the person. Staff had received training in end of life care and provided the support and care when required.

As part of the assessment and referral process, information was shared as to any known wishes expressed by the person regarding treatment in the event their health deteriorated, which had been recorded on a ReSPECT document or DNACPR (a document which records people’s advanced wishes should they stop breathing).