STEPS

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 changed to outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

This service scored 88 (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 always made sure people’s care and treatment was effective by thoroughly assessing and reviewing their health, care, wellbeing and communication needs with them. People's needs were assessed at the time of referral and throughout the reablement programme. As people regained their skills and confidence their needs were reviewed and support adjusted. Prior to people being discharged from the service a further review took place to ensure they had been sign posted to other services as they required. We saw examples of assessment visits carried out as an introduction with people and to obtain information regarding personal histories, families and health and support needs, including communication, mobility, meals and social activity. The carer situation was also discussed such as whether the person had a main carer or were living alone. For example, 1 person had experienced a stroke which had left them with visual changes and was a high risk of falls. The STEPS assessment had identified these concerns prior to hospital discharge and made the necessary arrangements to ensure the person could be discharged from hospital safely. STEPS achieved this by effectively liaising with the sensory team to explore how the person would navigate around their home, complete daily activities and communicate effectively. This led to the person regaining skills to live independently. A case manager [employed by STEPS] was based in the hospital to liase with the integrated discharge team and people whilst on the ward, so they could provide people with the support they required right from the point of discharge. A proportionate assessment was completed at home and support started the same day. Support packages were reviewed after 2 weeks and then when the service had been in place for 4 weeks. If longer term support was needed referrals to social work teams were made and the local authority brokerage team looked for a suitable support package. One family member said, “The meeting we had at first with STEPS before the care started really helped give us an idea of what to expect as [family member] had never needed care before.” One person said, “There was a meeting here [at home] when I was still in hospital and they [staff] spoke at length with [my relative]. [My relative] said they [staff] were very thorough.”

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. Care plans were detailed and up to date, including assessments for communication, nutrition and hydration, mobility, personal care and medication. Staff told us they used these plans daily to guide their practice. One relative said, “If the carers are doing meals some of them will make sure it is something [family member] would really enjoy encouraging [family member] to eat.” Another relative said, “[Staff] always give [family member] a choice of what to eat.”

The provider always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once. The provider worked closely with many other services both internal and external to the local authority. The service was part of the local authority’s rapid response team and worked extremely well together to ensure people received care and medical support at home to avoid a hospital admission. STEPS worked as part of a multi-professional approach to ensure people received the most appropriate support. STEPS were involved in the wider integration of community services in Doncaster; this was supported by all partnership organisations working closely to develop effective care and support with a joined-up approach. Excellent professional relationships had evolved which ensured organisations could be open and honest when discussing future developments of care services. Where packages increased and reablement has not been successful, the provider communicated with relevant professionals to obtain support and larger packages for people with regular and ongoing support. The case manager, employed by STEPS, were extremely passionate about ensuring people received the best possible outcomes and supported people by sharing information to ensure a smooth transition of care. STEPS also had good links to community services which would potentially benefit people, such as a meal delivery café, a community group or wellbeing services. Professionals commented positively about the teamwork and joined-up approaches. One professional said, “We have a really good relationship and work together for the benefit of the individual and problem solve any issues that may arise. I have had nothing but positive experiences when dealing with the STEPs service. The information they provide us has always been accurate and the staff have always been polite, professional, knowledgeable and extremely helpful.” People and relatives told us everything was sought for them. One relative said, “Through a referral by STEPS to the occupational therapy team, [family member] is now able to use a rotunda [stand aid] to stand with help and we have a referral to the continence team.”

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. STEPS provided a case manager who supported people to access all the support and healthcare they required. Staff promoted healthy living. One staff member said, “We support service users to access other external professionals for support in order to improve their wellbeing in all areas of their life.” One relative said, “[Family member] had a fall and they [staff] found [family member] and they called the paramedics and waited while they arrived. [Family member] had treatment at home. They called me to inform me too.” Professional spoke highly of the service. One professional said, “It is clear the team prioritises supporting people to remain at home wherever it is safe to do so. Staff work closely with individuals and carers to balance risk with independence and avoid unnecessary hospital admissions or prolonged stays. STEPS is particularly effective at bridging the gap between hospital discharge or admission avoidance and longer‑term community support, helping to prevent short‑term crises becoming longer‑term dependency.”

The provider monitored all people’s care and treatment 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. From the outset of service provision each person was allocated a case manager who remained an integral part of their support package, until the service was no longer required. The case manager liaised with other professionals and signposted people to other providers as required. the registered manager said, “We try to ensure people have a good starting point looking at cost, low level equipment and volunteers to ensure people remain as independent as possible.” STEPS had a dedicated occupational therapist working alongside case managers and staff to help people reach their full potential. For example, we heard about 1 person who initially required a lot of support, and the case manager and staff assisted the person to reach their goals until the only aspect of support required was shopping. Staff supported the person to shop online; therefore, they could still carry on shopping for themselves and choosing their own products. The registered manager said, “We work in partnership and the focus is always the individual.” The service demonstrated effective monitoring and continuous improvement of outcomes for a married couple through regular reviews, responsive adjustments to care, and strong multi-disciplinary working. Outcomes for this couple were actively monitored through ongoing communication between frontline staff, the case manager, family members, and partnership working. Changes in 1 person’s mobility, cognition, and confidence were promptly identified and used to inform care planning, resulting in timely reductions in support to match need and minimise risk. Improvements in this person’s mobility, engagement in transfers, and reduced reliance on equipment evidenced positive impact, whilst their partner was supported to maintain independence safely. The service used feedback and observed risks to improve practice, including occupational therapist involvement, staff education, and amendments to moving and handling plans. These actions demonstrate a proactive, learning-led approach that ensured the person’s care remained effective, person-centred, and responsive, with outcomes that improved safety, wellbeing, and their quality of life while preventing deterioration or unnecessary restrictions.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment. People told us they were fully informed about their care, and consent was sought prior to support being delivered. Appropriate documentation in place which had been signed by people or their representative to consent to STEPS providing reablement support. Staff told us they liaised with people to ensure they sought consent prior to delivering care and support. One staff member said, “The aim our service is to always promote independence and decision making and ensure that they are involved in making decisions about the care that they receive.” Another staff member said, “I prompt the service user and involve them in all aspects of their care to promote their independence. I encourage them to do things themselves by making them aware that I am there to support them when they need it at any time.”