West 1 Reablement Service Also known as Guildford Borough Council

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 remained good. This meant people’s needs were met through good organisation and delivery.

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 were at the centre of their care and support choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service promoted person-centred care by tailoring care and support to people’s unique preferences, strengths, and goals, working collaboratively with them to build autonomy and long-term independence.

People told us their views about their care were listened to, and that they were fully involved in planning and reviewing their support. Staff took time to understand people’s strengths, preferences, and goals and what mattered to them, ensuring support was tailored to promote independence, confidence and wellbeing.

Staff described how they ensured the service was designed and adapted to meet people’s needs. One member of staff told us, “The service is flexible, and we tailor visits to individual needs while encouraging people to do as much as possible for themselves.” Another member of staff said, “We always involve people in decisions, ask about their preferences, and adapt our approach accordingly.”

The provider understood people’s diverse health and care needs, so care was joined-up, flexible and supported choice and continuity.

People told us they received consistent support from skilled staff who understood their needs well. One person said, “Carers have come regularly and I have got to know them. They understand their jobs and have been very supportive.” Another person told us, “I have a group of about 5 regular carers and they are all very well trained and experienced.”

Staff worked effectively with other professionals, such as adult social care and hospital discharge teams, to ensure people’s transition between different stages of care was well-planned and coordinated.

Staff ensured that, where ongoing care was required following reablement, people experienced timely and well-coordinated handovers to adult social care teams. This supported continuity of care and enabled appropriate long-term support to be planned in line with people’s needs and preferences.

People had access to appropriate, accurate and up-to-date information in formats that were tailored to their individual needs.

Staff explained how they tailored their approach to meet each person’s individual communication needs. A member of staff told us, “We adapt how we communicate to the person's needs so they can take part fully, whether that means face to face discussion, family involvement, or using communication aids.”

The service met the Accessible Information Standard (AIS). The AIS outlines how health and social care providers should ensure disabled people and people with impairments or sensory loss have access to information about NHS and adult social care services in formats that are accessible to them and receive the communication support they need to access those services.

The registered manager described how the service ensured people could access information in formats that met their communication needs, saying, “We can provide information in different font sizes. We have a suite of easy read documents accessible. If someone is hearing impaired, we ask their family to be there for their assessments.” Information could also be made available in alternative formats for people with visual or hearing impairments through links with local organisations such as Sight for Surrey.

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.

The provider proactively sought people’s feedback about the service they received. People were invited to complete feedback forms within a week of the reablement service beginning, approximately 2 weeks into the service, and when the service ended. Feedback was shared with staff to identify what had worked well and any areas for improvement.

The provider had a complaints procedure which set out how any complaints would be managed. If people raised concerns or shared feedback, the provider responded fully and told the person what action had been taken as a result of the information they shared.

People who had provided feedback told us the provider had responded promptly to implement any changes they suggested. One person said, “Any changes or suggestions we have made have been actioned immediately.”

The provider made sure that people could access the care and support they required when they needed it. The service was designed to be accessible and available for people at the point of need, including those most likely to have difficulty accessing care. The provider had developed an inclusive model of support centred on people’s rehabilitation potential. This included tackling barriers to access where these were identified.

The provider had amended the referral criteria for the service with the aim of increasing the number of people who could access and benefit from it, including those whose needs had previously excluded them. The provider carried out an equality impact assessment before implementing this change to identify any barriers that could prevent people from accessing the service.

This change had improved the accessibility of the service to people with mental health conditions, people with a learning disability and/or autism, people with needs related to substance misuse, people with a partial weight bearing status, and people with long term deteriorating conditions.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care and support in response to this.

People’s care and support promoted equality, removed barriers and protected their rights. People’s experiences were listened to and acted on to improve care. The provider complied with legal equality and human rights requirements, including avoiding discrimination and having regard to the needs of people with different protected characteristics.

The service supported the delivery of the Council’s ‘No one left behind’ objective, a key principle focused on reducing inequalities and improving quality of life for all Surrey residents. Prior to a recent restructure of the service, support for people with mental health conditions and people with a learning disability and/or autism were provided through specialist pathways. The provider recognised that integrating support for people with these conditions into the mainstream reablement service would enhance equity, ensuring more consistent and inclusive outcomes for all the people using the service. To achieve this, reablement staff were provided with training through a series of workshops and opportunities to shadow colleagues who had previously worked on the specialist pathways.

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. Staff worked with people to identify goals, ambitions and expected life changes and put plans in place to achieve these. Support plans were developed collaboratively with people to reflect their wishes and preferences.

The provider had systems in place to gather information about people’s individual needs and wishes for the support they wanted to receive, including towards the end of their life. This helped ensure staff knew how to provide care that respected people’s wishes and choices.

Assessments recorded any advance decisions and whether people had a ReSPECT form or DNACPR in place. A ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) form records a person's clinical care preferences should they become too unwell to make decisions or express their wishes. A DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) form instructs healthcare professionals not to attempt cardiopulmonary resuscitation.