West 1 Reablement Service Also known as Guildford Borough Council

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (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 had a proactive and positive culture of safety, based on openness and honesty. Feedback and incidents were used as drivers for continuous improvement, and lessons were learned to continually identify and embed good practice.

Staff and people using the service were encouraged to raise concerns and suggest ideas for improvement. Leaders showed openness and transparency by acknowledging issues and reflecting on practice, implementing changes to procedures and working practices based on feedback. A manager told us, “We focus on reflective practice. There is a no blame culture. We are very open and transparent about our reporting processes.”

Leaders ensured lessons learned were embedded into practice, creating a responsive service focused on improving outcomes for people. For example, a manager had given a presentation to the team about lessons learned from a person’s hospital discharge experience.

Staff worked collaboratively with people to implement improvements and minimise the likelihood of incidents recurring. People who raised concerns or provided feedback were responded to appropriately, with clear acknowledgement and information about the actions taken.

The provider always worked with people and partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service demonstrated an exceptionally strong culture of collaborative working, which supported the delivery of well-coordinated, joined-up transitions for people. People’s reablement journeys were proactively planned and coordinated from the point of referral from hospitals and adult social care teams. All referrals were effectively triaged to ensure the service was appropriate and could meet people’s needs safely and promptly.

Transition arrangements were personalised, reflecting people’s individual circumstances, goals and preferences. Managers and staff maintained highly effective and timely communication with internal teams and external partners, which ensured care was well planned, regularly reviewed and responsive to people’s changing needs.

Multidisciplinary teams worked collaboratively to ensure care was well planned, responsive and aligned to reablement principles. This approach helped ensure people received safe, timely transitions which supported their reablement and promoted positive outcomes. For example, ‘transfer of care’ meetings were held twice daily to review and coordinate new referrals from hospitals, supporting safe, timely transitions into the service.

A manager explained the function and value of these meetings, telling us, “We attend daily meetings to discuss hospital discharges and identify people who may benefit from our service at home. We examine the OT [occupational therapy] discharge summaries carefully so we understand needs, risks and priorities and can discuss them meaningfully at the meetings for safe discharge planning. We keep in close contact with hospital staff, discharge co-ordinators and other professionals to make sure transitions are safe, timely and well-coordinated. The quality of our joined-up working helps prevent delays and ensures the right support is in place when the person returns home.”

The provider had Collaborative Reablement Service (CRS) contracts with 3 registered homecare services to maximise the capacity of the service to manage a high volume of referrals from hospitals and local community teams and prevent delays in the provision of care. Managers and staff worked collaboratively with CRS partners to ensure transitions were well planned and managed. One CRS provider told us, “The service works very effectively with our agency to ensure that transitions, including those from hospital to home-based support, are well managed. Communication across teams is excellent, and there is strong collaboration throughout.”

The provider had effective safeguarding systems in place to protect people from abuse and avoidable harm. Safeguarding practice was integrated within the service, with staff maintaining regular contact and reviewing risks in line with people’s progress towards achieving their independence goals.

The provider promoted an open culture where people felt safe to raise concerns and were supported to understand their rights. Concerns were acted on promptly, with referrals made to relevant partners where required.

Staff received safeguarding training and demonstrated a clear understanding of safeguarding procedures, including how to recognise and report concerns, and were confident in escalating issues appropriately. A member of staff told us, “I would initially discuss concerns within the team or with a senior colleague, then escalate to the team leader and manager if needed. Safeguarding concerns are always reported promptly following procedures and can be escalated outside the service if required.”

People were protected from avoidable harm because staff provided their care in line with recognised good practice guidance. One person said of staff, “They really are very safety conscious and make sure that all equipment is in place before they start.”

Staff involved people in managing risks by planning their support with them and providing advice and guidance relevant to their individual circumstances. A relative told us, “They have come up with lots of good advice and suggestions of how to do things in the safest way.”

Staff adopted a balanced and proportionate approach to managing risk in line with the principles of reablement. People were supported to take positive risks to achieve their reablement goals. A member of staff told us, “We balance safety and independence by using a doing-with approach, so people are supported to do as much as they can for themselves rather than staff doing tasks for them.” Another member of staff said, “We engage in positive risk taking, meaning we can’t remove risk completely, but manage it proportionately so people can regain their independence safely.”

We heard examples of how this approach had achieved positive outcomes for people. One person told us, “I have never once felt unsafe with the carers. Their attention to detail is very good and nothing is too much trouble.” Another person said, “It has been a big bonus having them as my mobility is impaired. I have felt safe with their support and encouragement.”

The provider effectively identified and managed potential risks within the care environment, ensuring equipment supported the safe delivery of care. Staff carried out assessments of the care environment before people began to use the service to identify and mitigate hazards. They made recommendations to enhance safety, such as the installation of key safes, and facilitated referrals to the Fire and Rescue Service for home safety visits where appropriate.

Reablement staff had access to a comprehensive range of equipment and adaptations, which they used proactively to promote people’s safety and independence. People consistently reported that the support and equipment provided had a positive impact on their confidence and ability to remain independent. One person said, “The care staff have been invaluable. They have helped me understand how to use the equipment I have properly and helped me to gain confidence.” A relative told us, “The carers are very knowledgeable and helped us obtain specific equipment to support [family member]. We recently purchased a specific non-slip bath mat, which is really good.”

The provider made sure there were enough qualified, skilled and experienced staff, who were recruited safely and received effective induction, training and development. They worked together well to provide safe care that met people’s needs.

Staff told us the training they attended was valuable and equipped them well for their roles and responsibilities. A member of staff said, “We receive a wide range of training and are encouraged to complete it regularly, with good support from team leaders. For example, transfer assessment training and Trusted Assessor training have been particularly valuable, allowing me to respond effectively when people are discharged from hospital and ensure appropriate equipment is in place.”

The upskilling of staff through trusted assessor training had a positive impact on people referred to the service, enabling more timely and responsive access to equipment and support. This approach supported a more efficient reablement pathway, reducing delays and promoting earlier intervention.

The registered manager told us, “We wanted more people to have access to OT throughout their reablement journey. For us, staff being skilled to identify and order appropriate equipment means more people can access the service quicker. OTs have oversight of the trusted assessor work; having access to OTs means our service is always therapy-led.”

The nominated individual said, “We sign them off and do competencies. We have clinics where they can get advice. They can order equipment, but they have to provide their clinical reasoning. The OTs can follow up if they have questions.”

Support for people with a learning disability and/or autism had previously been delivered by a specialist team. However, following recent changes to the structure of the reablement service, all staff had been trained to support people with a learning disability and/or autism, promoting a more inclusive and consistent approach across the service.

If people referred to the service had individual needs in which staff were not trained, managers sourced additional training to ensure staff had the necessary knowledge and skills to provide safe and effective support. For example, staff had recently received training in sensory integration and personality disorders in response to the needs of people using the service.

Clinical staff were supported to fulfil their professional development and registration requirements. Occupational therapists met regularly as a team and received monthly supervision to maintain their registration with the Health and Care Professions Council.

Staff assessed and managed the risk of infection. They controlled the risk of it spreading and understood their responsibility to share concerns with appropriate agencies if necessary.

Staff attended training in infection prevention and control and had access to personal protective equipment if they needed it.

Two managers were designated Infection Prevention and Control (IPC) leads for the service. Their responsibilities included providing staff with updates on current guidance, responding to queries, and supporting staff to carry out IPC risk assessments in people’s homes. The IPC leads also carried out quarterly hand washing audits and increased the frequency of these if rates of infectious disease were high locally, which meant risks were effectively managed.

The provider had effective systems in place to ensure medicines were managed safely. Staff received appropriate training and their competency in medicines management was assessed annually.

People were supported in a way that promoted their independence, with staff encouraging and enabling people to manage their own medicines wherever possible. Any risks associated with medicines were identified during people’s initial assessments, and support was adjusted if people’s needs changed.

Managers carried out regular audits which checked people were receiving their medicines as prescribed. Audits also checked medicines were stored appropriately, that any allergies to medicines were recorded, and that protocols were in place for any medicines prescribed ‘as and when required’ (PRN).