Community Rehabilitation Management

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 as Good. At this assessment the rating has remained 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 had individual care plans and risk assessments in place which had been developed to meet their current needs. People and other specialist healthcare stakeholders were involved in the initial care needs assessment and periodic review of their care plans where appropriate.

People’s care plans identified their care needs but also referred to people’s individual strengths and ways in which their control and independence could be supported and encouraged. Where appropriate to an individual’s circumstances, their care plan included rehabilitation support.

People’s healthcare needs were assessed and detailed in their care plans. People were supported to engage in community healthcare services, as well as more specialist healthcare services, to ensure their health care needs were met.

People’s assessments included details of their communication needs. People’s care plans also detailed when changes in people’s physical presentation, or emotional state, may indicate a deterioration in their health or wellbeing.

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’s care needs were detailed in their care plans, including guidance on how their specific needs were to be met. For example, people had detailed care plan sections in relation to rehabilitation activities they were to be supported with by staff, where they were relevant needs for them.

People received care, treatment and support which was evidence-based and in line with good practice standards. A person told us, “My support is a 1:1 care job. They have to be good, as they are literally keeping me alive. It is critical things that they do for me.”

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.

People were supported by managers and staff who worked well together and with other external health and social care professionals and bodies. An external healthcare professional told us, “CRM are a provider we use for complex care and case management.” Another external healthcare professional told us, “The care provided by the carers has been good, they have found carers who have a good rapport with the person.”

The registered manager had systems in place to make sure information was shared in a timely manner by everyone involved in people’s care. This all helped to ensure a joined up, consistent approach to delivering safe and effective care to people in line with their individually assessed needs and preferences.

Staff had access to the information they needed to appropriately assess, plan and deliver people’s care, treatment and support.

Where people received care from a range of different external staff, health teams or services, those links were co-ordinated effectively. All relevant staff, teams and services were involved in assessing, planning and delivering people's care and treatment, and worked collaboratively to understand and meet people's needs.

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.

People were encouraged and supported to make decisions about their own care needs by staff who understood their complex needs and preferences. Staff encouraged and supported people to make healthier choices to help promote and maintain their health and wellbeing but were also mindful that the person had the final say on decisions relating to their care.

The provider’s staff regularly monitored people’s health and supported people to access external primary healthcare support from GPs etc, as well as specialist hospital support when needed.

The provider routinely monitored people’s care and treatment to continuously improve it. They aimed to ensure that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

People told us they experienced positive outcomes from the service. There were effective approaches to monitor people’s care and treatment and their individual outcomes. For example, a person told us, “Because I have an active lifestyle, I need a certain kind of person to work with me. [Registered manager] really gets that and makes sure I am happy with the staff who care for me.”

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

Staff supported people to exercise their rights. Staff encouraged people to make decisions about aspects of their daily care routines, and staff told us they always obtained consent from the person before supporting them with personal care tasks.

People’s care plans contained assessments of people’s individual capacity to consent to specific decisions about their care. Where people were unable to meaningfully consent, appropriate best interest decisions were made and recorded in their care plans.