West 1 Reablement Service Also known as Guildford Borough Council

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider’s values included putting people who used the service at the centre of everything they did, setting consistently high standards of performance, being transparent, and respecting people, partners and colleagues.

The provider’s commitment to transparency meant people felt informed about their support and involved in decision-making. Staff exemplified respectful and inclusive practice, which ensured people felt valued and treated with dignity. Managers and staff had developed respectful and effective working relationships with internal and external partners,

Managers and staff understood the provider’s values and consistently demonstrated these in their practice. This ensured people consistently experienced care that was compassionate, respectful and aligned with the provider’s values, resulting in high-quality, person-centred support. A manager told us, “The whole service follows our Surrey Values, ensuring no one is left behind. To be respectful, open and honest in conversations, to be transparent and instil in staff their importance and value of their work.”

Staff worked in a collaborative way, demonstrating a strong culture of teamwork focused on meeting people’s needs. They recognised the skills and commitment of their colleagues and told us they supported one another well. One member of staff said, “What stands out most [about the service] is the people. The service attracts dedicated staff with an open-minded and compassionate approach, who genuinely want to help others. There is a strong sense of teamwork, and colleagues support each other while always focusing on what is best for the people we care for.”

Leaders understood the context in which they delivered care and support and embodied the culture and values of the organisation. Leaders had the skills, knowledge and experience to lead effectively. They did so with integrity, openness and honesty.

People who used the service and their relatives were confident in the leadership of the service. One relative told us, “Getting so many carers who are well trained and suitable to deliver appropriate care does not come by accident. There has to be good leadership and direction from the top to achieve this.”

Staff told us they received good support from their managers through structured performance conversations. They said these provided opportunities for learning and reflection, and to discuss any concerns they had. One member of staff told us, “Supervision provides an opportunity to discuss any concerns, reflect on practice, and receive support. I feel able to talk openly during supervision.” Another member of staff said, “Observational supervision does take place and feedback is provided, which supports improvement in practice.”

Managers explained they aimed to lead by example by modelling the behaviours they expected of colleagues. One manager told us, “As an individual I aim to model openness myself: admit mistakes, welcome challenge, and respect disagreements.”

The registered manager understood their responsibilities under the duty of candour, which is a legal requirement for health and social care providers to be open and transparent when things go wrong.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People who used the service and their relatives told us they were actively encouraged to give feedback about their care. They said their views were listened to and acted upon.

Managers said they aimed to create an environment in which staff felt able to raise concerns openly, knowing their feedback would be valued and used to drive improvement rather than assign blame. A manager told us, “We create a culture where speaking up is normal, safe, and acted on. In practice, that means combining trust, predictable routes for feedback, and routine follow through so we can show that raising ideas or concerns leads to improvement, not blame.”

Staff confirmed they felt confident to raise concerns without fear of negative consequences. A member of staff told us, “I feel I can speak up, and I do. Managers are listening and taking into account our views.”

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

The provider’s 'Organisation Strategy 2023 to 2028’ statement on Equality, Diversity and Inclusion (EDI) outlined its commitment to creating a fair and inclusive environment, stating, ‘For staff, the Council recognises the importance of a diverse workforce and is committed to providing a culture where everyone is valued and respected. People should feel comfortable carrying out their roles and the Council is committed to equality of opportunity being practised and promoted to all.'

The provider had an EDI action plan in place which set out the Council’s ambitions to tackle inequality and ensure that no-one was left behind. Key achievements from the 2024/2025 action plan included commissioning a confidential ‘Speaking Up’ service to enable staff to raise concerns about discrimination anonymously, developing and delivering introductory EDI e-learning for all staff, rolling out training on working with disabled people, and reviewing recruitment processes to strengthen inclusive and equitable recruitment practices.

The provider had established networks for staff with protected characteristics, and an EDI hub where staff could raise concerns and share their experiences. The registered manager of the reablement service was a member of the Directorate Equalities Group, demonstrating a commitment to promoting EDI across the service.

Prior to implementing any changes, the provider carried out comprehensive Equality Impact Assessments (EIAs) to ensure that policies, practices and service developments were inclusive, fair and did not disadvantage any group. This approach demonstrated a strong organisational commitment to equality, diversity and inclusive practice.

For example, ahead of the recent service restructure, an EIA was completed to understand the potential impact of proposed role changes on staff, including those with protected characteristics. The provider ensured that all existing reasonable adjustments were maintained, reflecting a culture of respect and inclusion.

In addition, one-to-one meetings were held with all staff to explore how proposed changes might affect them personally. The registered manager explained, “By having those one-to-ones, we understood the needs of every single member of staff.” This enabled the provider to respond sensitively and adapt plans where necessary, ensuring changes were implemented in a supportive and equitable way.

The provider also demonstrated this inclusive approach when reviewing the Reablement Referral Guidance, completing an EIA to ensure any changes continued to promote equitable access and outcomes for people using the service.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider demonstrated a clear commitment to sustainability, and had developed a climate change delivery plan which set out targeted actions to achieve carbon reduction goals.

Theprovider had developed a clear strategic framework and quality management systemto guide its work and achieve its vision.Key features of this framework included working within a continuous cycle of review and action, working together effectively with internal and external partners, and focusing on delivering improved outcomes for people. Performance was monitored using a RAG (Red, Amber, Green) rating system, enabling senior leaders to identify emerging issues and take timely action to address them.

The provider’s senior leaders regularly reviewed performance data, including how effectively the service worked with external partners. The senior leadership team key performance indicators (KPIs) for the service on a monthly basis. These KPIs were focused on the outcomes achieved for people who used the service, such as how promptly people’s needs were assessed and their reablement started following referral, and whether they were supported to achieve their goals. Where areas for improvement were identified, the provider took timely and effective action to improve the service people received.

The reablement team had established a multidisciplinary team (MDT) to review the effectiveness of the service to establish what had worked well and to identify any areas for improvement. Reablement managers assigned to the MDT carried out detailed evaluations of individual cases, including direct observation of staff practice, and reviews of outcomes for people using the service. Learning from these reviews was shared with managers and staff, ensuring reflective practice was embedded across the service. Where areas for development were identified, clear, accountable actions were recorded.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Managers and staff worked exceptionally well with partners to ensure the service was well run and responsive to people’s needs. Reablement managers held quarterly contract monitoring meetings with internal and external partners, during which performance and KPI data from the reablement team and CRS providers was reviewed. This supported oversight of outcomes, customer feedback, partnership effectiveness, and the overall sustainability of the service.

External partners spoke highly of the professionalism and commitment of managers and staff. The manager of one external partner organisation said, “A key strength of the service is the professionalism and dedication of the team. They are highly supportive, collaborative, and demonstrate a strong commitment to the CRS [collaborative reablement contract] project, making them a valuable partner to work alongside.”

Partners told us the reablement team worked effectively with them to ensure people received a consistent, high quality service. They highlighted the team’s flexibility and responsiveness in adapting to changing needs. A professional from a partner organisation said, “We have long had a good working relationship with the team, each and every member communicates effectively with all of the teams within the [hospital]. This has continued to improve since the development of the TOCH (Transfer of Care Hub) and the daily operational calls. They are also accommodating of the challenges affecting the discharges from the acute hospital and are always amenable to be flexible with timings for discharges.”

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider recognised the value of developing its workforce and offered staff a range of sponsored qualifications, including Health and Social Care levels 2, 3, 4 and 5, and management qualifications. Staff who had worked for the provider in adult social care for 2 years were able to apply for a fully funded social work or occupational therapy degree.

Most staff had attained relevant national vocational qualifications, and a number had been supported to undertake role-specific apprenticeships. This demonstrated a commitment to workforce development and continuous learning, helping to ensure staff maintained the skills and competencies required to meet people’s needs. As a result, people received care and support from a knowledgeable and competent workforce, which contributed to improved outcomes.

Manager and staff demonstrated a commitment to continuous learning and improvement. A member of staff told us, “We are continually reviewing and improving our practice as part of our day‑to‑day work. We consistently update our training, seek guidance and learning opportunities, and adapt our service in response to feedback and changing needs and this all happens very seamlessly. This ongoing process of reflection and improvement is embedded within the team.”

The provider made excellent use of technology to enable people to live independently and safely in their own homes. With people’s consent, staff could install motion sensors and smart plugs in people’s homes to provide non-intrusive monitoring. The use of sensors enabled the early identification of potential risks, supporting timely and proactive intervention. For example, sensors placed in a refrigerator could indicate whether a person was eating and drinking enough, while increased bathroom usage could highlight potential health concerns, such as a urinary tract infection. If sensors indicated a person had fallen, the system alerted an alarm receiving centre and the reablement service. Smart plugs could be programmed to monitor the use of, or shut off power to, appliances such as fridges, cookers and kettles.

The provider had also used technology to significantly improve the timeliness and quality of people’s reablement journeys, enabling faster progression from referral to support beginning. For example, the introduction of ambient voice technology (AVT) to transcribe assessments had reduced assessment times and improved efficiency. Feedback from staff also highlighted that AVT supported more meaningful, person-centred conversations, as staff were able to focus fully on engaging with individuals rather than recording detailed notes, enhancing both the experience and quality of assessments. A member of staff said of the AVT technology, “It is a valuable tool that supports staff to complete more person‑centred assessments. It enables staff to engage in fluid, face‑to‑face conversations rather than focusing on written notes, with discussions recorded where consent is provided. This has improved the quality of interaction and supports inclusivity, particularly for staff who are dyslexic, have difficulties with spelling, or where English is a second language.”