Our Reablement services work in partnership with Local Authorities, Discharge Teams and health professionals to offer a joined up approach to targeted reablement support.

We recognise that timely referral into a reablement service improves an individual’s chances of regaining their skills, recovering their health, and reducing their likelihood of needing ongoing care, and so our services are designed to be efficient and effective, through::

• Swift assessment and same day acceptance of referrals, providing preliminary information from our integrated systems on initial contact and assessment, service commencement, and timings of visits.

• Experienced, core teams of Professional Carers for each customer, ensuring continuity of care. Our Professional Carers for reablement services are chosen specifically for their ability to support a wide range of needs at pace. Our teams undergo our specific reablement training, to ensure that they understand the ethos and projected outcomes of their work.

• Comprehensive, streamlined Initial Assessments, capturing essential information about the customer and their needs, including input from their wider ‘Circle of Support’, such as family, friends, and healthcare professionals, feeding into a co-produced Care Plan, with integrated positive/dynamic risk assessments.

• Personalised outcomes, recorded on our bespoke Reablement Outcomes Tool, which breaks outcomes down into smaller, more manageable tasks, which boots customer confidence and motivation. Progress is recorded daily via our Cera App, enabling real-time monitoring.

• Additional health and wellbeing focused support, via our Smartcare technology. Our innovative Enhanced Falls Risk Assessment, part of our Healthier Lives initiative, uses customers’ health and wellbeing data to predict their risk of falling in real-time, pinpointing 97% of falls, enabling early intervention and prevention.

• Signposting on to relevant local services to support better wellbeing (such as reducing social isolation, or support with finances), for customers and any unpaid carers who also provide support.

• Exit planning incorporated into the customer’s care plan, with proactive support and partnership working to ensure that their onward transition from the service is positive.

Recovering from Guillain-Barré Syndrome

At 28 years old, “Henry” was living with his partner and two small children, successfully managing his Autism.

Suddenly, Henry became so unwell that he could no longer stand or walk, leading to a 999 call. He was admitted to the hospital but his stay was fraught with challenges and he felt that everyone doubted his ability to walk. He was moved from ward to ward, enduring numerous examinations, scans, invasive tests, and endless questions before being diagnosed with Guillain-Barré Syndrome (GBS).

GBS affected Henry’s neural pathway, primarily causing tingling and weakness of limbs, along with chronic fatigue.

On discharge from hospital, Henry was unable to walk, but could bear weight and transfer independently. Henry’s lung function was poor and his limbs were very weak. Critically, Henry had also lost a lot of his confidence due to his traumatic stay in hospital. He was also experiencing depression and anxiety as a result. Henry struggled on returning home, a struggle exacerbated by his neurodiversity and communication barriers.

We identified the things that were important to Henry, including:

• Being able to live independently, with his family
• Being able to make lunch for his children
• Regaining his independence with his personal care needs

We co-produced a Reablement Support Plan, based on these things, and supported Henry through:

• Emotional and practical support
• Encouraging his participation in rehabilitation programmes
• Monitoring his progress against his outcomes
• Promoting his independent living skills
• Advocating for Henry’s needs, wishes, and aspirations
• Building a positive, trusting relationship with Henry and his family

Since our support started, Henry has made significant progress with his mental and physical wellbeing. He is becoming increasingly independent, building on small steps and achievements, regaining confidence in his own abilities along with his strength. He no longer needs aids to walk!

Henry is enjoying being at home, preparing meals for his family, maintaining the garden, and sticking with his physiotherapy exercises.

We have worked with Henry to provide him with a toolkit for coping in stressful situations, especially where it is difficult for him to vocalise his needs and advocate for himself. Henry is planning to return to work shortly, and he and his wife are expecting another baby.

Person-Centred Care

In June 2024, “Mavis” was referred to us for a reablement package, with the aim to support her to gain confidence and independence, including personal care.

Mavis had become socially isolated during the Covid-19 pandemic, as all her family live in New Zealand, and she had lost links in the local community due to isolating as per Covid-19 guidelines. Mavis had not received any visitors to her home in almost 5 years, which had significantly impacted her ability to trust and engage with others. We were reliant on the information provided by Mavis’ Social Worker and multi-disciplinary health team, along with pieces of information which Mavis felt comfortable sharing, to build a personalised Care Plan for her. We worked on gradually building rapport and a good working relationship with Mavis, through our Field Care Supervisor having informal ‘catch-ups’ with her at home, reducing her anxiety about visitors, and encouraging her to open up more.

The outcomes that Mavis and her Social Worker agreed on were for Mavis to become independent with personal care, and maintaining her home. It was apparent that Mavis had developed a number of fears during Covid-19, exacerbated by her prolonged loneliness and isolation, and which included:

• Using the shower
• Washing machine (due to noise)
• Agoraphobia (causing reliance on meal service) - We created a person-centred delivery plan, breaking down the above into achievable goals with smaller outcomes, supported through our Keyworker system, to ensure continuity of care and familiar faces supporting Mavis. Each element of our service incorporated aspects of exposure therapy to challenge Mavis and support her to achieve her outcomes in a gradual way.

Outcome 1, Showering Independently: Week 1 & 2 Tasks: Staff supported getting in/out of the shower, and with intimate hygiene. Week 3 & 4 Tasks: Enter independently, and wash herself. Staff available to assist if needed. Week 5 & 6 Tasks: Independently shower with no support.

Outcome 2, Washing Laundry: Week 1 & 2 Tasks: Mavis to direct staff with laundry. Week 3 & 4 Tasks: Mavis loads/unloads the washing machine and turns on/off. Week 5 & 6 Tasks: Mavis completes laundry independently.

Outcome 3, Ordering and collecting food from home: Week 1 & 2 Tasks: Mavis to write a shopping list for Keyworkers to arrange. Week 3 & 4 Tasks: Mavis calls Morrisons independently to arrange delivery, with Keyworkers on hand to support. Week 5 & 6 Tasks: Mavis orders independently.

Outcome 4, Gain Social Confidence: Week 1 & 2 Tasks: MR to walk from front door to front gate. Week 3 & 4 Tasks: MR to walk from front door to halfway up the street Week 5 & 6 Tasks: MR to walk from front door to end of street and chat with neighbours.

Each day, we recorded progress and Mavis’ feedback, including key achievements and any barriers to inform and improve our approach. Our Field Care Supervisor visited weekly to ascertain and discuss progress at a more comprehensive level to support self-reflection and confidence.

At Week 2, we arranged a meeting with Mavis’ Social Worker as there was a lack of progress in Outcome 4 as planned. We consciously recognised and empathised with her anxiety and nervousness and addressed each concern of hers, and redirected using a strength-based motivational approach.

Following this, we continued and successfully achieved the outcomes as above, and incrementally reduced from 2 daily visits to one 30 minute visit per week at Week 5.

At Week 6, we extended the package for a further 2 weeks to ensure full confidence in her ability to independently order and collect her food shop.

Having achieved all her outcomes, we ended her package at Week 8, and Mavis has since rekindled old friendships with neighbours and entered local food shops for the first time since 2020.