West 1 Reablement Service Also known as Guildford Borough Council

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 good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 79 (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 support was effective by assessing and reviewing their care, wellbeing, and communication needs with them. In line with reablement principles, assessments focused on people’s strengths and what they could achieve, rather than what they could not.

People told us their initial assessments had been comprehensive and that personalised care plans had been developed from the information gathered. One person said, “There was a full discussion before I started using the service to agree a care plan and make sure all of my needs were covered. The plan has been perfectly followed and reviewed on a regular basis.” A relative told us, “A thorough assessment was done the day after [family member] came home and the support service started the next day.”

Staff ensured people were fully involved in their assessments, and that there was a clear focus on achieving outcomes that reflected their individual goals as well as their assessed needs. A member of staff told us, “At assessments, I ask people what is important to them; what do they want to achieve from reablement? It is about regaining skills that they used to be able to do." Another member of staff said, “At the initial assessment, I speak to people to find out about them and set goals they would like to work towards with our support. I seek feedback at the reviews and communicate any changes with our team. I also involve family and carers to ensure their views are taken into account.”

The provider always 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.

The service was therapy-led, with OTs providing clinical oversight and guidance to reablement staff, ensuring care was evidence-based and focused on improving outcomes. An OT told us, "We are therapy-led. Everything a reablement assistant does is underpinned by OT. We sit in on the [daily] huddles, we give advice to reablement workers. We help with triaging cases, for example a referral from hospital. We also help with training and upskilling people."

People’s support was planned and delivered in line with the principles of reablement. This meant goals were person-centred and outcome-focused and that people were active partners in planning and reviewing their reablement journey. The service consistently applied a strengths-based approach, focusing on what people could do and actively building on these capabilities to promote confidence and independence, rather than focusing on limitations.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing information effectively when people moved between different services.

Managers and staff worked effectively in partnership with colleagues across the reablement service, other teams within the Council and external partners. This was achieved through clear communication, which supported coordinated decision-making and continuity of care. As a result, people experienced a seamless service that was responsive to their needs and promoted positive outcomes throughout their reablement journey. A member of staff outlined the benefits of this approach to achieving good outcomes for people, saying, “We are highly responsive to the particular needs of each of our service users, and we professionally adapt to how those needs might be met through working with all agencies.”

Staff reported effective collaboration and supportive relationships with colleagues. One member of staff told us, “There is a strong sense of teamwork within the service, and staff support each other well. I feel that we work together rather than in competition, and colleagues are always willing to help or offer advice when needed.”

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 supported to manage their health, care and wellbeing needs by staff who understood their needs and preferences. Staff encouraged people to make healthy choices to help promote and maintain their health and wellbeing.

People received care and support that was well co-ordinated and enabled them to live their lives as they chose. Staff focused on identifying risks to people’s health and wellbeing early and supported people to prevent deterioration.

The reablement team worked with the council’s Discharge to Assess (D2A) scheme. Under the D2A scheme, people who are medically fit to leave hospital are discharged immediately rather than waiting for a long-term care assessment in a hospital bed. This enabled people to continue their recovery and rehabilitation at home with support that promoted independence, and improved overall health and wellbeing.

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

People’s support plans were reviewed with them every 4 days. These frequent reviews ensured people’s support was personalised to their individual needs and that progress towards their identified goals was be adapted as necessary. A manager outlined the benefits of this approach, saying, “Regular reviews with the same reablement practitioner ensure that goals are regularly reviewed and checked if they are met.This fast-moving review process keeps the service user with clear objectives and goals to achieve on a daily basis.This is very much about a strengths-based approach to our work with service users, focusing very much on what they are able to achieve, not what they can’t do.”

Staff told us they supported people using individualised programmes developed by OTs, which were regularly reviewed and adapted according to people’s progress. A member of staff said, “We support daily exercise programmes recommended by therapists, so the person feels confident to try with our support. Support is reviewed regularly and adjusted as the person's confidence and ability improve, so the plan stays safe but also promotes progress.”

People told us they were encouraged to contribute to their reviews and that any adaptations needed were implemented promptly, which supported their progress towards achieving independence. One person said, “We have regular reviews and everything is discussed then. Any changes or suggestions are actioned immediately.” Another person said, “Progress is discussed and changes made to support me gaining confidence and independence.”

The reablement team held daily multidisciplinary huddles to review each person using the service, closely monitoring progress towards identified goals and enabling timely adjustments to support improved outcomes.

A member of staff explained how this approach benefited people, saying, “We support daily exercise programmes recommended by therapists, so the person feels confident to try with our support. Support is reviewed regularly and adjusted as the person's confidence and ability improve, so the plan stays safe but also promotes progress.”

The provider told people about their rights around consent and staff respected these when delivering care and support. This meant that people received their care in line with the principles of the Mental Capacity Act 2005.

People’s consent to their care was sought at their initial assessments. Staff ensured people were given the information, support and time they needed to make informed decisions about their support.

Staff understood the importance of consent and relevant legal requirements. If people lacked the capacity to make decisions, the provider involved people’s families and representatives to ensure decisions were made in their best interests.

People confirmed that staff sought their consent on a daily basis. One person told us, “They are very good at communicating and gaining my consent before they do anything.” Another person said, “They chat with me and make sure I am happy with what they are doing.”