homecare re-ablement cssr scheme directory update april … · • 17% of reported services only...

GERALD PILKINGTON ASSOCIATES

…… specialists in health and social care - 1 -

HOMECARE RE-ABLEMENT

CSSR Scheme Directory

Update April 2012



The original Discussion Document published by the Care Services Efficiency Delivery (CSED) programme and launched at its workshop held in January 2007 contained a summary of information provided by Councils with Social Services Responsibility (CSSRs) on their Homecare Re-ablement schemes. This was compiled as part of their work during 2006 and updates to this section were published in September 2007, May 2008, March 2009 and then again in November 2010 Many CSSRs continue to implement schemes or are making significant changes to existing schemes and so, given the level of interest in this information, and in response to numerous enquiries, we invited CSSRs to update and return an outline for their council.. Throughout this document, a ‘self assessment’ colour code has been used to provide a quick visual identification of the current stage of development for each CSSR. The colour code used is as follows: Service in place with no declared intention to extend / expand / amend Service in place but seeking to extend / expand / amend Establishing a Service (various stages – commonly operating a pilot) No scheme in place but wish to develop (various stages – commonly planning a service No plans to introduce service No information known Colour coding has not been used where we have no information on a service. In addition, where a scheme exists, but for which we have limited knowledge, it has been assumed that the service is not undergoing any enhancement and so is coloured yellow. We would like to thank all those CSSRs that have provided an update of the status of their scheme. We continue to work with councils to help them enhance their re-ablement services, as well as other service areas. Further updates or requests for information should be sent to Gerald Pilkington, whose contact details are as follows: Email: [email protected] Website: www.geraldpilkingtonassociates.com Mobile: 07713 511585



SUMMARY OF HOMECARE RE-ABLEMENT SCHEMES as at April 2012

Table of contents

Executive Summary ......................................................................................................... 7

CSSR Homecare Re-ablement Status – National Map of Coverage ................................ 8

Intake and Assessment or Hospital Discharge Support ................................................. 10

Model of service: Selective or De-selective .................................................................... 10

Funding of the Homecare Re-ablement service ............................................................. 12

Delivery of the Homecare Re-ablement Services ........................................................... 12

CSSR Scheme – FACS Level and Application ............................................................... 13

CSSR Scheme – Service subject to charge ................................................................... 14

EAST MIDLANDS REGION ........................................................................................... 16

Derby City Council (UA) ...................................................................................... 16

Derbyshire County Council .................................................................................. 16

Leicester City Council .......................................................................................... 17

Leicestershire County Council ............................................................................ 18

Lincolnshire County Council ............................................................................... 18

Northamptonshire County Council ...................................................................... 19

Nottingham City Council (UA) .............................................................................. 20

Nottinghamshire County Council ........................................................................ 21

Rutland Council (UA) ............................................................................................ 21

EASTERN REGION ....................................................................................................... 23

Bedford Borough Council (UA) ............................................................................ 23

Cambridgeshire County Council ......................................................................... 23

Central Bedfordshire Council (UA) ...................................................................... 23

Essex County Council .......................................................................................... 24

Hertfordshire County Council .............................................................................. 24

Luton Borough Council (UA) ................................................................................ 25

Norfolk County Council ........................................................................................ 25

Peterborough City Council (UA) .......................................................................... 26

Southend on Sea Borough Council (UA) ............................................................ 27

Suffolk County Council ........................................................................................ 27

Thurrock Council (UA) .......................................................................................... 28

LONDON REGION ......................................................................................................... 29

Barking and Dagenham (London Borough of) ................................................... 29

Barnet (London Borough of) ................................................................................ 30

Bexley Borough Council (London Borough of) .................................................. 30

Brent Council (London Borough of) .................................................................... 31

Bromley Council (London Borough of) ............................................................. 31

Camden Council (London Borough of) ............................................................... 32

City of London Council ......................................................................................... 32

Croydon Council (London Borough of) ............................................................. 33

Ealing Council (London Borough of) .................................................................. 34

Enfield Council (London Borough of) ................................................................. 35

Greenwich Council (London Borough of) ........................................................... 36

Hackney Council (London Borough of) ............................................................. 37

Hammersmith and Fulham Council (London Borough of) ................................ 38



Haringey Council (London Borough of) .............................................................. 38

Harrow Council (London Borough of) ................................................................ 39

Havering Council (London Borough of) .............................................................. 40

Hillingdon Council (London Borough of) ........................................................... 41

Hounslow Council (London Borough of) ............................................................ 43

Islington Council (London Borough of) .............................................................. 44

Kensington & Chelsea Council (Royal Borough of) .......................................... 44

Kingston Council (Royal Borough of) ................................................................. 45

Lambeth Council (London Borough of) .............................................................. 45

Lewisham Council (London Borough of) ........................................................... 47

Merton Council (London Borough of) ................................................................. 47

Newham Council (London Borough of) .............................................................. 48

Redbridge Council (London Borough of)............................................................ 48

Richmond Council (London Borough of) ............................................................ 48

Southwark Council (London Borough of) .......................................................... 49

Sutton Council (London Borough of) ................................................................. 50

Tower Hamlets Council (London Borough of) .................................................... 51

Waltham Forest Council (London Borough of) .................................................. 52

Wandsworth Council (London Borough of) ........................................................ 53

Westminster City Council ..................................................................................... 55

NORTHERN REGION .................................................................................................... 56

Darlington Borough Council (UA) ........................................................................ 56

Durham County Council ....................................................................................... 57

Gateshead Council (Metropolitan) ....................................................................... 58

Hartlepool Council (UA) ........................................................................................ 58

Middlesbrough Council (UA) ................................................................................ 59

Newcastle City Council (Metropolitan) ................................................................ 59

North Tyneside Council (Metropolitan) ............................................................... 60

Northumberland Council (UA) .............................................................................. 60

Redcar & Cleveland Borough Council (UA) ........................................................ 62

South Tyneside Council (Metropolitan) .............................................................. 62

Stockton-on-Tees Borough Council ( UA) .......................................................... 63

Sunderland City Council (Metropolitan) .............................................................. 63

NORTH WESTERN REGION ........................................................................................ 66

Blackburn with Darwen Borough Council (UA) .................................................. 66

Blackpool Borough Council (UA) ........................................................................ 68

Bolton Borough Council (Metropolitan) ............................................................. 69

Bury Borough Council (Metropolitan ) ................................................................ 70

Cheshire East ........................................................................................................ 70

Cheshire West and Chester................................................................................. 71

Cumbria County Council ...................................................................................... 71

Halton Borough Council (UA) .............................................................................. 72

Knowsley Borough Council (Metropolitan)......................................................... 72

Lancashire County Council .................................................................................. 73

Liverpool City Council (Metropolitan) ................................................................. 74

Manchester City Council (Metropolitan) ............................................................. 74

Oldham Council (Metropolitan) ............................................................................ 75

Rochdale Borough Council (Metropolitan) ......................................................... 75

Salford City Council (Metropolitan) ..................................................................... 77

Sefton Borough Council (Metropolitan) .............................................................. 77



St. Helens Council (Metropolitan) ........................................................................ 77

Stockport Borough Council (Metropolitan) .......................................................... 78

Tameside Borough Council (Metropolitan) ......................................................... 80

Trafford Council (Metropolitan) ........................................................................... 80

Warrington Borough Council (UA) ...................................................................... 80

Wigan Borough Council (Metropolitan) .............................................................. 81

Wirral Borough Council (Metropolitan) ............................................................... 81

SOUTH EASTERN REGION .......................................................................................... 83

Bracknell-Forest Borough Council (UA) ............................................................. 83

Brighton & Hove City Council (UA) ..................................................................... 83

Buckinghamshire County Council ....................................................................... 84

East Sussex County Council................................................................................ 84

Hampshire County Council .................................................................................. 85

Isle Of Wight Council (UA) ................................................................................... 86

Kent County Council ............................................................................................. 86

Medway Council (UA) ........................................................................................... 87

Milton Keynes Council (UA) ................................................................................. 89

Oxfordshire County Council ................................................................................ 90

Portsmouth City Council (UA) .............................................................................. 90

Reading Borough Council (UA) ........................................................................... 91

Royal Borough of Windsor and Maidenhead (UA) ............................................. 91

Slough Borough Council (UA) ............................................................................. 92

Southampton City Council (UA) ........................................................................... 93

Surrey County Council ......................................................................................... 93

West Berkshire Council (UA) ............................................................................... 94

West Sussex County Council............................................................................... 95

Wokingham Borough Council (UA) ..................................................................... 95

SOUTH WESTERN REGION ......................................................................................... 97

Bath and North East Somerset Council (UA) ..................................................... 97

Bournemouth Borough Council (UA) .................................................................. 98

Bristol City Council (UA) ...................................................................................... 98

Cornwall County Council ..................................................................................... 99

Devon County Council ........................................................................................ 100

Dorset County Council) ...................................................................................... 100

Gloucestershire County Council ....................................................................... 102

Isle of Scilly ......................................................................................................... 102

North Somerset Council (UA) ............................................................................. 102

Plymouth City Council (UA) ............................................................................... 103

Poole Council (Borough of ) (UA) ...................................................................... 103

Somerset County Council .................................................................................. 105

South Gloucestershire Council (UA) ................................................................. 106

Swindon Borough Council (UA) ......................................................................... 107

Torbay Council (UA) ........................................................................................... 107

Wiltshire County Council ................................................................................... 107

WEST MIDLANDS REGION ........................................................................................ 110

Birmingham City Council (Metropolitan) .......................................................... 110

Coventry City Council (Metropolitan) ................................................................ 110

Dudley Borough Council (Metropolitan) ........................................................... 112

Herefordshire County Council ........................................................................... 114

Sandwell Borough Council (Metropolitan) ........................................................ 115



Shropshire County Council ................................................................................ 116

Solihull Borough Council (Metropolitan) .......................................................... 116

Staffordshire County Council ............................................................................ 118

Stoke on Trent City Council (UA) ....................................................................... 118

Telford & Wrekin Council (UA) ........................................................................... 121

Walsall Council (Metropolitan) ........................................................................... 122

Warwickshire County Council ............................................................................ 122

Wolverhampton City Council (Metropolitan) .................................................... 126

Worcestershire County Council ......................................................................... 126

YORKSHIRE AND HUMBERSIDE REGION ................................................................ 128

Barnsley Borough Council (Metropolitan) ........................................................ 128

Bradford Council (Metropolitan) ........................................................................ 128

Calderdale Council (Metropolitan) ..................................................................... 129

Doncaster Council (Metropolitan) ...................................................................... 130

East Riding of Yorkshire Council (UA) .............................................................. 131

Hull City Council (UA) ......................................................................................... 131

Kirklees Council (Metropolitan) ......................................................................... 132

Leeds City Council (UA) ..................................................................................... 133

North East Lincolnshire Council (UA) ............................................................... 134

North Lincolnshire Council (UA) ........................................................................ 136

North Yorkshire County Council ........................................................................ 137

Rotherham Borough Council (Metropolitan) .................................................... 137

Sheffield City Council (Metropolitan) ................................................................ 138

Wakefield Council (Metroplitan) ......................................................................... 139

City of York Council (UA) ................................................................................... 141

APPENDIX 1 – INTAKE AND ASSESSMENT or HOSPITAL DISCHARGE ONLY ..... 142

APPENDIX 2 – SELECTIVE or DE-SELECTIVE MODEL ............................................ 145

APPENDIX 3 – FUNDING OF HOMECARE RE-ABLEMENT SERVICE ..................... 147

APPENDIX 4 – DELIVERY OF HOMECARE RE-ABLEMENT .................................... 150

APPENDIX 5 - APPLICATION OF FACS ELIGIBILITY CRITERIA .............................. 153

GERALD PILKINGTON ASSOCIATES .................................................................................................. 155

The Table of Contents above provides shortcut links to each of the regional or council sets of information. By ‘resting’ the cursor on a specific regional or council name, holding down the Ctrl key and clicking the left key on your mouse, it will take you immediately to the start of the regional section or individual council section. CSSRs are in alphabetical order within each regional group. Within the tables that follow, any narrative in red indicates, for established services, that this information has not been made available by the CSSR. For CSSRs that are at an early stage of planning (colour code), these decisions may not yet have been made.



Executive Summary

This is the fifth update since publication of the original CSSR Homecare Re-ablement Scheme Directory, and it reflects the latest known position as shared by councils with social services responsibility (CSSRs) across England. The previous update was in November 2010, since when a few notable changes have occurred. Some of these have been a continuation of previous trends whilst others appear to be a reversal. It is too early to know if these are temporary or the start of a new direction. The main features and changes are

• 17% of reported services only support people from hospital whilst the vast majority support referrals from the community and hospital

• 67% of reported services operate on a de-selective basis. Between March 2009 and November 2010 there was a slight shift with some de-selective services changing to a selective model. However, since the there has been a small shift back with a few selective models changing to a de-selective model. As experience grows, some de-selective services are refining their criteria so that, for instance, people with large packages of care and double staffing are under closer scrutiny to consider whether re-ablement truly can improve independence .

• 71% of reporting services are funded solely by the council with the rest being funded by the council and health partners. In some cases the health ‘funding’ takes the form of providing OT input rather than hard cash. Interestingly, despite the heightened drive to encourage integration between social care and health, none of the services reporting their funding source have indicated a newly created funding arrangement with health. A few have, however, referred to use of the additional funding that has been made available via PCTs for use by social care.

• Unsurprisingly, the biggest change has been in the number of services outsourced. Of the reporting services, 110 are operated in-house, 24 are now outsourced in a variety of ways and a further 5 have a mix of in-house and outsourced services. In addition, within those currently operated in-house, one is known to have sought expressions of interest from external providers whilst another is understood to be close to creating a local authority trading company (LATC). The number and rate of change appears to be increasing as some councils consider the costs of operating even effective services. 1

• 69% of reporting services use FACS as an eligibility criteria for entry to their service. However, since the last update in November 2010, four of the services that previously applied FACS on entry to their re-ablement service now only apply it afterwards if ongoing support is required.

Many councils are still trying to improve both the volume of activity and performance of their service as they address funding levels, whilst others are preparing for outsourcing. These continue to be areas where GPA is working with councils and other providers.

1 The Outsourcing of Homecare Re-ablement Services, Aug 2011, Gerald Pilkington Associates



CSSR Homecare Re-ablement Status – National Map of Coverage

The following map provides a pictorial view of the national position as known to us and uses the same colour scheme as applied within the tables that follow. Since January 2007, 115 of 152 CSSRs have changed their status in terms of progressing their implementation plans. Of the remaining councils that have not reported any change to their status, 12 are established with no plans to change, 19 are established but seeking to extend, and 3 remain in pilot status.

Service in place with no declared intention to extend / expand / amend Service in place but seeking to extend / expand / amend Establishing a Service (various stages (commonly operating a pilot) No scheme in place but wish to develop (commonly planning) No plans to introduce a service No information available to CSED



A regional summary is as follows:

Service in place with no declared

intention to extend / expand / amend

Service in place but seeking to

extend / expand / amend

Establishing a Service (various

stages)

No scheme in place but wish

to develop

No plans to introduce a

service

No information held

North West 2 15 4 2 0 North East (Northern) 0 8 1 2 1 Yorkshire & Humberside

1 7 6 0 1

East Midlands 1 8 0 0 0 West Midlands 3 6 5 0 0 South Western 1 9 2 2 2

Eastern 1 6 1 3 0 South Eastern 3 11 2 3 0 London 2 22 9 0 0 TOTAL (152) 14 92 30 12 0 4 TOTAL reported in Update Nov 2010 (152)

15 72 46 15 0 4

TOTAL reported in Update Mar 2009 (150)

24 69 29 22 0 6

TOTAL reported in Update May 2008 (150)

34 61 22 19 1 13

TOTAL reported in Update Sept. 2007 (150)

37 53 16 24 0 20

TOTAL reported in Discussion Document (150)

36 24 10 28 0 52

In addition to information now being available from a larger number of CSSRs (98%, previously 91%, 87% and 65%), progress has been made by a number of councils as they implement their plans. A total of 122 (80 %) of CSSRs are in the process of either establishing a scheme, or enhancing or extending an existing scheme.



Intake and Assessment or Hospital Discharge Support

Within earlier work councils were categorised services into one of two groups, namely, those that form part of the intake and assessment function and so take referrals from the community, hospital discharges, etc. or those that only or primarily support people on discharge from hospital. The nature, prime focus, characteristics and volumes of both types of service differ. For instance, intake and assessment services, as their name implies, means that the vast majority of people referred for homecare support will pass through and so it becomes the default pathway. Often they work on a deselection basis i.e. people referred for a potential homecare package will undergo a phase of homecare re-ablement unless it is agreed that the service is not appropriate. (i.e. unless deselected). In comparison, hospital discharge services tend to work on a selective basis i.e. people are selected to participate on the basis that they will benefit from participation. Others not selected are immediately offered a ‘maintenance’ homecare package. See the separate analysis on selective / de-selective services below. In recent years we have seen some of the hospital discharge support services broaden their role and evolve into intake and assessment services, thereby multiplying the number of people they support and ‘diluting’ their overall ‘performance’ percentage but increasing the actual number of people being returned to full independence. Also, in recent years we have seen some CSSRs establish a new service by first establishing a hospital discharge service and then, in accordance with their plans, develop it into an intake and assessment service. Thus, in some cases, hospital discharge support services have become a stepping stone to introducing a ‘full’ service. Based on the responses included within this document, a summary of the known position is as follows

INTAKE AND ASSESSMENT SERVICE HOSPITAL DISCHARGE SUPPORT (solely or primarily)

110 22 Further details with names of specific CSSRs can be found in Appendix 1

Model of service: Selective or De-selective

As outlined in the section above, in our earlier work most but not all intake and assessment services operated on a de-selective basis. However, as a result of our recent work with councils it has become clear that a number operate a selective model within their intake and assessment service. Selection or de-selection differs from the application of FACS criteria (see below) and reflects a fundamental principle about who is likely to benefit. A de-selection approach assumes that most people will benefit from a phase of homecare re-ablement unless there



are specific issues that mean that this is highly unlikely. Thus, these services have declared de-selection criteria, which often include the following

• not an adult and so will not pass through adult services

• primary need is for end stage life support and the person does not feel it to be appropriate

• high mental health or learning difficulty needs to the extent that they are unable to identify and work towards goals over a 6 to 8 week period

In addition, some services deselect people with lower limb fractures in plaster because they are not able to participate, and so entry is delayed until after removal. Also, we have seen a few examples where councils consider the size of the original package. For instance, some consider that if the package is over, say, 25 hours and includes two carers at the same time, then they have determined that there is little likelihood of benefiting and so the person does not enter the re-ablement service. A selection approach assumes that only a specific group of people / conditions will benefit and so unless these criteria are met, the person will pass to ‘routine’ support whether that be provided or commissioned care, or a direct payment, etc. This approach also assumes that an assessment tool and process is used that can readily identify people that meet the selection criteria. Unsurprisingly this approach will result in lower numbers passing through than is the case with a de-selection based service. We are not aware of any widely used and consistent assessment tool in use across services. A couple of services use the Canadian Occupational Performance Measure (COPM) and we are aware that at least one is trialling a tool from Australia. Work within one of the English regions in recent years sought to develop a consistent assessment tool. Two initial pilot sites were involved in the development work but after a matter of months it was apparent that they had both customised it to their own needs. The absence of at least a common framework is an indication of the variety in services operating and highlights an area of potential development that would benefit many services. Comments received during a workshop with OTs from virtually every council in one region indicated that some people passing through their local service had been seen to benefit from the phase, but it was the view of the OTs concerned that they would not have been selected if a formal assessment of ability to benefit had been applied. Almost as a reversal of what was seen when the scheme directory was last updated in November 2010, since then we have seen a small number of intake and assessment services change from a selection approach to one of de-selection. Based on the responses included within this document, a summary of the known position is as follows SELECTIVE DE-SELECTIVE Intake and Assessment service 17 51

Hospital Discharge Support (solely or primarily) 10 5 Further details with names of specific CSSRs can be found in Appendix 2



Funding of the Homecare Re-ablement service

A common differentiating characteristic remains the source of funding for the service with the most common being funded only by the council or jointly with health. Whilst a number of services are operated and funded jointly with health (whether that be through pooled budgets or by agreement), other services are funded solely by the council, albeit they may have speedy access to therapists and other health colleagues. Some councils appear to still have problems with attracting the interest of health colleagues whilst others are concerned that health seek to impose a medical model rather than a social care model of support. Linkages to intermediate care services are also variable. In most services, homecare re-ablement differs in its approach, focus and purpose, location of service, skill mix of staff and numbers of people supported. Homecare re-ablement complements rather than replaces intermediate care and tends to support a much larger proportion of people referred, albeit that some people will require the support of both at different stages of their progression towards independence following a ‘crisis’ in their lives. In our work with CSSRs we encourage them to consider homecare re-ablement within the full range of support services operated by them and health, rather than in a silo. This includes intermediate care but also includes other services.

Since the previous update in November 2010, there has been an increase in the number of schemes reporting their funding source, and so the number of unknowns has reduced. However, so far despite encouragement by the Department of Health to see a joining up of health and social care services, none have reported a shift in the funding of their service from council to council with health.

Based on the responses included within this document, a summary of the known position is as follows

FUNDED BY THE COUNCIL FUNDED WITH HEALTH

92 37 Further details with names of specific CSSRs can be found in Appendix 3

Delivery of the Homecare Re-ablement Services

Back in 2007 few homecare re-ablement services were outsourced and of those some had arisen after the outsourcing of homecare. Since then, most services developed have been with in-house staff who, with appropriate training, have evolved from the homecare service. Whilst this is still predominantly the case, a number CSSRs have adopted a different approach and in recent years there has been a growing number of outsourced services and an even greater number considering the option.. For instance, both Essex and Sefton Council decided to outsource all of their in-house provision by transferring it to wholly owned trading subsidiaries of the council and there are



2 others who have followed this route. Another is understood to be considering this change shortly. In other CSSRs, where they do not have an existing in-house homecare team to refocus on the new service, some have started to engage the external provider market. For instance, Hertfordshire County Council and the London Borough of Richmond have adopted this route, whilst Kent County Council and Brighton Council have added to the capacity of their own in-house service by engaging with external providers to provide homecare re-ablement. One of the main inhibitors to engaging external providers appears to arise from the desire to ensure that there is no conflict of interests for a provider because they may ‘pick up’ any subsequent ongoing homecare package requirement. CSSRs would also appear to be concerned about how they can ensure that the maximum level of independence was achieved as a result of the homecare re-ablement phase. In view of the importance and reliance by care managers on the input and advice of the homecare re-ablement service, many have, historically, decided that this would best be served by an in-house service. However, that situation is changing and we are likely to see an increase over the next year or so in both the number of outsourced services and the rate at which they arise.2 Based on the responses included within this document, a summary of the known position is as follows

IN-HOUSE OUTSOURCED (in part or whole)

110 24 (of which 4 are LA trading companies and 2

provide in-house OT support for an outsourced service)

In addition, 5 CSSRs have a mix of both in-house and outsourced provision. Further details with names of specific CSSRs can be found in Appendix 4

CSSR Scheme – FACS Level and Application

For a number of years it has been apparent that there is some diversity in the application of FACS levels in terms of when as well as how they are applied. This has been a regular source of enquiry by those CSSRs seeking to establish or implement significant changes to their services because they wish to understand the interplay between an authority’s FACS level, if applied at entry to the service, and the order of benefit likely to arise for participants. Services that work with health partners do not tend to apply FACS as an eligibility criteria, not least of all because health do not recognise or use FACS themselves. However, even within services that are operated only by the council, there appears to be a difference in how FACS is applied. For instance, some apply it as a rigid approach on the day of the

2 The Outsourcing of Homecare Re-ablement Services, Aug 2011, Gerald Pilkington Associates



assessment for need whilst others consider the level of need likely to arise shortly if support were not to be offered at the time of the assessment. Since the last update in November 2010 four of the services that previously applied FACS as an eligibility criteria for entry to their re-ablement service now apply it only if ongoing support is required. Based on the responses included within this document, a summary of the known position is as follows:

FACS LEVEL FACS APPLIED AT ENTRY TO SERVICE

FACS APPLIED ON EXIT FROM SERVICE

TOTAL

Low and above 4 1 5 Moderate and above 21 5 26 Substantial and above 59 31 90 Critical and above 2 1 3 TOTAL 86 38 124 Further details with names of specific CSSRs can be found in Appendix 5. In response to requests from CSSRs we have brought together further examples of the benefits of homecare re-ablement, and particularly within those councils that support people with needs at substantial and above, or critical. The results from 14 services across 13 CSSRs have been published and the document 3 is available via the CSED website. In summary, the examples show that Homecare Re-ablement does have significant benefits for people at substantial and even critical levels of need. What is also clear is that CSSRs need to continually monitor operational performance, identify fluctuations, investigate reasons and amend practice if they are to ensure that clients gain maximum benefit. The CSED Homecare Re-ablement Implementation Toolkit provides some valuable guidance and examples 4

CSSR Scheme – Service subject to charge

The legal definition for intermediate care, as set out in the Community Care (Delayed Discharges) Act 2003, is as follows:

"Intermediate care" means a qualifying service which consists of a structured programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live in his home."

3 CSED Benefits of Homecare Re-ablement for people with different levels of need. (January 2009) 4 CSED Homecare Re-ablement Implementation Toolkit



Local Authority Circular (DH)(2010)6 states, "Regulation 4(2) of the 2003 Regulations requires that intermediate care is provided free of charge for the first six weeks. Accordingly, re-ablement services are likely to fall within the definition of intermediate care services and should not be charged for the first six weeks".i5

5 LAC (DH) (2010) 6: The Personal Care at Home Act 2010 and charging for re-ablement: Local

Authority Circular



Service in place with no declared intention to extend / expand / amend Service in place but seeking to extend / expand / amend Establishing a service (various stages – commonly operating a pilot) No service in place but wish to develop – commonly planning a service No plans to introduce a service

EAST MIDLANDS REGION

CSSR Current Service Next Steps

Derby City Council

(UA)

(updated Jun 2010)

Intake and Assessment Service (see note 1 below) Model: de-selective Funding: by the Council Provision: in-house service (see note 4 below)

FACS: Moderate and above and applied on entry to and exit from the re-ablement service

1. Initially implemented a hospital discharge support service but developed this and from Jan 2009 it became an intake and assessment service taking virtually all new referrals with the exception of people with LD needs

2. Service supports people over 18 yrs for up to 6 weeks 3. The service is council wide and operates 7 days a week from

7am to 10.30pm 4. Service is delivered by former homecare staff with access to

therapists for training and specialist support. 5. Ongoing homecare support is commonly provided by

external providers

6. Currently undertaking a review of the service to improve and bed down good practice

7. Considering future expansion for clients with MH and LD needs

Derbyshire County

Council

(updated Jun 2010)

Intake and Assessment Service Model: de-selective Funding: by the Council Provision: in-house service

FACS: Low and above applied on entry but moderate on exit from the service (see note 3 below)



1. Service in the south of the authority became operational in June 2009 and in the north from October 2009

2. Service initially operated on a selective basis but now operates on a de-selective basis.

3. Entry to the service is subject to meeting the Low level of need. However, if an ongoing package us required the level is moderate and above.

4. The service supports people for up to 6 weeks and is not subject to charge

5. Service supports approx. 1,500 people per annum with approx. 47% not requiring subsequent homecare packages

6. It is open to all client groups and operates between 6am and 10pm 7 days a week

7. Seeking to implement a 24hr service

Leicester City Council

(updated Jun 2010)

See Volume 2: Additional

Information of CSED

Discussion Document

Hospital Discharge support service (see notes 2 and 7 below) Model: selective (see note 3 below) Funding: by the Council and Health (see note 4 below)

Provision: in-house service

FACS: Substantial and above and applied at entry to and exit from re-ablement service. (see note 3 below)

1. Initial implementation phase ended March 2010. 2. The service supports hospital discharges from 1 of 3

hospitals and saw 188 service users in first 6 mths. 3. Service users are screened into the service and service

users must meet local FACS criteria 4. Service funded by the council with funding from health for

therapist input 5. The service is currently open to all discharges from Leicester

General Hospital, but these are mainly older adults. 6. The service operates from 7am to 1pm and then 5 pm to

10pm 7 days a week. 7.

8. Hoping to extend service to all (intake and assessment) with an increase in hours.



Leicestershire County

Council

(updated Jan 2012)

See Volume 2: Case Studies

section of CSED Discussion

Document

See CSED Assessment

Tools and Satisfaction

Surveys Document

See CSED Retrospective

Longitudinal Study

Document

See CSED Benefits of

Homecare Re-ablement

Document


FACS: Substantial and above and applied at exit from re-ablement service.

1. Intake and Assessment scheme operated since early 2000. Evaluated by De Montfort University

2. Approx 3,600 users pa in 20119/12 3. Focusing on a service for up to 6 weeks 4. Service supports all client groups, the majority of users are

older adults 5. The approach is now also applied to people with dementia

but the time scale is extended to up to 12 weeks 6. Sits at beginning of SDS Customer care pathway and

assesses for eligibility 7. Seniors are trusted assessors 8. The services operates from 7am to 10.30pm, 7 days per

week.

Lincolnshire County

Council

(updated Jan 2012)

Intake and Assessment Service (see note 4 below) Model: de-selective (see note 4 below) Funding: by the Council Provision: in-house service (see notes 6 and 7 below)

FACS: Substantial and above and applied on entry to and exit from the service.

1. Service specification, care pathway, documentation, outcome measures in place. Service is now fully established across county. Forms part of mainstream care pathway and is available to all new service users requiring an immediate domiciliary care service (crisis and short-term support).

6. Service is provided by In-house teams (3,500 hours per week) who are also withdrawing from being a long term community



2. Service is called LARS (Lincolnshire Assessment and Re-ablement Service) and combines assessment and case management with reshaped in-house home care service. Current planned capacity is for service to support up to 78 new entrants each week..

3. Discharge from service, for people needing ongoing social care support, is now via individual budget and support planning arrangements.

4. Service is offered to all new cases, and existing service users if a practitioner believes they would benefit from a phase. Current activity is around 50 new entrants a week and around 450 people are being supported in LARS at any one time.

5. The service has a target of up to 6 weeks. Current average length of stay is 47 days. It operates from 7am to 10pm 7 days a week

service provider. 7. Current developments this

year:

• Direct referrals from Customer Service centre.

• Testing provision by independent sector home care providers.

• Joint working on reablement pathways with health

• Integrating within an `intake` assessment and care management service, including OTs.

Northamptonshire

County Council

( Feb 2012)

Kerry Tio

Hospital Discharge service (see note 2 below) Model: selective Funding: by the Council Provision: in-house service

FACS: Substantial and above. but only applied on leaving the service.



1. Currently reconfiguring our START service which started in 2003 and which was reorgainsed in Jan 2007. Adding Telecare from Apl 2010.

2. The service seeks to work with hospital discharges, mainly older people, as the priority and some admission avoidance.

3. Service sees approx. 40% not requiring any ongoing care package.

4. Service operates from 7am to 11pm 7 days a week. In addition, an overnight service is available

5. All staff have NVQ2 and 50% have NVQ3

6. Considering join with ICT and extend to include pharmacy technician and access to equipmentConsidering change to LATC Apl 2012

Nottingham City

Council (UA)

(updated Jan 2012)

Intake and Assessment Service (see note 1 below) Model: selective (see note 1 below) Funding: by the Council Provision: in-house service

FACS: Moderate and above and applied at entry to and exit from re-ablement service.

1. The.service receives 40% of clients from hospital and 60% from the community and people entering are assessed to be able to benefit

2. Currently the service sees approx. 900 people a year 3. The service is open to all adults but the majority (90%+) are

older adults. Average durations are between 6 and 8 weeks but some extend to 13 weeks.

4. The service operates from 7am to 10.45pm 7 days a week. A review is completed at 4 weeks and then again on transfer at 6 or 8 weeks.

5. Now putting people through to transfer on personal budgets. 6. Have a full time O.T who works closely with care workers at

the persons initial entry into intake re-ablement 7. Staff and O.T have worked to develop a weekly monitor of

peoples progress which is currently being piloted 8 ..

8. Considering the inclusion of OTs in the service.

9. New service to be developed looking blending the o.t .telecare s/w team and reablement so that all services come under the umbrella of reablement with key worker seeing the process through for the citizen to brokerage as appropriate but using same care/support plan . New project will also involve work with the community



and developing the preventative agenda

Nottinghamshire

County Council

(updated Jul 2010)


FACS: Moderate and above and will apply at exit from re-ablement service. (see note 2 below)

1. The START service is now operational across the whole County.

2. The service is positioned between the Customer Service Centre or hospital (‘light touch’ referral sources) and ongoing service with the Self Directed Support Assessment being completed towards the end of the re-ablement period for those who will need ongoing service

3. Following a review of Occupational Therapy services a number of OTs are being gradually moved into START.

4. Roles and responsibilities of re-ablement and intermediate care are being carefully considered to enable maximisation of resources

5. Service users are predominantly older adults with some under 65 yrs with non-severe dementia and some with MH needs. LD services are considering their own service.

Rutland Council (UA)

(update Jun 2010)

Intake and Assessment Service (see note 1 below) Model: de-selective Funding: by the Council Provision: in-house service (see note 1 below)

FACS: Moderate and above and applied on entry to and exit from the service.



1. REACH Service was fully operational from July 2009 and supports all adult client groups across the authority from the community and hospital discharges.

2. The service supports people for up to 6 weeks 3. The service operates from 7am to 10pm 7 days a week




EASTERN REGION


Bedford Borough

Council (UA)

(Jun 2010)

Intake and Assessment Service Model: selective (see note 2 below) Funding: by the Council Provision: in-house service

FACS: Substantial and above and applied on entry to and exit from re-ablement service.

1. The service was established in 2008 and underwent a review following the split of Bedfordshire into two unitaries wef Apl 2009

2. Proposing to develop into a deselection services by Mar 2011 and increase activity levels

Cambridgeshire

County Council

(Apl 2009)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council with health (see note 1 below) Provision outsourced service (see note 1 below)

FACS: Substantial and above.

1. Service has been outsourced to PCT

2.

Central Bedfordshire

Council (UA)

Intake and Assessment Service (see note 2) Model: de-selective Funding: by the Council Provision: in-house service



(Feb 2012) FACS: Substantial and above and applied on exit from the re-ablement service.

1. The service was established in 2008 and underwent a review following the split of Bedfordshire into two unitaries wef Apl 2009

2. It operates as an intake and assessment model with ade-selective approach.

3. The service is co-located with the ITC service, affording easy access to therapy input when required.

Essex County Council

(updated Feb 2012)



Document

See CSED Assessment


Surveys Document

Intake and Assessment Service (see note 1 below) Model: selective / de-selective Funding: with health (see note 2 below) Provision: out sourced service (see notes 3 and 5 below)

FACS: Substantial and above and applied at entry to and exit from re-ablement service.

1. The initial hospital discharge service was expanded to an intake and assessment service wef Oct 2008., although the majority of referrals are currently from hospital.

2. The service is funded with health. 3. The re-ablement team is a Local Authority Trading Company

called EssexCares. They were an in-house service that has now been established as a private company. Other subsidiaries of Essex Cares provide other services.

4. The service currently receives approx. 3,100 referrals a year

5. Essex County Council confirmed its decision on the ‘reprocurement of reablement services’ on 31st Jan 2012. They are currently reviewing their contract and have invited expressions of interest from a range of providers.

Hertfordshire County

Council

(updated Feb 2012)

Intake and Assessment Service (see note 4 below) Model: de-selective (see note 4 below) Funding: by the Council (see note 3 below) Provision: outsourced (see note 4 below)


1. Historically the service was delivered through two different 5.



models. The first through contracts with external providers and the second through intermediate care services provided by health.

2. Both models took referrals from community but the majority were hospital discharges and both are selective

3. The homecare model was funded by health whilst that operated with health is funded by both

4. The service was awarded to Goldsbrough Healthcare and went live in August 2010. A staged roll-out across the county followed.

Luton Borough

Council (UA)

(updated Feb 2012)

Intake and Assessment Service (see note 2 below) Model: selective Funding: by the Council Provision: in-house service


1. Scheme in operation for two years, providing support for up to 6 weeks

2. Referrals taken from hospital and community

3. Phase 1 from Nov 2008 took older adults > 65yrs

4. Re-ablement Service currently being reorganised to expand to under 65yrs

Norfolk County

Council

(updated Jul 2010)



Document

Intake and Assessment Service (see note 4 below) Model: de-selection Funding: by the Council (see note 1) Provision: in-house service (see note 1 below)

FACS: Substantial and above and applied at entry to and exit from re-ablement service (see note 8 below).

1. Norfolk County Council Adult Social Services remodelled its home care services and commenced our assessment and re-ablement service in February 2008.



2. To date 37% of service users have not required an ongoing service.

3. Hours transferred to the independent sector show a reduction of 69% from the total number of hours delivered in the first week of Norfolk First Support.

4. Norfolk First support receives referrals from the acute hospitals, community hospitals, transitional beds and community services, where they meet the criteria.

5. To date we have provided the service to 4,375 people. 6. Norfolk First support service is a six week service of

intensive input to optimise service users independence, following which any ongoing homecare needs are supported by external providers.

7. The County has 21 Block Contracts with 10 Independent Home Care Providers

8. The service is subject to FACS assessment at entry to service.

9. Norfolk first support has trained 250 staff who work in the service in assessment and re-ablement skills. The service works closely with our Occupational Therapy teams .

Peterborough City

Council (UA)

(updated Jan 2010)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: outsourced service (see note 2 below)


1. Currently, the service is quite diverse. 2. Delivery undertaken by the provider services through the

PCT.

3. Currently reviewing services to introduce a re-ablement service across the council



Southend on Sea

Borough Council (UA)

(Jul 2010)

Intake and Assessment Service Model: de-selective Funding: with health (see note 4 below) Provision: in-house service

FACS: Substantial and above and applied on exit from re-ablement service.

1. The Collaborative Care Team provide intensive rehabilitation at home to promote optimum independence, with the outcome to enable people to remain in their own homes and prevent long term admission to residential care. It has also provided a re-ablement service since April 2009.

2. Team supported by an occupational therapist and a physiotherapist with nursing input from a community matron and assessment nurse. The nursing input is in the process of being increased due to the complexities of some of the patient groups.

3. Working closely with the intermediate care teams and the Cumberlege Intermediate Care Centre (residential), the team have enabled a reduction in home care packages that would have been provided by the independent sector.

4. Funding is predominantly by the council with some from health

5. A business case for an enlarged service has been approved and work has commenced on this project.

Suffolk County

Council

(updated Jan 2008) See CSED Benefits of


Document

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service

FACS: Substantial and above and applied at entry to and exit from re-ablement service

1. The in-house Home First scheme was first started in Sept 2006, initially offering a 12 weeks re-ablement service. The

4. Wish to undertake an evaluation



service changed in October 2008 and now provides a re-ablement and assessment service for up to 6 weeks for people being discharged from hospital or at a point of crisis.

2. Any remaining need the customer has for long-term home care is commissioned from private sector providers.

3. Scheme has been successful in terms of helping people to reach and maximise their potential, support the assessment process and reduce hospital delays in transfers of care.

Thurrock Council

(UA)

(updated Jun 2010)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council with health Provision: in-house service


1. Establishing an intake and assessment service that supports people for up to 6 weeks.

2. Service will be operated with health in-house and not be subject to charge

3. Clients to be supported will be all adult groups other than older clients with mental health needs.




LONDON REGION


Barking and

Dagenham (London

Borough of)

(updated Jun 2010)



1. Service is called First Response. Initially it was focused on hospital discharges but then expanded, as planned, into an intake and assessment service...

2. Work to refocus the in-house homecare service started in Sept 2008 and the new service commenced Jan 2009. Service formerly launched in May 2009 following training of all teams. Subsequent work to increase focus of seniors on clients by establishing support roles to undertake rostering.

3. In-house staff numbers reduced and some former homecare staff now support in-house specialist dementia team and four extra care facilities.

4. Referrals will initially come following FACS, though we may review this for the re-ablement element if we feel people are being denied access who would benefit.

5. We have scoped the size of the service by looking at previous referral data (which is subject to FACS).

6. Adult Social Services operate an ‘apprentice’ scheme to train

7. Focusing on level of non-completers mainly as a result of inappropriate referrals



young people across the organisation including the re-ablement service. This has been a positive step to create skilled workers with relevant experience.

Barnet (London

Borough of)

(updated Jun 2010)

Intake and Assessment Service Model: De-selective Funding: by the Council Provision: outsourced service

FACS: Substantial and above and applied at entry and exit to re-ablement service.

1. The enablement service is still technically a pilot although in terms of timescales the pilot of 6 months was extended for another 6 months ( it is available to all adult groups and across whole area )

2. Service is outsourced to a single provider

3. Plans to increase the volume of activity

Bexley Borough

Council (London

Borough of)

(updated Jan 2012)

Intake and Assessment Service (see note 2 below) Model: De-selective Funding: by the Council and health (see notes 3 and 4 below) Provision: outsourced service (see notes 3 and 4 below)


1. Reablement service started in full in August 2009. 2. In addition to intake and hospital referrals, re-ablement is

also used after yearly reviews and to people with learning disabilities.

3. The re-ablement provision is outsourced to a number of care provider agencies but the service is monitored by an in-house service of OT’s and Rehabilitation Assistants.

4. Health monies enabled the temporary recruitment of a Social Work Assistant and a Physiotherapist (seconded from health).

5. Telecare just introduced to complement re-ablement 6. 82% of new referrals for care packages go through re-



ablement 7. 48% of clients ended without a care package

a. 52% with a care package of which 20% ended with the same care package as at start of reablement, 13.5% with an increase and 66.5% with a decrease

Brent Council (London

Borough of)

(updated Jul 2010)

Intake and Assessment Service, (see note 1 below) Model: de-selective Funding: by the Council Provision: out-sourced (but see note 2 below)

FACS: Substantial and above and applied on entry to and exit from re-ablement service.

1. A new intake and assessment re-ablement service was launched on the 19th April 2010 and is being phased in to March 2011. The service will also include people on long term review and discharges from hospital.

2. The main re-ablement service has been outsourced to a range of providers whilst OT support is provided in-house, and physiotherapy support provided from Health.

3. Planning to extend authority wide by Mar 2011

4. Numbers are being phased in so by March 2011 75% of referrals will go through re-ablement service

Bromley Council

(London Borough of)

(updated Jan 2012)

Intake and Assessment Service Model: de-selective Funding: Jointly with health (see note 5 below) Provision: in-house service (see note 6 below)

FACS: Substantial and above and applied at entry to homecare re-ablement.

1. Have an intermediate care service with 60 beds and 2 Community and Assessment Rehabilitation Teams with domiciliary care staff. This service is not charged.

2. Started planning and mobilisation in Aug 2009. 3. Hospital discharge pilot started Jan 2010. Now standard

service for new referrals as per plan. 4. Refining selection criteria in light of experience.

5. Most funding from LBB but some of the “reablement “ funding that went to the PCT was used to increase the speed of roll-out

6. We are considering market testing for all our in-house services and



have a contract with 2 providers for non-FACS individuals using the “Reablement” funding

Camden Council

(London Borough of)

(updated Dec 2009)

Hospital Discharge Support (solely or primarily) (see notes 2, 4 and 5 below) Model: de-selective Funding: by the Council Provision: outsourced service (see note 3 below)

FACS: Substantial and above.and applied on entry to the service

1. Ran an early discharge Scheme using Enabling Carers (managed by Health but jointly funded) for 6 weeks to supplement OT and Physiotherapy interventions. 90% have reduced care packages, approximately 80% needing no care at the end of 6 weeks intervention.

2. Currently running a pilot hospital discharge services from Oct 09 with a view to completing a review in Dec 09.

3. Pilot service is outsourced to external providers: one in the north and one in the south

4. Dec 09 – will evaluate pilot with aim to expand

5. Subject to outcome of pilot plan to roll out an intake and assessment service from Jan 2010. This will operate on a deselection basis

City of London

Council

(Dec 2009)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service (see note 1 below)

FACS: Substantial and above and applied on entry to and exit from re-ablement service. )



1. A service is in place within adult homecare services

3. Currently planning to develop it as part of the overall plan for Home care and make the service fully inclusive.

4. Target for implementation is Autumn 2009

Croydon Council

(London Borough of)

(updated Apl 2008)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: outsourced service

FACS: Substantial and above and applied at entry to and exit from the re-ablement service.(see note 3 below)



1. Croydon previously operated a re-ablement service to facilitate hospital-discharges but this service was decommissioned due to cost pressures.

2. We continue to offer a range of re-ablement and rehabilitation-type services including a few re-ablement flats and rooms, within residential establishments, and we offer up to six weeks of free domiciliary care to all new service users, that have not previously received service, discharged by the hospital-based care managers.

3. Croydon's FACS criteria were originally set at 'substantial and critical only' and we do not see this changing in the foreseeable future. It is not applied to entrants to the service from hospital discharge

4. We are about to undertake a review of all of the Council's hospital discharge, intermediate care and the remaining re-ablement service, with a view to coming up with a more streamlined set of services which maximise benefit to users.

5. Seeking to establish a hospital discharge service as first stage

Ealing Council

(London Borough of)

( Jan 2012)

Intake and Assessment Service Model: selective Funding: by the Council Provision: in-house Re-ablement service

FACS: Substantial and above.and applied on entry to the service

1. The In-house Homecare Service provides a selective re-ablement service to customers who have been referred by care management teams. This service provides care for a period of 6 weeks, a review by the Service determines whether future care needs are required.

2. The Service is predominately targeted towards providing re-ablement care to customers from Active Rehabilitation and Intermediate Care Services (ARISE) Referrals are also considered from the Community Teams following an assessment.. . .

3. Reablement services work closely with the assessments teams and during less busy times can undertake welfare checks to determine level of service required



4. Reablement Services can undertake follow-up visits following discharge from hospital for individuals who may decline support on discharge . The visit will determine if support is needed or in situations individuals may be signposted to other amenities. Within their community.

5. Reablement services also cover Telecare Responses between 7 am and 8pm daily.

Enfield Council

(London Borough of)

(updated Jun 2010)

Hospital Discharge Support (see note 9 below) Model: selective Funding: by the Council Provision: in-house OT service working with in-house and external providers (see notes 7 and 8 below)

FACS: Substantial and above and applied on exit from the service

1. The pilot Homecare Enablement Service commenced on 28th May 2007, with one Occupational Therapist working with both the in-house and external care providers. Since this time, the pilot has continued to make substantial savings, thus helping the continued funding of the post.

2. The project has proven to be successful in terms of educating and working together with Providers, Care Workers and Service Users; moving from traditional care practices to more outcome-focussed person centred care planning. Presentations have been made to all providers, including specific BME providers and we are starting to link in more with Telecare.

3. Care workers are experiencing significant changes to way in which they assist service users in their daily activities. This is providing both service users and carers with greater confidence to develop new techniques and skills.

4. Of the 89 service users who received input from the re-

8. Plans are in place to expand the project by Aug 2010 to achieve;

a. Maximisation of service user’s functional independence and performance satisfaction

b. Establish a full intake service by focusing the in-house homecare teams on re-ablement

c. Ongoing financial savings



enablement occupational therapist, 35% were able to have their care package reduced.

5. The Canadian Occupational Performance Measure (COPM) is being used as an outcome measure to record improvements in functional performance. In time, the COPM will be used to provide further data regarding benefits of re-enablement input to service users.

6. We work with all clients. We accept self-referrals along with those from other professionals. The only 2 main criteria is that they receive a care package funded by social services and that they are 65+.

7. The enablement service offered is an OT who will work with Provision: in-house and external providers. We don't have a dedicated care provider we work with.

d. Better use of existing services

e. See how this service fits in with Personalisation.

Greenwich Council

(London Borough of)

(updated Jan 2012)

Intake and Assessment Service (see note 1 below) Model: de-selective Funding: with health Provision: in-house service (see note 1 below)

FACS: Substantial and above and applied at exit from the service

1. Greenwich Intermediate Care at Home Team was developed in 2005 from the in house home care team as a specialist re-ablement service. Following a re-organisation in April 2011 the service became the provider element of the new integrated Health & Social care model in Greenwich.

2. All new care packages and existing care packages that require a significant change are offered a period of

re-ablement. 3. All Support Workers have received enablement training and

all trained to carry out diagnostic testing. 4. Between April – December 2011 643 service users



completed a period of re-ablement. Approx 61% did not require on going homecare after re-ablement

Hackney Council

(London Borough of)

(updated Jun 2010)

Intake and Assessment Service Model: de-selective (see note 4 below) Funding: with health


FACS: Substantial and above applied at entry to re-enablement service.

1. The team has been running for over 10 years. Originally, its remit was to support people leaving hospital with potential to make substantial improvements within 6 weeks with the support of Rehabilitation Care Workers.

2. In 2004, the team added an Occupational Therapist and an OT Assistant to the establishment to increase the rehab focus - to develop more detailed rehab plans and support the manual handling challenges of complex care needs in the community. The service has grown incrementally since then and currently supports approx. 1,000 service users each year.

3. The service has three streams: intermediate care with clear rehab goals (average 55% reduction in packages); standard for those coming to the service with apparently stable needs (average 55% reduction in packages); palliative care for those with life limiting illness.

4. The service works on a de-selective basis.



Hammersmith and

Fulham Council

(London Borough of)

(updated Jun 2010)

Hospital Discharge Support (solely or primarily) (see note 4 below) Model: selective (see note 4 below) Funding: by the Council Provision: in-house service

FACS: Greater Moderate and above and applied at entry to and exit from re-ablement service.

1. Scheme in place ‘STARS’ (Short term assessment & re-ablement service)

2. The new service operational from Oct 1st 2007 was formed from the reorganisation of the in-house directly provided home care service.

3. The service structure is entirely new with new job descriptions for re-ablement officers and dedicated training. All staff have been appointed since September 07

4. Service was originally targeted and linked to hospital discharge working closely with hospital therapy and within a line management arrangement linking with Careline and hospital social work services. Extended to take limited referrals from the community in July 2009 through a pilot in the south of the borough.

5. Service operates on a selective basis 6. Currently an average of 65 users at any one time

7. Service expansion plans are currently being developed

Haringey Council

(London Borough of)

(updated Jun 2010)

Hospital Discharge Support (solely or primarily) (but see note 8 below) Model: selective Funding: by the Council Provision: in-house service

FACS: Substantial and above and applied at entry to re-ablement service. (see note 6 below)



1. Prevention and Enabling Team has now broadened so that the whole service is Re-ablement and incorporates an increased focus on admission prevention alongside hospital discharge. Thus it is largely focussed on hospital discharge referrals.

2. The majority of home carers have had enabling training. In 06-07 there were 608 service users of which 406 were independent within 8 weeks- 67%.

3. The Re-ablement Service was consolidated in recent years, with all home carers receiving re-ablement training, including the in house Staff Bank workers.

4. Admission Prevention care packages doubled during the 2007/08, and generally the service users had more complex needs than previously. This means that the number of people who were independent within 8 weeks decreased during 2007/8.

5. In 2007/8 the Rapid Response Team received 1,081 referrals, of which 559 had a care package from the Re-ablement Service. 67% were independent or had their care package substantially reduced within 8 weeks.

6. The service is subject to FACS at entry, providing at the level of critical and substantial.

7. S31 funding in place with Health

8. Plans underway to move to a council wide intake and assessment service from Oct 2010.

Harrow Council

(London Borough of)

( Jan 2012)

Hospital Discharge Support (solely or primarily) – see note 2 below Model: de-selective Funding: by the Council with health (see note 5 below) Provision: outsourced service (see note 6 below)

FACS: Substantial and above and applied on exit from the service.



1. The Current service was developed from a pilot linked to Intermediate care and hospital discharges. This extended model has been in place borough- wide since October 2010 and is accessible to new users 18 yrs and over entering social care. The service will be extended to existing service users from April 2012.

2. A dedicated Reablement team have been established as part of the overall transformation of Adult Social Care in Harrow.

3. The Reablement service’s key focus is empowering people to help themselves, maximising independence, preventing hospital admissions and facilitating safe, effective discharge. Service Users are signposted to the Harrow’s Citizen portal- Shop4Support site where possible to facilitate access to services and equipment.

4. A specialised Reablement Skills and Support Programme provided for a period of up to 6 weeks has been developed as part of the suite of Reablement services in Harrow. RSSP is delivered by a multi- disciplinary staff team including OT’s; day services staff and physo’s based in a Neighbourhood Resource Centre.

5. Health funding contribution through Harrow Strategic Partnership

6. Reablement Home support of the service is outsourced to two providers working in different parts of the borough however the new Reablement Skills & Support arm is delivered by in-house staff

7.

8. Outcome measures include: 79% of service users do not require ongoing support following Reablement and overall satisfaction with the service is high (91%) of service users.

Havering Council

(London Borough of)

Intake and Assessment Service Model: selective (see note 4 below) Funding: by the Council Provision: in-house service (but see note 5 below)



(Feb 2012) FACS: Substantial and above and applied on entry to and exit from the service.

1. Service in place with referrals taken from hospital, ICAT and community.

2. Service also has a residential option at Royal Jubilee Court since Jan 2009

3. Service is subject to charge after 6 weeks

4. Working towards a de-selective model

5. External providers have been invited to submit expressions of interest as part of the Council’s consideration of outsourcing the service.

Hillingdon Council

(London Borough of)

( Feb 2012)

2012

Hospital Discharge Support primarily (see notes 7 and 9 below) Model: selective Funding: by the Council Provision: in-house service




1. The London Borough of Hillingdon’s Reablement service started in August 2010 but is only since April 2011 when the in-house team had completed the transfer of existing long term Homecare packages to the private sector that the council now offers an in-house reablement service only. Service Users who need continued Homecare support following the 6 week reablement period are transferred to Private Agency Care Providers. The council FACS criteria is Substantial and Critical.

2. Specific Reablement training for all Carers has been undertaken over the last 18 months which enables the workforce to deliver a fully focussed Reablement Service. The Senior Carers for Reablement have undertaken a Trusted Assessor training course to enable them to order Occupational therapy aids and adaptations.

3. Mobile working is now in place utilising Laptops and Printers. This enables the Senior Carers to complete a Risk Assessment and set realistic aims and objectives to support the reablement process whilst meeting with the service user/carer.

4. The IT system (Protocol) offers a structured screening process and enables clear communication between all departments. This is because all documentation is entered electronically thereby enabling all relevant parties within the department to share a service users information.

5. The support of Occupational Therapists and Physiotherapists are proving to be a major factor in achieving the service users outcomes and/or decreasing any ongoing care packages for service users that maybe necessary.

6. The council invested £700k (ongoing) in April 2011 to enable the existing Careline and Telecare service combine into a new service which the council has called TeleCareLine. This



investment has proved to be an invaluable part of the service. Further information can be found at http://www.hillingdon.gov.uk/index.jsp?articleid=22389.

7. The team receive 15-22 referrals per week which are primarily Hospital Discharges. When a Care Package starts with Reablement the Senior Carer allocated to that care package, must complete an initial assessment within 24-48 hours. The care plan undertaken at that time, reflects the service users aims goals and objectives which are reviewed weekly to ensure good progress is being made.

8. The prescription service is available so that the Service User has more control and choice over which equipment is recommended by the Occupational Therapist and Senior Carer who is a trusted assessor. This is an important and vital part of the holistic approach which allows the service user to discuss and agree the equipment they need to support there needs.

9. Have an intake service for which the majority of referrals (90%) are hospital discharge

Hounslow Council

(London Borough of)

(updated Jun 2010)

Intake and Assessment Service (see note 3) Model: de-selective Funding: by the Council Provision: in-house service

FACS: Substantial and above and applied on exit from the re-ablement service. (see note 4)

1. Expanding our in-house “Assessment and Re-ablement” Service so that during 2007 all new cases (including younger disabled people) receive the optimum type and level of service.

2. Evaluation to date has been encouraging, indicating strong volumes and performance delivering modest purchasing

4. Application of FACS is subject to a review



budget savings and increased independence. 3. Service operates on a de-selective basis

Islington Council

(London Borough of)

(updated Jul 2010)

Intake and Assessment Service (see note 1 below) Model: de-selective Funding: by the Council (see note 3 below) Provision: in-house service (see note 2 below)

FACS: Moderate criteria and above are applied at entry to and exit from the Reablement service.

1. .July 2009 - Open to all new referrals and clients already receiving social care services as well as clients from the community, hospital and A&E who would benefit from a period of Re-ablement

2. The Re-ablement Service is managed and staffed by Islington employees. It is managed as a joint service between NHS Islington and London Borough of Islington as part of intermediate care services across the borough

3. The service has a strong OT philosophy and the staff are managed on a daily basis by the two OTs

4. The service operates from 7am to 11 pm 7 days a week. 5. Integrated pathways and seamless/interdisciplinary working

has improved productivity and outcomes for clients and staff improved productivity

6. Further on going work to integrate intermediate care services across LBI and INHS will be ongoing through out 2010.

Kensington & Chelsea

Council (Royal

Borough of)

(updated Jun 2010)

Hospital Discharge Support (solely or primarily) (see notes 1 and 2 below) Model: selective (but see note 2 below) Funding: by the Council Provision: in-house service


1. The re-ablement service has principally focused on 2. Planning to expand the



discharges from one hospital and operational for 5 yrs+. However, it has recently expanded over the last 9 mths and now works across all hospitals and accepts community referrals

service further and move to a deselection model from mid 2010.

Kingston Council

(Royal Borough of)

(updated Jan 2012)

Intake and Assessment Service Model: selective Funding: by the Council Provision: in-house service

FACS: Substantial and above

1. The Assessment and Reablement Team (ART) consists of care managers /Occupational Therapists /Enablers working together to provide a reablement service for up to a 6 week period.

2. The Occupational Therapists identify set goals with the customer . The progress is reviewed on weekly basis . If longer –term support is required after the service has ended the care manager will arrange this incorporating the final report from the Occupational Therapist.

3. r

Currently we are reviewing the provision of reablement and intermediate care with a view to integrating health and social care

Lambeth Council

(London Borough of)

(updated Jan 2012)

Hospital Discharge Support & Community Care Support (Community Social Care Teams) (see notes 1 and 3 below) Model: selective Funding: Health and Social Care jointly fund (see note 2 below) Provision: Outsourced service (see note 4 below)

FACS: Substantial and above and applied on entry to and exit from the service

1. Currently moving into third phase – including all adult Lambeth residents who are discharged from hospital and all adult Lambeth residents from Community Social Care Teams that meet FACs criteria to receive homecare services.

6. Service expansion plans are currently being developed and exploring closer working relationships around Enablement with adjoining local authorities.



2. The service is integrated service between Health and Social Care and is an integral part of intermediate care service and community care provision.

3. There is no charge for the enablement service for up to 6 weeks.

4. Services are commissioned from a single external home care provider. The home care provider is responsible for the overall management of the home care staff. The integrated health and social care team provide training to home care staff on a 6 weekly basis and will soon launch “refresher” afternoons to maintain good practise, knowledge and skills.

5. Health provides physiotherapy, occupational therapy as well as nursing. Social Care provides administrative and social work intervention and support.



Lewisham Council

(London Borough of)

(Oct 2009)


FACS: Substantial and above and applied on entry to the service

1. Pilot went live Nov 09 and operates on a selective basis 2. Service is not subject to charge for the first 6 weeks

3. Intend to benchmark against others services

Merton Council

(London Borough of)

(updated Oct 2008)

Intake and Assessment Service (see note 1 below) Model: selective / de-selective Funding: by the Council (but see note 4 below) Provision: in-house service (see note 1 below)


1. Currently running a project to turn our current home care and hospital discharge service into a smaller re-ablement service providing short term (6-8 weeks), but intense intervention to all individuals; either following discharge from hospital or following a community referral. (Went live with the service in October 2008)

2. This will involve downsizing the current teams by approximately 50%, possibly through evoking TUPE regulations and transferring all existing service users in receipt of on-going care over to the independent sector.

3. A project plan has been developed and a project team launched with input from health partners, including therapy professionals. We are currently working through the various stages required to implement a robust social care re-ablement model of practice and hope to have the service up and running by September 2008.

4.

5. Following this, it is our intention to then undertake further work with health partners to extend the model into a joint health and social care re-ablement / intermediate care service.



Newham Council

(London Borough of)

(updated Jul 2010)

Intake and Assessment Service Model: selective (but see note 7 below) Funding: by the Council Provision: in-house service


1. Small pilot re-ablement service attached to Home rehab service established Feb.08 for 6 months with evaluation

2. Establishing a full service: Project resource in place scoping in-house home support re-design to develop a full re-ablement service for all adults 18+

3. FACS critical and substantial-likely FACS criteria will be applied on exit.

4. Currently council does not charge for home support 5. We currently have an in-house home support service (3,500

hours per week) and commission externally (approx 16,000hours) from our contracts

6. Newham commenced enablement February 2010. Transformation of Adults service to be in line with enablement. 4 main teams: Hospital, Intake & Review, Independent Living Services (Enablement sits here) and Supported Care

7. Intend to move to de-selective model when fully staffed

Redbridge Council

(London Borough of)

(updated Jun 2010)

Hospital Discharge Support (solely or primarily) (see notes 1 and 3 below) Model: de-selective (but see note 3 below) Funding: by the Council Provision: outsourced service (see note 2 below)

FACS: Substantial and above

1. Hospital discharge service launched in Dec 2009 to complement an existing intermediate care service.

2. Service is outsourced.

3. Planning to move to an intake and assessment model during 2010

Richmond Council Hospital Discharge Support (solely or primarily) (see notes 2 and 6 below) Model: selective



(London Borough of)

(updated Jun 2010)

Funding: with health Provision: outsourced service (see note 3 below)

FACS: Moderate and above and applied on exit from the service.

1. Introduced a homecare re-ablement service wef 27th Apl 2009.operating on a selective basis

2. Implementation over 3 phases, the first being a hospital discharge support service

3. Engaged with three external providers but considering need for more. Subsequently appointed Housing 21 as the provider.

4. Activity to 5th August 2009 showed 71 referrals of which 61 started the service and of these 23 had left. Of these 17 returned to the community and 6 were either admitted to hospital or long-term residential care, or died.

5. Of those that returned to the community a. 3 reduced their package by 0 to 24% b. 1 reduced their package by 25 to 49% c. 3 reduced their package by 50 to 74% d. 1 reduced their package by 75 to 99% e. 7 required no further homecare support

6. Phase 2: roll out of an intake and assessment service for older adults, MH, LD and younger adults

7. Phase 3: improved linkages to community groups, voluntary sector, etc.

Southwark Council

(London Borough of)

(Jul 2010)

Intake and Assessment Service (see note 2 below) Model: selective (see note 2 below) Funding: by the Council Provision: outsourced service

FACS: Substantial and above. and applied on entry to and exit from the service

1. Pilot service started Oct 2009 and operates on an intake and assessment basis.

2. It has been outsourced to one provider 3. Entry is both selective and subject to FACS



Sutton Council

(London Borough of)

(updated April 2008)


Longitudinal Study

Document



Document


FACS: Moderate and above and applied at entry to and exit from the re-ablement service.

1. Scheme started principally to support hospital discharges 2. In line with the Councils plans to modernise Community

Based Services in September 2007 the Councils Executive Committee approved plans to transform the in-house Home Care service into a Re-ablement ‘intake’ team by September 2008

3. The previous START service, which formed part of the in-house team was greatly expanded so that all new users of homecare services in Sutton have the opportunity to receive a period of intensive assessment and rehabilitation in the home, in order to assist people to be as independent as possible

4. Existing service users also have the opportunity to be referred to the service if it has been identified they would benefit from a short-term period of assessment to meet changing needs

5. The expansion of the START service means the in-house Home Care team are no longer be able to provide long-term care packages.

6. Our intention is to provide a service which:

• Is a universal re-ablement service open to all, regardless of diagnosis or clinical rehabilitation potential.

• Works closely with service users and carers to maximise independence

• Assists service users to link in with other support services and social activities in order to promote choice and well-



being.

• Takes referrals from both health and social services, including GPs, nurses, intermediate care practitioners and care managers.

• Refers directly to specialist health care practitioners where required.

• Is a flexible service, which can respond quickly according to need and can accept referrals out of traditional hours.

• Where ongoing care needs are identified, reviews and hands over individualised outcome focussed care plans, which will be maintained by mainstream providers.

7. And which focuses on the following types of situation:

• Intake of all new homecare referrals to promote independence from first contact with services.

• Support of timely hospital discharges

• Prevention of admission to hospital

• Prevention of admission to residential or nursing care.

• Prevention of care breakdown /provision of crisis support to informal carers

• Detailed assessment of complex cases - for instance where there is uncertainty about risk management

Tower Hamlets

Council (London

Borough of)

(updated Jul 2010)

Intake and Assessment Service (see note 3 below) Model: de-selective Funding: by the Council (see note 5 below) Provision: in-house service (see notes 3 and 4 below)

FACS: Substantial and above and applied on exit from the re-ablement service.

1. The LBTH supported a project (funded by neighbourhood renewal funds) to pilot the enhanced homecare service within Tower Hamlets, providing homecare assistants of the in-house intensive homecare service with training from both Nursing and Occupational Therapy. This training was

4. May consider need for external providers to support BME groups if in-house service does not provide appropriate



designed to develop their skills, enabling them to do simple nursing tasks thus reducing the need for qualified nurses to visit so frequently and to improve the standard of care. It also provided enablement skills training so homecarers are more able to support service users to retain or develop their functional independence and thus maintain or improve their health and well-being

2. The OT’s also carry out social care assessments and provide technological (e.g. community equipment, telecare etc) or environment adaptation solutions (e,g, level access shower, entry-phone system, stair lift) to enable the service user to be more independent in their home and community and reduce where possible their dependence on the homecare service.

3. Progress to date:

• Started with an in-house hospital discharge service April 2009,

• completed an evaluation in Sept 2009

• completed full year evaluation Mar 2010

• and then developed into intake and assessment April 2010

coverage.

5. Looking at joint Short Term Intensive Services with health.

Waltham Forest

Council (London

Borough of)

( Updated Jan 2012)

Hospital Discharge Support (solely or primarily) – (but see notes 5 to 8 below) Model: de-selective Funding: by the Council Provision: In-house service

FACS: Substantial and above and applied on entry to the Reablement service



1. We have developed our Home Care Services to be a 100%

reablement only service. Initially taking all hospital

discharges with a reablement agenda n now taking

community referrals and service users with existing care

packages but with a reablement agenda. Vision and

business case for the service is complete, with a clear

acceptance criteria.

2. Reablement works with people over 18 yrs and and is

developing to skills to be able to provide support for all client

groups.

3. The service supports people following a discharge from

hospital, a temporary illness or permanent disability, a fall or

crisis at home or a change in circumstances relating to them

or their carer.

4. Support workers are experiencing significant changes to way in which they assist service users in their daily activities. The Support workers are now working to a flexible working schedule, with adjustments made to existing contracts.The team now have an OT and this has significantly impacted on skilling up the support workers in embracing the reablement agenda , providing both service users and support workers with greater confidence to develop new techniques and skills.

5. From 01/01/11 to 31/10/11 540 service users who received input from the reablement team, 42% were reabled with no on-going care and 11% ended up with a reduced care package.

6. Phase 5 Further training and Consultation with staff to expand training for working with service users with LD & Sensory

7. Expand on the MDT working and recruit a Physiotherapist.

8. To continue to deliver on-going financial benefits.

Wandsworth Council Intake and re-ablement service. Model: re-ablement is selective but short term assessment is de-selective Funding: by the Council – but see notes below



(London Borough of)

(updated Oct 2009)



1. Re-ablement is provided for up to six weeks to those service users assessed as able to benefit, and service is open to referrals from all operational social work teams. It became fully operational from September 2008

2. The START coordinator visits each service user at the beginning of the six week period to agree the activities of daily living that the service user would like to work on to regain skills and confidence, and to set goals that the service user will be helped to achieve during the six week re-ablement period.

3. The home carers then work, during the assessed home care hours, to help the service user to do more for themselves, and the service user’s needs are reassessed towards the end of the six week period.

4. Re-ablement co-ordinators closely monitor progress made during the six week period and work closely with the service users, home carers, relatives and our health and social care partners to ensure that the goals set are being achieved.

5. Short term assessment is provided for service users who have been assessed as unable to benefit from a six week period of re-ablement , but whose need for home care has increased following a period in hospital or a significant change in assessed need in their own home.

6. Under the Short term assessment model, service users would receive services for up to six weeks in order to confirm their level of need for long term home care services, prior to the transfer to an external provider.

7. The model also assumed that all existing home care service users who, following reassessment, were deemed to have

8. Current re-ablement service continuing:. working through restructuring, transfer of users, and has designed a monitoring and evaluation systems to monitor progress and effectiveness of the START Service.

9. Pathways are being developed to work more closely with Intermediate Care / Telecare / OT service and to promote Direct payment & Telecare and to drive forward the personalisation agenda.

10. To provide re-ablement services to step down bed for up to six weeks with the aim to prevent residential and nursing care placement.

11. Wish to develop an holistic vision of re-ablement across Health and Social Care services in



increased needs for home care would be referred to the START Service for a short period of either re-ablement or short term assessment.

Wandsworth.

Westminster City

Council

(Jun 2010)


Information section of

CSED Discussion Document

Intake and Assessment Service (see note 2 below) Model: selective Funding: by the Council with health (see note 2 below) Provision: Outsourced service (see note 3 below)


1. The service was originally an in-house specialist team. The whole in-house home care service was transferred to Housing 21 in 2001.

2. The service was developed, working with Health, and in Phase 1 (Apl 09) it took all new referrals from south of the borough and then in Phase 2 (Aug 09) it took all new referrals from the community and hospital discharges across the borough

3. The service remains outsourced to Housing21 with therapists and assistant therapists provided in-house.




NORTHERN REGION


Darlington Borough

Council (UA)

(updated Jan 2012)

Intake and Assessment Service Model: de-selective Funding: by the Council Provision: in-house service with the provision to spot purchase

FACS Moderate and above and applied on exit from the service

1. The service will be for all adults for a period up to six weeks except those who are deselected due to end of life conditions, complex long term conditions, safeguarding or an inability to benefit from the service. The service will be open to people who have an apparent need for domiciliary support prior to FACs being applied

2. The service has been growing since its inception with over 36,000 hrs, The service has been provided by both the in-house service as well as with independent provider, who have provided approx a third of reablement service

3. 70% have no longer needed a service following reablement, and 65% were very satisfied with the service they received.

4. Currently developing a performance framework that cuts

7. .



across the continuum of Intermediate Care which includes different elements of reablement, i.e. British Red Cross hospital discharge scheme, Enablement low level service, Lifeline, Assistivwe technology.

5. Implementation has begun to integrate reablement with ICS health

6. Review of Reablement to be undertaken to determine to tender with one/two independent providers to provide reablement as opposed to all 12 under the Framework Contract

Durham County

Council

(updated Jul 2010)

Intake and Assessment Service (see note 1 below) Model: de-selective (see note 1 below) Funding: by Council Provision: in-house service


1. Proposed that the re-ablement team will eventually be an intake and re-ablement service for all new home care referrals taking referrals from the Integrated Teams and the Intermediate Care Teams.

2. Currently refocusing the in-house home care service from traditional long-term home care to a de-selective re-ablement service.

3. The service will continue to be part of DCC’s Adult Care Service and funded by them.

4. Currently developing pathways, procedures, training programme, performance measures and engaging stakeholders .

5. Planning to implement from Jan 2011, initially recruiting staff from existing homecare service, but may be able to offer opportunities to existing staff who are working in residential care.

6. The in house home care service will cease to provide any long term home care packages



Gateshead Council

(Metropolitan)

(updated Oct 2010)

Intake and Assessment Service (see note 2 below) Model: de-selective (see note 2 below) Funding: by the Council Provision: in-house service

FACS: Substantial and above. and applied at entry to and exit from re-ablement service (see note 2 below)

1. The new re-ablement service will commence on 1/11/2010, and will be called START (Short Term Assessment and Reablement Service).

2. The service will be for all adults for a period up to six weeks except those who are deselected due to end of life conditions, serious safeguarding concerns or a very obvious inability to benefit from the service. The service will be open to people who have an apparent need for domiciliary support prior to FACs being applied.

3. The Service has capacity initially to intake 200 hours of demand each week with a total of 1200 hours provision in the service at any one time.

4. In addition to taking new work the service would also anticipate being able to take on a proportion of reviews, particularly looking at longer term packages that have remained static over time or significant increases in current packages.

5. Closely monitor the effectiveness and processes for the new service over the next six months.

6. Review capacity issues 7. Link in closely with Health

to ensure there is a good balance between this service and intermediate care

8. Link in with short term residential intermediate and assessment units to maximise the effectiveness of these services

Hartlepool Council

(UA)

(updated Aug 2010)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service OR outsourced service

FACS: Substantial and above and applied at exit from re-ablement service if any ongoing package required



1. Service in place linked to intermediate care, 2. Operational for five years and includes access to telecare,. 3. Amalgamated homecare re-ablement with floating support

services to create one holistic service called Direct Care & Support Team in 2009

4. Service available 24/7 using an outcomes approach.

Middlesbrough

Council (UA)

(updated Apl 2008)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service


1. Scheme operating 2. We have recently reorganised our in-house services to

create more opportunity to undertake re-ablement work through a "first contact" service.

Newcastle City Council

(Metropolitan)

(updated Apl 2008)


Information Section of CSED

Discussion Document for

details of scheme in pilot phase

Intake and Assessment Service (see note 5) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service

FACS: Substantial and above and applied at entry to and exit from the re-ablement service.

1. Pilot phase in a specific area of the city has been thoroughly evaluated and service rolled out to the rest of the city.

2. Establishing the service further so that all new service users go through the re-ablement service before moving on to mainstream services if required.

3. The STAR team continue across the city for all service users who meet the FACS criteria

4. The vision is that ALL service users will go through the



STAR service as part of their assessment for long-term services, and the very process of receiving a STAR service early on will reduce their need for intensive long-term services. We expect to make progress on it within the year.

North Tyneside

Council (Metropolitan)

(updated Jan 2012)

Hospital Discharge Support ( primarily) (see note 3 below) Model: de-selective Funding: by the Council with some funding from health Provision: in-house service

FACS: Substantial and above and applied on exit from the service

1. The internal home care service has successfully changed remit to that of the Home Support Reablement Team. We continue to work with independent providers to offer a mixed economy of care within the Borough.

2. For some time now, we have used our Intermediate Care at Home Team to offer a multi-disciplinary assessment of need prior to a home care package being offered. This team is now integrated with the reablement service.Timely intervention provided in the person’s own home has proven that the individual is more likely to improve their functional ability with the support of a worker who has undertaken intensive training in therapy techniques and rehabilitation The integrated team facilitate discharge from hospital and prevent unnecessary admission to hospital and long-term care. North Tyneside are developing a pathway for community based urgent care

Northumberland

Council (UA)

(updated Apl 2009)


FACS: Critical and above and applied at entry to and exit from re-ablement service



1. The Short Term Assessment & Re-enablement Service (S.T.A.R.T.) formerly The Home Care Assessment Team (HCAT) commenced as an initial 6 month pilot in October 2003 in an urban area of the County.

2. Following an extensive evaluation of the pilot, the decision was taken to roll out the service in a series of phases initially across the remaining urban areas with a view to then extending the service County wide to include the more rural areas.

3. Purpose of S.T.A.R.T.

• To produce better outcomes for service users by enabling and promoting their independence.

• To provide an improved service to vulnerable older people with medium/long term complex stable and unstable needs

• To provide short term intensive home care at the outset with a view to reducing longer-term use of service by achieving care plan outcomes sooner.

• To enhance workforce skills and change the culture of home care provision from ‘doing for’ to ‘doing with’ in line with National Care Standards.

• To assist independent sector home care providers in managing service delivery, by reducing unpredictable and fluctuating demand on their services.

• To achieve the ‘correct’ level of ongoing care for those who need it.

4. The current position is that that the southeast urban area of the county is approximately 60% operational and currently reviewing situation . In the northern semi-rural area of the

5. To continue recruitment with a view to having the S.T.A.R.T. service across each locality of the county.

6. Work more in partnership with the independent sector

7. Continue to bridge gaps between Health & Social Care and become better integrated with intermediate Care Teams and Care Management.



county S.T.A.R.T. is operational. In the remaining semi-rural west area, recruitment needs to be reviewed.

Redcar & Cleveland


(Jul 2010)


FACS: Substantial and above and applied on exit from the services (see note 4 below).

1. Planning to start implementation of a service from 1st October 2010.

2. First phase will be staffed with 8 re-ablement assistants, 4 senior re-ablement assistants, one co-ordinator and one OT.

3. Currently identifying and commissioning bespoke training on Re-ablement and Personalisation including Person Centred Thinking, Support Planning and Outcome Based Reviews.

4. Proposing to apply FACS if a subsequent care package is required following re-ablement

South Tyneside


(May 2009)



1. The re-ablement service in South Tyneside (HART) started 5. We are hoping to increase



to work with their first clients a couple of months ago. It is in the very early stages, but the feedback from people we have worked with and the carer staff involved has been extremely positive.

2. The first phase of the service has started quite small with only twenty four carers being trained initially.

3. Referrals come from care managers for:

• first time referrals for a homecare service

• people who are existing service users but whose needs or circumstances have changed substantially and who are likely to benefit from the HART service.

• people for whom a significant gain in independence is not one of the identified outcomes of the care plan, but where it is necessary to establish what level of ongoing care they will need.

• People who are being discharged from hospital after a recent stroke and have been referred by the community stroke service.

4. The service works with clients for up to 12 weeks and it is free.

our team of staff gradually over the next few months and evaluate the service in October/November 2009. The evaluation is likely to be undertaken in-house rather than involve Northumbria University

Stockton-on-Tees

Borough Council ( UA)


FACS: Moderate and above.

Sunderland City


Intake and Assessment Service Model: selective / de-selective Jointly Funding: with health – see notes below Provision: in-house service – see notes below



(updated Jan 2012)


Information Section of


FACS: Low and above and applied at entry to and exit from re-ablement service. (see note 2 below)

1. Sunderland Council still operates within all four needs bands. The FACS banding is applied at the assessment stage. The banding may therefore be applied prior to Community Re-ablement services being set up, or, if a rapid response is required the service is set up and the banding is applied as follows:- a. Within the first 10 days of package, the allocated Care Manager, in line with their Team manager instructions, to contact an appropriate Service Coordinator to discuss the package and transfer/exit strategy for team. b. Between two weeks to six weeks, the sustaining package to be agreed, prior to service being transferred over to mainstream home care. c. Formal six-week review is completed. 2. Sunderland City Council currently has fifteen community Re-ablement Teams working across five geographical areas of the City. 3. Community Re-ablement Teams are accessible via an Intermediate Care and Reablement Single Point of Access pilot and operate as part of a wider Social & Health Care Service (working within the Council’s Health, Housing & Adult Services Directorate). Services provided may include Extra Care / Extra Care Reablement apartments, Time to Think Residential placements, Intermediate Care Bed Based Services. 4. Community Re-ablement Teams are staffed by Community Support Assistants, trained via a specifically designed dual NVQ 3 Social & Health Care Training Programme (the Council was awarded the UK Skills National Training Award 2006 for this Programme), to provide personal care, re-ablement and rehabilitation, together with basic nursing tasks under the direction



of a health professional. 5. The objectives of the service are to :- a. provide short periods of intensive support for people at home b. maximise opportunities for independence through rehabilitation and re-ablement c. support discharge from hospital, to prevent unnecessary admission/readmission to hospital or long-term care d. maximise care and support resources in the community and reduce duplication across services e. help people to regain their confidence and ability to continue to live at home f. provide support to people and their carers in the event of an emergency g. ensure short term interventions are monitored and care packages adjusted accordingly to meet changing needs, to sustain people at home h. promote wellness through screening and advice




NORTH WESTERN REGION


Blackburn with

Darwen Borough

Council (UA)

(updated Jan 2012)

Intake and Assessment Team (see note 2 below) Model: selective / de-selective Funding: by the Council Provision: in-house service

FACS: Substantial/Critical and applied on entry to the service

1. .

1. The service launched in September 2008 and developed from the in-house Domiciliary Care Service. Initially Reablement was under Provider Services but is now with the Commissioning Team of the Council.

2. Referrals are from hospital and community social work teams. For those service users who do not meet the FACS criteria of Substancial/Critical are sign posted to a range of preventative services.

3. The Reablement/Crisis Service is a 24/7 service and runs an out of hours Crisis Response service. It is registered with CQC

4. The Service has one Manager, three Deputy Managers, eight Reviewing and Assessment Officers, thirty five Support Workers, two



administrators, three Social Workers and one Occupational Therapist. The Reablement Team also has links with in house Initial Access Team (Social Workers), Moving and Handling Coordinator, Assistive Technology Team and Sensory Impairments Team.

5. The Reablement Service work with service users over the age of 18.

6. The Reablement Service receives referrals from Social Workers, for potential Reablement cases, short- term assessments, for increase in domiciliary care packages and twelve monthly statutory reviews of domiciliary care packages.

7. The Reablement Service works with service users for up to six weeks, although, if there is potential for a person to reach maximum independence, will work with the service user beyond six weeks.

8. All long-term care provision is commissioned from the independent sector.

9. Reablement/Crisis is a free service. 10. Reviewing and Assessment Officers have trained in

prescribing items of equipment to assist people in their daily living and as assessors for Assistive Technology.

11. Staffs have trained for the provision of Self Directive Support.

12. All staffs within Reablement are qualified to NVQ level 2, 3 or 4, Health and Social Care, Leadership and Management, Learning and Development, Business Administration. All have had Reablement training and mandatory training required by CQC.

13. The service works closely with the in house



Residential Intermediate Care Team. It also works closely with Health Colleagues e.g. Domiciliary Rehabilitation Team, Rapid Assessment Team, Physiotherapists, Stroke Team etc.

14. The Service has received positive comments from service users.

15. Service Users leaving the service independently has been above the national average.

Blackpool Borough

Council (UA)

(updated Oct 2009)

Intake and Assessment Service Model: selective / de-selective Funding: with health Provision: in-house service

FACS: Substantial and above and applied at entry to the re-ablement service.

1. This forms a very small part of in-house home care and is part of our wider intermediate care service that includes two resource centres [ARC and Hoyle] and Vitaline which is our assistive technology service. The service is also offered for 10 days to prevent delayed discharges from hospital, this is classed as interim care.

2. Have full multi disciplinary team meetings twice a week to go through referrals and ensure that the individual is directed to the correct service i.e. home care, a six-week assessment in the resource centre and always linked with what technology could support the person at home. OT support available on a limited basis.

3. A number of the staff have been trained as generic workers with health and can also provide some low level nursing care such as skin care, simple dressings and blood sugar monitoring. It is further hoped to expand this training.

4. The packages are flexible where necessary and not

8. Hope to expand the service to provide shorter six-week assessments.



always limited to the six week period. 5. We undertook a sample of clients and compared to the

longitudinal study commissioned by Care Services Efficiency Delivery and undertaken by the Social Policy Research Unit at York University. The Blackpool sample contained more clients in the 85+ age group, (41%), with 72% of the clients over 75 years. We looked at 32 clients who received the enablement service for a total of 1,178 days and the average length of time with the service was 37 days. The shortest time a client received enablement was 11 days and the longest time receiving service was 60 days.

6. The length of time spent per day on enablement ranged from 30 minutes to 4 hours.

7. Of the clients who received the service, 66% have not gone onto receiving home care services.

Bolton Borough


(updated Aug 2010)

Intake and Assessment Service (but see note 6 below) Model: selective (but see note 5 below) Funding: by the Council (see note 4 below) Provision: in-house service

FACS: Moderate and above and applied on entry to re-ablement service



1. Scheme partly in operation 2. Short-term assessment and support team currently

undergoing a review. 3. All referrals/requests for domiciliary support for Older

Adults are supported by this team who evaluate how needs can be best met – then commissioned from Ind. Agency.

4. Currently in house service with no PCT input. 5. Currently operate on a selective basis but moving

towards a de-selective basis

6. Considering a focus on hospital discharge support to improve benefits for clients and seeking to implement by Jan 2010

7. Service operates through Community Re-ablement Team and a Mental Health Team. Looking to merge into one service and improved integration with OT’s.

Bury Borough Council

(Metropolitan )

(updated Jul 2010)


FACS: Substantial and above and applied on entry to the service.

1. Scheme launched in 2007 2.

Cheshire East

Intake and Assessment Service Model: de-selective Funding: by the Council

Provision: in-house service (see note 2 below)

FACS: Substantial and above and applied on entry to the service

1. The services was launched in 2009 and rolled out to all areas of the authority in 2010.

2. Operates on a de-slective basis and is called Care4CE



3. 550 staff have undertaken modular Re-ablement training 4. Action planning and outcomes recording agreed 5. Data collection methods currently being agreed

Cheshire West and

Chester

Intake and Assessment Service Model: selective / de-selective Funding: by the Council


FACS: Substantial and above and applied on entry to the service.

1. Pilot started 2009

Cumbria County

Council

(updated Sept 2010)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service (see note 5 below)


1. Currently in the design phase to create a homecare re-ablement service (July to Nov 2010)

2. Work is ongoing to see how the re-ablement service will relate to other services such as Short Term Intervention (STINT), Telecare, the retail model for community equipment and other preventative services

3. Phase 2 will see a testing of the service in South Lakeland (Dec 2010 to Feb 2011)

4. Phase 3 will be the full roll out across the council by Apl 2011

5. The service will be delivered by staff within Cumbria Care alongside involvement of others including OTs



Halton Borough

Council (UA)

(updated Jan 2012)





FACS: Substantial and above and applied at entry to Rapid Access Rehabilitation Service

1. Evaluated internally 2. Have the following re-ablement services attached to an

MDT within intermediate care services, providing intensive re-ablement

• Rapid Access Rehabilitation Service 3. Have the following not attached to an MDT

• in-house home care service incorporating crisis intervention

• extra care- some element of re-ablement as required

Knowsley Borough


(updated Jul 2010)

Intake and Assessment Service Model: de-selective Funding: by the Council (see note 2 below) Provision: in-house service

FACS: Moderate and above and applied at entry to re-ablement service. (see note 3 below)

1. The service became operational in November 2008 having developed from the in-house service, which was completely subsumed in to the new service. We did not pilot the service, but moved straight to the new model of delivery, as we were of the view that there was now sufficient evidence that this was the appropriate step to take.

2. Although funded by the council, the service works closely with health

3. FACS criteria is applied for access to the service, but it extends to moderate, particularly where preventative

5. It has recently been agreed with the Commissioners to extend the service to older people with a mental health need, offering up to 12 weeks re-ablement, to support people through diagnosis, where appropriate, as well as hospital discharge. This will be a 12 month pilot to test



services are appropriate, or where intervention is targeted to identified risks that could increase to critical or substantial without time limited support. Thus the service is relatively inclusive in its approach.

4. There is also a good range of preventative services, so that people with lower level needs can be directed to these for support.

demand for the service, and outcomes.

Lancashire County

Council

(updated Apl 2008)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service – see notes below

FACS: Substantial and above and applied at exit from the re-ablement service. (see note 5 below)

1. Our Assessment and Re-ablement Service commenced operation in April 2007. All of Lancashire is covered but service has grown more quickly in some areas due to time taken to recruit and train staff.

2. The provider is the in-house domiciliary care service, which is commissioned to provide assessment and re-ablement under an SLA with the Adult and Community Services Directorate. The service is registered with CSCI.

3. All long-term care provision for adults is now commissioned from the independent sector.

4. The service has Home Care Officers (Re-ablement) who undertake overview assessments using SAP and also organise the re-ablement input. Home Care Assistants provide the re-ablement support.

5. Referrals are made from Adult and Community Services staff. The final FACS judgement is made at the end of the Assessment/ Re-ablement period.

6. A new SLA is to be negotiated for 2008/09.



7. A re-ablement with therapy service is available in some areas but not all.

8. Assessment and Re-ablement staff can assess for and deliver certain items of equipment to assist people in their daily living.

Liverpool City Council

(Metropolitan)

(updated Jan 2012)

Hospital Discharge Support (solely or primarily) (see note 1 and 2 below) Model: selective / de-selective Funding: by the Council (but see note 4 below) Provision: in-house service

FACS: Low and above. and applied at entry to and exit from re-ablement service

1. Hospital discharge, Short Term Assessment and rehabilitation at home service

2. Seeking to establish an intake scheme .

3. Pilot project established in part hospital to home team – support ongoing assessments and support planning following hospital discharge working in conjunction with reablement providers)

4. Pilot part funded through PCT Funding

Manchester City


(Jul 2009)

Intake and Assessment Service Model: de-selective Funding: with health Provision: in-house service

FACS: Substantial and above and applied on exit from service.

1. Community and hospital discharge service established that supports those who are in significant risk of losing their



safety and independence (see Council website) 2. Work with clients for up to 6 weeks 3. Service results show that 48% need no further care, 35%

have a reduced care package (11 hrs down to 6 hrs on average) and excellent customer feedback

Oldham Council

(Metropolitan)

(updated Aug 2010)

Intake and Assessment Service Model: de-selective Funding: with health Provision: in-house service (but see note 3 below)


1. Established Community Independence Team in October 2007. Team operates 7 days a week till 10pm.

2. Criteria: Dementia, Re-enablement and Mental Health problems. Team will work with service users for up to eight weeks until care is stabilised, then pass to the long-term team.

3. Service is provided internally with some external provision

Rochdale Borough


(updated Aug 2010)


FACS: Moderate and above and applied on entry to the service

1. Rochdale has established a project team to implement a Re-ablement and assessment service by April 2008.

2. It is anticipated that Rochdale will no longer provide any long-term care services.

3. Also looking to implement a small discreet Mental Health Service which will focus on Assessment in Respite, Day Care at home and Outreach.



Salford City Council

(Metropolitan)

(Jan 2007)



Document


Longitudinal Study

Document


FACS: Moderate and above and applied on entry to service

1. Intermediate Home Support team established 2. Rapid Response service operated as well with part funding

from health

Sefton Borough


(updated Jul 2010)

Intake and Assessment Service Model: de-selective Funding: by the Council Provision: Outsourced service (see notes 1 & 2 below)


1. The Re-enablement service is provided by Sefton New Directions Ltd (New Directions).

2. New Directions is commissioned by Sefton Council to provide the service.

3. The service employs 122 including management and administrative support.

4. The service is provided for a maximum of six weeks.

St. Helens Council

(Metropolitan)

Intake and Assessment Service or Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the council or with health Provision: in-house service



(updated Aug 2010)

See CSED Assessment


Surveys Document

FACS: Moderate and above

1. No re-ablement service. 2. St Helens have a community based Intermediate Care and

Rapid Response Team which is jointly funded (PCT and LA) multi-disciplinary team, and currently provides services to people aged 18 and over.

3. The Team includes nurses, therapists, a pharmacist, social workers and a CPN who undertake specialist assessments and put in short term programmes to maximise the persons level of independence. It also includes 17 multi-skilled support workers (providing approximately 500 hours per week) who support the professional members of the team by working with the service users on the re-ablement programmes.

4. Plans are underway to develop an enablement service and link it to Intermediate Care

Stockport Borough


(updated Aug 2010)

Intake and Assessment Service (see note 4 below) Model: selective / de-selective Funding: by the Council (see note 3 below) Provision: outsourced service (see note 3 below)

FACS: Substantial and above and applied on entry to and exit from the service.(see note 2 below)

1. Stockport MBC commenced a home support re-ablement pilot in August 2009 and, following the pilot, the service was launched to all new service users on the 15th August 2011

2. The service is subject to FACS criteria (Critical & Substantial).

3. The service is being operated by Stockport Council and provided by 'Individual Solutions SK' (ISSK), a wholly owned company of Stockport Council. http://interactive.stockport.gov.uk/ISSK/

8. Information governance arrangements have been reviewed and the provider will have restricted access to the Councils Adult Social Care database which will include data input by May 2012.

9. Work is on going to consider the next phase of



4. Referrals are accepted from both hospital and the community.

5. The service has been strengthened through the introduction of a pilot enabling two Adult Social Care employed Social Workers and two Occupational Therapists to be based with ISSK. This team focuses on undertaking reviews for those services users discharged from hospital. The pilot will be evaluated in April 2012

6. A Just Checking system has been purchased and a second system is to be obtained to enable the assessment process to consider needs, as required, over a 24 hour period

7. A performance monitoring framework has been developed and is being refined on an on-going basis

implementation and to extend to all new cases presenting for assessment



Tameside Borough


(updated Aug 2010)

Hospital Discharge Support (solely or primarily) Model: de-selective Funding: by the Council Provision: in-house service

FACS: Substantial and above. and applied on entry to and exit from the service

1. Tameside set up an intake re-ablement service from an existing in-house team of Homecare workers..

2. Currently training staff and hoping to start with discharges from the hospital in Tameside.

3. Initially the service will start small. Piloting at the first stage new service users and also existing service users known to us who require an increase in service

4. Pilot started Re-ablement on the 13th July 2009 with phase 1 through referrals from the Hospital Discharge Team.

5. Evaluation of pilot completed and so now planning to move to mainstream model as part of wider transformation agenda by Sept 2010

Trafford Council

(Metropolitan)

(updated Jan 2010)


FACS: Substantial and above and applied on entry to and exit from the re-ablement service.

1. Have a scheme in place 2. Expanding the scheme, and undertaking further

development work

Warrington Borough

Council (UA)

(updated Aug 2010)


FACS: Moderate and above and applied on exit from the service.






1. Currently scheme focuses on supporting hospital discharges

2. Seeking to extend scheme to encompass community intake

Wigan Borough


(updated Jul 2010)

Intake and Assesment service: (see note 3 below) Model: de-selective (see note 3 below) Funding: funded with Health Provision: in-house service.


1. Service is in place and has been well established over the last two and a half years.

2. Clear distinction made between role of Home Care and role of re-ablement has been beneficial in change of culture/expectations for all stakeholders

3. Initially with selected users but now expanded across all pathways, and is increasing access from Hospital Discharge to all service users (including community) requiring assessment, reassessment and review

4. Outcomes in line with general findings from CSED reports 5. Added value in positive comments from service users and

job satisfaction/low sickness levels of staff

6. Using enablement /re-ablement as part of the approach in the Transformation of Social Care and developing into other service user groups (LD, PD, MH etc)

Wirral Borough


(updated Feb 2012)

See Volume 2: Case Study

of CSED Discussion

Intake and assessment service Model: de-selective Funding: service is operated in partnership with health Outsourced


1. After a number of years of operating a hospital discharge support service, Wirral decided to expand the service to



Document


Longitudinal Study

Document



Document

become an intake and assessment service. In August 2007 the name was changed from Wirral Enablement Discharge Service to Wirral Short Term Home Assessment and Re-ablement Teams (Wirral STAR)

2. The service was increased to cope with most of the hospital discharges and to take some of the work from the newly established access teams and also the long term care management teams. They also undertook assessments in relation to provision of direct payments.

3. A clear strategic lead was been given by movement of the Wirral HART service from the care services division into the Access and Assessment division. The role of the team as assessors was clearly established and strengthened in the growth of the service

4. Wirral HART Organiser staff were trained as assessors for assistive technology, referrers for medicines management and in the pathway for provision of Direct payments

5. In mid 2011 the service was outsourced whilst the assessment and quality assurance functions were retained in-house.




SOUTH EASTERN REGION


Bracknell-Forest


(updated Jun 2010)

Intake and Assessment Service for both community and hospital discharge referrals Model: de-selective Funding: with health (see note 1 below) Provision: in-house service staff free to choose LA or NHS contract

FACS: low and above and applied at entry to the re-ablement service (see note 3 below)

1. Joint service with the PCT under S75 includes re-ablement in the community and in a specialist residential setting.and ASC duty team.

2. In house home care service has been reviewed - posts transferred to boost the joint team to ensure that anyone who needs long term care goes through this service initially

3. On leaving the service the council applies a substantial level of FACS for those requiring ongoing support.

4. Service is subject to charge after 6 weeks.

Brighton & Hove City

Council (UA)

(updated Jun 2010)

Intake and assessment : (see note 3 below) Model: de-selective Funding: by Council: (see note 3 below) Provision: in-house service (but see note 6 below)

FACS: Moderate and above applied prior to re-ablement.

1. Implementation with in-house homecare from October 2008 on a phased basis.

6. Pilot with independent homecare providers to



2. Implementation began within Day Care and Transition. 3. Intake via Single ASC Access Point and Assessment via

Hospital using in-house home-care team, PLUS Hospital Discharge Intermediate Care Service operated by the Council with health

4. Approach extended to Assessment Teams (OT and Care Management) from 1st April 2009

5. The deselection criteria includes those requiring terminal care and those unable to engage due to advanced dementia

allow existing clients on review to be considered for re-ablement phase started May 2010.

Buckinghamshire

County Council

(updated Jun 2010)



1. No scheme 2. Set up a Rapid Response team June 2008 3. Considering the appropriateness of a homecare re-ablement

service 4. Mar 2009: required to market test services including

potential re-ablement service

East Sussex County

Council

(updated Jan 2012)

Intake and Assessment Service (but see note 5 below) Model: de-selective Funding: by the Council Provision: in-house service (but see note 5 below)


1. East Sussex Directly Provided Home Care Services (DPS) developed a short-term re-ablement service (called Living at Home Service, LAHS) in 2009 following a formal review in December 2008.

2. There are 3 WTE Occupational Therapists and 1 WTE

3. 5. A one year pilot with independent homecare providers to allow existing clients on review to be considered for re-



Physiotherapist based with the team 3. LAHS recently also introduced Therapy Outcome Measures

(TOM’s). This provides a standardised and reliable measure of changes in service user’s physical or psychological pathologies (Impairment), their involvement of the activities of life (Activity), social involvement and roles (Participation) and Wellbeing. LAHS use this data to assist in enhancing the effectiveness of the reablement programme as they effect change in the individual.

4. Approximately 68% of referrals are from hospital wards and 32% from community and hospital gateways (A&E, MAU, SAU)

ablement phase started October 2011

Hampshire County

Council

(updated Aug 2010)

June 2011

Intake and Assessment Service. (but see note 8 below) Model: selective Funding: by the Council Provision: in-house service (see note 2 below)


1. Communuity Response has been continuing to develop its re-ablement approach and focus, and is now well established across the County .

2. The Community Response Service in Hampshire is an in-house service that works with service users, who have been referred through care management, or occupational therapy for a period of up to 6 weeks.

3. Team Leaders in Community Response work within the care management process to provide on going assessment and review within the period of intervention and determine the future care needs of people using the service. The focus of the service is on hospital discharge /avoidance, right sizing, no further care required post re-ablement, crisis intervention, and carer support.

. 6. Current focus is on

moving to hospital discharge only. May consider commissioning admission avoidance for community referrals.

7. June 2011 invited expressions of interest to join panel of providers for dom care



4. There has been and will continue to be a comprehensive workforce development programme for Team Leaders through Action Learning. For Community Response Assistants there will be continual role development to reflect an enabling approach and further up skilling in re-ablement.

5. Through Hampshire County Council Occupational Therapy Services they have Occupational Therapists in the Community Response service. This supports re-ablement and continue the development already in place on goal setting, and an outcomes based approach. The Community Response Service supports the personalisation agenda through this approach and through an Individualised Service User plan being developed with the service user which aims to meet their individual needs.

Isle Of Wight Council

(UA)

(Jul 2008)



1. Early stage of planning for a homecare re-ablement service 2. Have some re-ablement residential beds available

Kent County Council

(updated Aug 2010)

See Benefits of Homecare

Re-ablement Document

Intake and Assessment Service Model: deselective Funding: by the Council Provision: in-house service and outsourced service (see note 1 below))

FACS: Moderate and above.and applied on entry to and exit from the service

1. Referrals are initially directed to the in-house service. Where in-house capacity is unavailable, referrals are offered to the 9 contracted P&V providers. The 9 providers have 23 contracts



across the 12 pre-restructure districts (each district has between 1 and 3 P&V providers). Referrals are alternated between the contracted providers.

2. Enablement is available for up to 3 weeks, with the potential for an extension, where assessed as needing an extension of the service. Enablement should last no longer than 6 weeks.

3. Intermediate Care Teams operate across Kent to provide multi-disciplinary therapy input. A period of enablement can follow a period of intermediate care.

4. Some enabling services which were contracted prior to the current enablement contracts remain active. These contracts are PCT funded and provide a hospital discharge domiciliary service and are also enabling. Work is needed to revise the contract specifications to ensure that there is a clear distinction between the hospital discharge domiciliary service and the enablement service.

Medway Council (UA)

(updated Jun 2010)

Intake and Assessment Service (proposed – see note 5 below) Model: selective Funding: by the Council Provision: outsourced service (see notes 6 and 8 below)

FACS: Substantial and above but will apply moderate on entry to Prevention element (see note 7 below)

1. No scheme in place. 2. Option appraisal to implement re-ablement project is

currently taking place.

3. Project team scoped the future enablement service pathway which will be called MEaPS (Medway Enablement and Prevention Service).

4. A proposal was agreed in May 2009 at Programme



5. Board to run a pilot and anticipate having suitable arrangements (including additional staff) in place by October 2009 to run an 18 Month pilot.

6. The scheme will include: Prevention services, home based rehab and short stay rehab in a specialist rehab unit. Intend for our Intake team to triage all referrals into the enablement pathway.

7. Currently outsourcing our domiciliary care team to an independent sector provider and intend for the outsourced service to provide specialist enabling domiciliary support. The provider will have an office based in our rehab unit and will be part of the multi disciplinary team.

8. Will look to apply FACS at Critical and Substantial, dropping to Moderate for the prevention element of the scheme.

9. Intend to train Care Manager Assistants as



Trusted Assessors and in addition we will be working with local Universities to train existing care staff (Domiciliary and rehab unit staff) as Rehabilitation Assistants, using an accreditation system to allow staff to enter Occupational Therapy qualification courses at a later date if they so wish.

Milton Keynes Council

(UA)

(May 2008)

See volume 2: Case Study of



FACS: Substantial and above and applied at exit from the re-ablement service

1. Rehabilitation home care service in operation 2. All service users receive this service for the first six weeks.

Service starts same day as referral. 3. Service is all in house but integrated into intermediate care

service with PCT. 4. After 6 weeks, those who need long term home care get in-

house or external. If external, care is arranged with independent providers though one point in contracts.

5. We strongly believe in rehabilitation/ re-ablement and having a longer assessment process than just a one off social work visit. We believe that our service has both helped people to become more independent at home quicker and controlled out long-term home care expenditure. The service has also



impacted on hospital admission avoidance where we have a very low rate of GP referral to hospital and where attendance at A & E are growing at only 1% a year (less than the population growth). So the service fits with the White Paper aim of services closer to home and can save money in the health economy as well as in local authority.

Oxfordshire County

Council

(updated Jul 2010)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: outsourced service (see note 1 below)


1. Scheme incorporated within intermediate care service and sub-contracted to health

2.

Portsmouth City

Council (UA)

(updated Aug 2010



1. Re-enablement service in place (10.03.2008) 2. Service works to facilitate hospital discharges, prevent

admission to hospital, assess all new care packages, reduce existing long term packages of care within the community

3. There is Occupational and Physiotherapy input into the team 4. Charging commences once goals met and/or service user

attains their optimum level of re-enablement if no capacity within the independent sector.

5. Handover to independent sector. 6. Also, have a separate in-house team providing long-term

dementia care to service users with medically diagnosed



middle to severe dementia. 7. April 2010 combined the re-ablement and assessment

services

Reading Borough

Council (UA)

(Jan 2009)

Intake and Assessment Service (see note 4 below) Model: selective / de-selective Funding: with health (see note 2 below) Provision: in-house service (see note 2 below)


1. First phase of implementation underway. 2. Phase 1: 20 homecarers volunteered, have been trained

and have capacity to deliver Re-ablement homecare together with a Multi Disciplinary Group from Health of therapists (Ots and Physios and Nurses)

3. A second batch of volunteers (another 20 homecarers) going through training now.

4. Currently seeking to establish an intake service as part of transformation of social care.

Royal Borough of

Windsor and

Maidenhead (UA)

(updated Jan 2012)

Intake and Assessment Service (see notes 1, 2 and 3 below) Model: selective Funding: with health Provision: in-house service (see notes 5, 8 and 10 below)


1. Providing an enhanced intermediate care service with primary focus on admission prevention with a guaranteed 2 hour response to urgent referrals

2. Hospital discharge to ensure timely discharge home of medically fit patients

3. Intake and assessment scheme in operation for new community referrals for social care including rehabilitation assessment for potential of improving independence

4. Provision of End of Life Care at home for those with prognoses of less than 12 weeks



5. Although currently in-house, consideration being given to involving at least one external provider re less complex social care packages due to 25-30% increase in demand for service during past 12 months

6. All staff trained to perform low level therapy tasks and they work through/encourage and supervise the rehabilitation/re-ablement programme with the service users under instruction from the qualified therapists and report back on progress

7. The outcomes of Service intervention inform the self directed support assessment for ongoing social care

8. If necessary, the Service will work with an external provider during a pre-determined handover period to ensure a smooth transition

9. This Service has been in existence since November 1999 as a separate service but worked alongside the In house Home Care Service which was externalised in March 2011

10. A likely outcome of a current Service Review is that this Service will merge with the Hospital SW Team and come under single management which will facilitate closer integration

Slough Borough

Council (UA)

(updated Jun 2010)

Intake and Assessment Service Model: de-selective (see note 3 below) Funding: by the Council Provision: in-house service (see note 2)

FACS: Substantial and above.and applied on entry to and exit from the service (see note 3 below)



1. Current operate a small intermediate care service but seeking to create a homecare re-ablement service.

2. Seeking to create an intake and assessment service by Apl 2011

3. It is currently proposed that the service will be de-selective and entry will be subject to meeting FACS

Southampton City

Council (UA)

(updated April 2008)



1. Scheme in operation 2. Run a rehab scheme alongside our continuing care scheme

but there is a project plan in place to change this probably within next year

Surrey County Council

(updated Aug 2007)


FACS: Critical and above.

1. Currently have a range of services across different areas of the County. These include both stand-alone and joint services with health.

2. An Assessment & Re-ablement service is provided by the in house home care team. This is well established in the west of Surrey and rolling out in the east.

3. The service is provided free for up to 6 weeks. 4. There is an occupational therapist attached to the team to

10. Currently reviewing range of schemes with a view to adopting consistent approach



ensure a rapid response to equipment needs. 5. A community support worker works alongside the care staff

to provide additional support for people using the scheme and as a link to care management.

6. The teams work closely with both acute and hospitals and with local social care teams to ensure the service is inclusive of all.

7. The team feeds into the overall assessment process and produce the care plan

8. If long term care is required a handover is given to new provider

9. There is active use of assistive technology and links to all local resources

West Berkshire

Council (UA)

(updated Jan 2012)



Document

Intake and Assessment Service Model: de-selective Funding: by the Council and ICS with CRT coming through Health Links Provision: in-house service

FACS: Critical and above and applied on entry to and exit from the service.

1. Full Implementation across whole in-house service 2. in third year of operation 3. 4. Supports ICS – Community Re-ablement Team, Crisis and

Hospital Discharge. 5. Team has authority to decrease or increase hours of care in

6 week period of care 6. Ability to move service user on after 2 weeks if no re-

ablement potential 7. If long term care is required then handover to external

agencies at which point a minimum of 24 hour handover shadowing provided

8. Whole team trained in re-ablement techniqunies and rolling



annual training programme in situ. 9. Participation is a pre request before a personal budget is

offered in terms of a domiciliary care packages 10. over 650 service users per annum 11. Remaining long term care being transferred to external

market to increase capacity of intake service so no long term cases held

West Sussex County

Council

(updated Aug 2010)

Intake and Assessment Service Model: selective Funding: by the Council :


FACS: Moderate and above.and applied on entry to and exit from the service

1. Intake and Assessment service although the majority of referrals are from hospital discharges

.

Wokingham Borough

Council (UA)

(updated Jan 2012)



Document

Intake and Assessment Service Model: de-selective Funding: by the Council Provision: outsourced (see note 7)

FACS: Critical and applied on exit from re-ablement service.

1. Intake and assessment scheme in operation with approx. 309 clients pa

2. Dedicated OT 3. Footcare Service available 4. A&E can refer direct OOH 5. Hand over to long-term provider if required. 6. Trusted assessors 7. All adult social care provided services were transferred to

Optalis (LATC) from June 2010 This includes day centres,



employment services, home care, residential care and supported housing services, as well as brokerage and support and sensory needs services.




SOUTH WESTERN REGION


Bath and North East

Somerset Council

(UA)

(updated Aug 2010)



1. Scheme in operation 2. Service in its third year and continues to provide short to

support in order to maximise individuals independence. Cover’s the whole of the authority and provides four service types:

a. Intake – Supporting individuals who are new to receiving services and require support to adjust,

b. Assessment – Supporting the Adult care teams to assess and identify actual needs,

c. Re-enablement – supporting individuals to maximise independence within their own homes,

d. Holding – short term support while long term provisions are found(very short term)

3. Continue to be a separate service from the PCT intermediate care team.



Bournemouth Borough

Council (UA)

(updated Aug 2010)

Intake and Assessment Service Model: de-selective Funding: by the council Provision: in-house service


1. Re-ablement service offered to community referrals and hospital discharges for over 65’s meeting the re-ablement criteria including all new referrals for homecare.

2. Operates as a multi-disciplinary team of social workers, care managers, occupational therapists and occupational therapy assistants and re-ablement care assistants who provide up to 6 weeks re-ablement in people’s own homes promoting independence

3. Following review, if ongoing care is required, this is provided by the independent sector

4. Currently rolled out to 2 of 3 localities within the Borough – full rollout by end of 2010

5. Provides validation and preparation for Directed Support. 6. In-house intermediate care centre is using re-ablement

approach and starting to deliver outreach work.

7. Considering scope to extend the service to include people at review stage as well.

Bristol City Council

(UA)

(updated Mar 2009)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council (but see note 2 below) Provision: in-house service


1. Short Term Assessment and Re-ablement Service (STAR) takes all new referrals for home care.

2. In house service operated by BCC but with Community Mental Health Nurse and Pharmacist employed by Bristol Community Health working as part of the team. The Team



also includes occupational therapy

Cornwall County

Council

(updated Aug 2010)

Intake and Assessment Service (see note 2 below) Model: de-selective (see note 2 below) Funding: by the Council (see note 1 below) Provision: in-house service (STEPs) and mixed health and social care staff service (RATS)

FACS: Substantial and above and applied at exit from re-ablement service

1. The internal Homecare service is restructuring to become a short term enablement and planning service (STEPs). A pilot is underway in one district which will then inform the rollout across the county, to be achieved by April 2011..

2. This pilot service currently takes all new referrals with a view to ceasing services within 6 weeks where the individual has regained their independence and does not require ongoing support.

3. Where ongoing support is required at the end of the enablement phase the package will have been optimised by the team and the individual will then receive ongoing support via the independent sector, direct payment, personal budget route.

4. The rapid assessment team (RATS) is a joint funded multi agency service providing intermediate care and rehab. The service focuses on facilitating hospital discharge and avoiding admission.

5. Cornwall Council in conjunction with Cornwall Health partners is carrying out a review of all intermediate care services and will be developing an integrated model of care that will see further developments and opportunities to maximise enablement and IC services. The above services are part of this strategy.



Devon County Council

(updated Jun 2009)



1. Exploring the possibility of introducing a re-ablement type service in Devon.

2. Early stages of developing a specification around which we can redesign the existing in-house Dom care workforce.

Dorset County

Council)

(updated Aug 2010)

See CSED Discussion

Document: Additional

Information



Document

Intake and assessment service Model: selective / de-selective Funding: by the council (see note 5 below). Provision: in-house service (see note 5 below)

FACS: Substantial and above and applied on exit from services (see note 5 and 6 below)

1. Dorset County Council undertook a re-ablement pilot project in the Weymouth and Portland locality between September 2007 and March 2008. This involved the in-house domiciliary support service offering a six week re-ablement programme for all service users referred for home care.

2. Weymouth re-ablement scheme operated solely by the Council

3. The service was only available to those whose needs already met the eligibility criteria (substantial or critical) and was a charged for service, although a flat rate charge (£43.15) not the full home care cost.

4. The project was evaluated and the evaluation demonstrated a significant level of success in reducing or right sizing packages of care.

5. The county then piloted a service from March to September 2009 which was available prior to a FACS assessment and



offered as part of an integrated, multi-agency intermediate care team.

6. The project is viewed as part of the Transforming Social Care preventive agenda and, if successful, will be rolled out across the county.



Gloucestershire

County Council

(updated Feb 2009)



Document



1. From 1 April 2007, Gloucestershire County Council's in-house domiciliary care service moved to an Enablement model and was renamed 'Community STEPs’ (Short Term Enablement Programmes).

2. The service focused upon facilitating hospital discharges and the prevention of unavoidable admission to hospital and long term residential care. It has recently expanded to provide an intake function for all new referrals. The aim is to promote independence, enabling people to remain in their own homes.

3. The service is subject to FACS on entry and is short-term - on average six weeks. Following review, if ongoing care is required, this is provided by the independent sector.

4. We have demonstrated that with timely and skilled support the level of care package can be reduced, or even cease to be required.

5. Refreshing the training programme to introduce increased knowledge and understanding of long-term conditions and their impact upon potential for enablement.

6. Reviewing roles to enable the issuing of agreed pieces of equipment that support independence in the home.

Isle of Scilly Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service OR outsourced service


North Somerset Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective



Council (UA)

(updated Mar 2008)

Funding: by the Council OR with health Provision: in-house service (see note 2 below)


1. North Somerset Council is presently developing a re-ablement service.

2. We are in the early stages of transforming our In House service.

Plymouth City Council

(UA)

(updated May 2008)



1. An established service is now in place following a pilot.. 2. At present we are using our 4 star in-house team to develop

a rapid discharge service with an intermediate care function. 3. The pilot team included therapy support both OT and physio,

care management and 250 hours of in-house care per week. It now has 750 hours per week dedicated to intermediate enabling and 750 hours dedicated to dementia

4. After 4-6 weeks, depending on the review outcome, people are able to access independent sector care if they meet FACS criteria.

5. However, in most cases we are achieving success in improving functionality of service users so that they are fully independent after the IC episode.

6. The service includes a joint fractured neck of femur project with the PCT utilising an independent residential home to deliver IC as a step down from acute in patient treatment

Poole Council Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective



(Borough of ) (UA)

(Jan2012)



Document

Funding: with health Provision: Outsourced service


1. The re-ablement function is delivered by an independent sector provider, who was awarded the contract in early 2012.

2. The service, which has capacity for 600 hours per week, can be called off by any staff within the intermediate care team (an integrated service between Borough of Poole and Dorset Healthcare University Foundation Trust) or the Long Term Conditions fieldwork team.

3. The reablement service will be offered to all patients/service users who present with an appropriate need, either for hospital discharge or for admission avoidance.

4. FACS (Critical and Substantial only) is applied during the re-ablement episode to determine whether an individual would be eligible for services following the episode.

5. The Intermediate Care team is an integrated service with Dorset Healthcare University Foundation Trust only, Bournemouth and Dorset have their own separate arrangements. The re-ablement service, which will be deployed mostly from within the intermediate care team, is a piece of joint commissioning between Borough of Poole and the PCT.

6. Candlelight Homecare Services have just been awarded the contract as the re-ablement homecare provider.

7. The plan is for individual social workers, nurses etc from the intermediate care team (and long term fieldwork teams as well) to be able to directly deploy an episode of re-ablement



and to then work with the candlelight care assistant throughout that episode. So, although the re-ablement element is provided by an independent sector provider, it should all feel joined up from the service users perspective.

Somerset County

Council

(updated Apl 2008)

Intake and Assessment Service (see note 6 below) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service OR outsourced service

FACS: Moderate and above but see note 6 below.

1. We have a number of schemes in place, which aim to stabilise and maximise individuals potential. We also carry out some joint assessments to ensure that we are taking a multidisciplinary, holistic approach.

2. Initial response/Rapid response. This is provided by our block home care providers and there is flexibility to allow the individual to settle and maximise their independence, before transferring to either core home care services or direct payments.

3. We have access to community rehab teams (from occupational therapists and physiotherapists) through our colleagues in Health who provide goal orientated rehabilitation programmes for service users in their own homes and in our ‘Step up’ and ‘Step down’ beds. (This is an intermediate care service where people receive care and

7. Our aim is to have a more coherent approach by working closely with our colleagues in the new PCT to further enhance service user outcomes.



rehab in residential settings, to avoid hospital admission or facilitate hospital discharge)

4. We also access support to maximise service users independence through Housing related support from Supporting People, and through volunteers and the Partnerships for Older People

5. New admission avoidance service jointly operated with the PCT but content is as described above.

6. For re-ablement that relates to discharge from hospital or admission avoidance FACS is not applied. We also use a re-ablement approach at the front end of all new home care referrals that come forward as part of our adult social care services. These referrals will be subject to FACS.

South Gloucestershire

Council (UA)

(updated Jul 2010)




Hospital Discharge Support (see note 1 below) Model: selective Funding: by the Council Provision: in-house service and outsourced (see note 5 below)


1. Scheme is known as the Intake Team and currently only takes hospital discharges.

2. All levels of physical disability and mental health go through the Intake Team.

3. The services has been externally evaluated. 4. Service Users are supported to be as self-caring as

possible. Although there may not be the potential re ablement for many people referred, by spending 6 weeks with this team, it is hoped that routines can be established and packages settled prior to moving to longer-term provision. This means that the level of care being purchased by the department is realistic and appropriate to meet that person's needs



5. Brunelcare are currently operating a pilot service. This commenced in January 2012 and will be run for 43 weeks.

Swindon Borough

Council (UA)

(updated Apl 2008)

Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service OR outsourced service

FACS: Substantial and above but not applied to either service (see note 3 below).

1. No homecare re-ablement scheme 2. Operate both Early Hospital Discharge (up to 6 weeks) and Crisis (hospital avoidance, up to 10 weeks ) schemes 3. Neither are subject to FACS criteria for service

Torbay Council (UA)

(Feb 2009)

Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: with health Provision: in-house service


1. No scheme 2. Looking to establish a range of reablement options which will include internal services and the use of external providers such as domiciliary care agencies

Wiltshire County

Council

(updated Jul 2010)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service (but see notes 7 and 8 below)




1. Reablement service in operation. 2. Evaluation completed with University of Bath and service

modified following consultation 3. A customer’s ability to progress through re-ablement determines

the length involvement, with a maximum in general of 6 weeks 4. Works in conjunction with NHS Intermediate Care Service -

Community Support Workers working alongside Community Nurses and therapists are directly line managed by Re-ablement Manager.

.

5. A re-ablement enhanced service pilot using new person-centred review and assessment tools including, falls risk assessments and provided in conjunction with assessment for Telecare commences in August 2010.

6. Working to include community resources (universal services) and is being evaluated by Commissioners, informing the added value of early, intensive intervention and design specification of new Care & Support Contract

7. It is understood, from their website, that Wiltshire are using the results of a local evaluation and other data about the effectiveness of reablement to commission a new Independent Living Service from the organisations in Wiltshire that deliver services to help people live at home. Their plans were to begin operating in the summer or early autumn of 2011, subject to approval by members of the Council.

8. It is also understood from



presentations at various conferences in 2012 that they are working with external providers to develop a framework to ‘commission for outcomes’ and so payments to providers will be based to some extent on that.




WEST MIDLANDS REGION


Birmingham City


(updated Apl 2009)






1. .Currently trialling Rapid Enablement Approach for Care at Home (REACH) in 3 areas

2. Designing a strategic model as part of the overall transformation agenda.

3. Intend to roll-out by end of 2010.

Coventry City Council

(Metropolitan)

(updated Jul 2010)

Intake and Assessment Service (see note 2 below) Model: de-selective Funding: with health (see note 1 below) Provision: in-house service (see note 5 below)

FACS: Substantial and above and applied on exit from the service if appropriate (see note 7 below).



1. The service is City wide, operating within an integration Agreement between health and social care. The City Council being the lead agency.

2. The Service forms part of one of 5 pathways within the Care Out of Hospital Project. The service offers a pathway for active recovery from acute illness or injury and promoting independence / enablement interventions. The service offers short term targeted intervention which aims to reduce longer term dependency on support services.

3. The service supports timely hospital discharges and admission avoidance. The service is split into three localities with each locality managed by a locality manager. Each locality has a multi disciplinary team – occupational therapists, physiotherapists, nursing, support staff, domiciliary care managers , admin and clerical.

4. There is a central referral point where referrals are screened and the most appropriate pathway within the service identified.

5. In addition to community based services the service is supported with access to approximately 50 beds, provided both in house and contracted beds, these are a mix of residential light touch and nursing beds.

6. The service is able to offer interventions up to a maximum of 12 weeks. Urgent referrals are responded to within 2 hrs whilst non-urgent have a response time of 24 hrs.

7. FACs is not applied at admission to service, the service enables individuals to have a period of on going intervention and an assessment of their eligibility and longer term support needs is not undertaken until the end of their episode within the service.

8. The service is delivered as part of the integrated intermediate care service

9. Review of capacity in view of changing nature of users of service. Higher dependency individuals being referred. Review skill mix required to support individuals through process..



Dudley Borough


(updated Mar 2009)




Intake and Assessment Service (see note 3 below) Model: selective / de-selective Funding: by the Council (see note 2 below) Provision: in-house service

FACS: Moderate and above and applied on entry to and exit from the service

1. Dudley MBC Directorate of Adult, Community and Housing Services , is currently undertaking an evaluation of all intermediate care and re-ablement services. It is also currently involved in two pilot projects with GP practices. These are jointly funded (Health and Social Care), and aimed at early identification of people ready for discharge from hospital, and care to enable a speedy return home.

2. The Short Term Assessment and Re-ablement Team (START) became operational in 2005 and provides a Borough-wide service. It is funded by the council.

3. Referrals to START are via the hospital or locality social work teams including the older peoples mental health team. The team operates from 7.00 am until 11.00pm daily. START offers a period of re-ablement and assessment for up to 28 days, The care is reviewed within 7 days and again at 21 days. Care is then transferred to a long term provider. If the care needs are stable, the care can transfer prior to the 28 day period. START can also provide a quick response to emergency situations (Primary care Response) when a care package can be in place within 4 hours.

4. A team of peripatetic night carers provide care throughout the night if required. This team undertakes toileting and turning to individual service users. Short Intensive Night Service (SINS) is a night sitting service which can respond to crisis situations and avoid hospital admissions. This service can be provided up to a maximum of 72 hours. The

13. Planning to increase the number of referrals able to undertake a phase.



service user is assessed overnight, so an accurate ongoing care plan can be provided

5. The care staff receive training in re-ablement techniques, dementia care and medication administration. Each member of START is trained to undertake environmental risk assessments. Once the care package is stable the medication is placed on the monitored dosage system (MDS). Two of the supervisors for START are also moving and handling trainers and can instruct staff in safe moving and handling

6. START has a dedicated OT assistant and links are made to the PCT Occupational Therapists who are able to devise a care-plan for the individual to promote and maximise independence. The carers on START work with the individual following the care-plan. The progression of the service users is monitored by the OT assistant and the OT, and adjusted as required.

7. Running alongside START further funding was obtained to expand the Elderly Mental Ill service. It is now planned that this service will become a part of internal mainstream provision

8. Dudley MBC has a very successful Palliative Care Team. The care is provided by specially trained carers (social care funded) and health care assistants (PCT funded) and enables people to die at home if they so wish.

9. During the period the service user is on START their longer-term care needs are actively being sourced by the Capacity Coordinating Team. . The Capacity Coordinating Team negotiates with both internal and external long term providers of care from the onset of the START care to enable ongoing care to be in place at the end of the START



process. A decision is made during the assessment period about the future care needs of the individual. .

10. A comprehensive handover is arranged between START and the new provider to ensure a consistency of care for the service user. The Single Assessment Process (SAP) documentation is an essential element and supports the whole process.

11. All long-term care is sourced by the Capacity Coordinating Team, saving Social Work time in ringing providers to access care.

12. The Capacity Coordinating Team provide management information on the placement of all care packages in Dudley.

Herefordshire County

Council

(updated Jun 2010)

See CSED Assessment


Surveys Document



Document

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service – see notes below


1. STARRS has been operational since September 2004. Prior to this, Herefordshire Council ran a Re-ablement Service which consisted of a Residential Unit called Homeward Bound and attached to this was a small domiciliary outreach service. This ran from March 1999 until October 2003 when it transferred in Partnership with the PCT to the Hillside Intermediate Care and Outreach service.

2. Hold a database for all service users of STARRS, which details service provision at the beginning of the service and at the end of our involvement, stating either the ongoing care required or whether the service user is independent and does not need any further services.

10. Planning to integrate teams and improve transition to external providers for those requiring ongoing packages.

11. Seeking to increase activity levels and introduce electronic monitoring and rostering systems.

12. Reviewing performance



3. Conduct reviews after 6 weeks and three month to check the progress of the clients.

4. All new referrals coming to the Social Work Department are scrutinised for suitability for an assessment period with STARRS . This also applies to all Hospital discharges. In addition to this, we support service users who have the wish to return from residential care to more independent living.

5. The STARRS team consist of three teams covering the whole of the County. Each team consists of two Senior Support Assistants and four Support Assistants most of whom were Homecare Assistants prior to their appointment. We also have one full time Occupational Therapist working with the team and are looking for resources to add a Physio Therapist to the team.

6. STARRS is the only in-house domiciliary service remaining in Herefordshire Council

7. Roving Night Service commenced on the 28th of Jan 2009 8. Also established on the above date a Mental Health

Intermediate Care Service to provide a more intensive service to clients who might have been considered not suitable for the existing Intermediate Care Services.

9. Linking in with both the above services, we have introduced the telecare “just checking“ system, which monitors clients activities and can trigger a response from the above services.

management reporting.

Sandwell Borough


(updated Jun 2011)

Intake and Assessment Service Model: selective / de-selective Funding: with health (see note 4 below) Provision: in-house service (see note 3 below)

FACS: Substantial and above and will be applied at entry to and exit from re-ablement service. (see note 7 below)

Charge for service: not subject to charge (see note 6 below)



1. Service now modernised: Fast Response, STAR 6 week re-ablement and OPMH service established as at July 2008, looking now to review first stage and improve.

2. Fast Response service runs for up to a maximum of 6 days after which we expect that some people will go into the STAR 6 week service.

3. STAR (short-term assessment and re-ablement) operated by the council. 6 week service established and commenced July 2008.

4. Significant investment from PCT for FR and STAR under signed section 28a agreement.

5. We also have an established service for older people with mental health problems which we are planning to expand. This makes up the third of our in house home support specialised services.

6. There are no charges for Fast Response and STAR. There is a charge for the OPMH service.

7. Seeking to improve first stage.

8. Seeking to expand service supporting older people with mental health problems and to increase the number of referrals able to pass through the service Issued invitation for expressions of interest to tender June 2011 for services including re-ablement. Note states TUPE may apply to some services !

Shropshire County

Council

(Oct 2009)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service OR outsourced service


1. START service in operation

Solihull Borough


( Jan 2012)

Intake and Assessment Service Model: de-selective Funding: by the Council Provision: in-house service and outsourced service (see note 2 below)


1. Service operates through 3 teams across North, South and Central areas which equate to approx. 80% of the authority.=



between the hours of 7am to 6 pm 2. Six external providers also provide an evening service after

6 p.m. 3. The service provides reablement to adults over the age of 18

and is extending its client group to adults with mental ill-health and adults with a learning disability.

4. The service has a team of reablement OTs and 2 Trusted assessors to support therapy and equipment needs.

5. Referrals are taken from Hospital Social work teams as well as from the Community Social Work Teams.

6. Plans are underway to appoint Reablement Assessment & review workers based in SW teams to undertake the screening, assessment & review tasks and to provide a fast response to referrals. and to facilitate the provision of ongoing packages of acre where there are any residual care needs following reablement.

7. Solihull has a long established Reablement service working with older people with mental health issues, largely dementia type conditions. This service is provided across the Borough and is for a period up to 12 weeks.



Staffordshire County

Council

(updated Oct 2009)


Information Section

See CSED Assessment


Surveys Document

Intake and Assessment (see note 4 below) Model: de-selective (see note 4 below) Funding: by council Provision: in-house (see note 6 below)

FACS: Substantial and above and applied at entry / exit to re-ablement service. (see note 5 below)

1. Currently the in-house homecare service operates through 8 districts.

2. Operating first phase of implementation of a re-ablement service in Moorlands and Newcastle area.

3. Developing a re-ablement model with launch of the new service due in mid 2010. across the county

4. Plan to operate as an intake and assessment services on a de-selective basis.

5. Service will be subject to FACS criteria for community referrals but not hospital referrals

6. Plan to operate an inhouse service

7.

Stoke on Trent City

Council (UA)

(updated Jun 2010)



1. Homecare services have been realigned into three specialist areas, Rehabilitation, Older People Mental Health and Long Term Support following consultation with staff, HR and the trade unions. This formed part of the overall realignment of services and assessment and care

25. Planning to improve the service by integrating social workers, streamline assessments and improve access.



management teams. The three specialist areas all focus on short term interventions with a rehab focus across all specialist areas.

2. The rehabilitation service is significantly larger than the older peoples mental health service and long term support service.

3. The three specialists are: Rehabilitation 4. Rehabilitation is based around the 2 centres of excellence 5. The rehabilitation home care service is part of the

professional service to be provided by rehabilitation. Staff are involved in the future care needs and decisions of service users whilst they are in a centre of excellence

6. There is a rapid response service, and a part of the service that responds to falls.

7. The rehab service provides an in-reach service into the centres of excellence.

8. The aim of the service is to also reduce the length of stays from 6 weeks to 4 weeks.

Older People Mental Health 9. Key part of the service is the home care service 10. Commitment from the council to deliver services with a

rehab approach and to enable service users to remain in their own homes

Stay @ Home Scheme 11. The Stay at Home scheme has an OT and CPN as part of

the scheme. 12. All staff receive appropriate training in mental health as part

of the development of the service. 13. The older peoples mental health service provides an in-

26. Implementing electronic monitoring and rostering.

27. Seeking to work closer with health



reach service into the centres of excellence. 14. Older Peoples Mental Health will be based around 4 centres

of excellence 15. The Stay at Home scheme will provide intensive support to

people with a dementia type illness, within their own homes, such as personal and practical support. The scheme can provide up to 24 hours of care in a person’s home dependent upon their need during the assessment period. This will be achieved by using assistive technology.

16. The scheme is intended to reduce unnecessary admission to hospital or long-term care and support can be arranged on discharge from hospital or as a response to crises situations when a person is at home.

17. The team will consist of Social Care Practitioners, Home Care Manager, Home Care Seniors, Home Care Workers, Community Psychiatric Nurse and Occupational Therapist with forged links with Telecare and other teams and agencies.

18. The Stay at Home scheme will be free of charge for the 2 week assessment period.

Long Term Support

19. Includes aspects of home care, day opportunities, social work teams, residential homes

20. There will be a whole systems approach focused on short term interventions with a rehab approach throughout promoting independence and outcome focused

21. There will be links to health, community matrons, extra care and telecare

22. Similar sized home care team to OPMH 23. Looking at developing a specialist ‘End of Life’ team that will

encompass day opportunities, social work teams etc 24. Service users receiving long-term support will have to pay



for their service following a fairer charging assessment.

Telford & Wrekin

Council (UA)

(updated Jun 2010)

Intake and Assessment Service Model: de-selective Funding: with health (see note 8 below) Provision: in-house service

FACS: Substantial and above and applied at exit from re-ablement service (see note 6 below)

1. In 2001, we considered whether to retain an in-house Home Care service, given that all residential and day care provision for older people had been externalised.

2. Concluded that we would retain the service, but reduce it in size and differentiate it to provide short-term interventions only on a rapid response basis in an emergency; as a rehabilitation and enablement support service to our multi-disciplinary joint intermediate care service and as a contributing part of the social care assessment of needs - enabling service users to reach their full potential with daily living tasks

3. Transferred the remaining long-term clients to independent providers and commenced re-skilling the workforce. This was achieved on target and our registered home care provider now focuses on rapid response and support to Intermediate Care. The Co-ordinators of the Home Care service are an integral part of the multi-disciplinary Intermediate Care Team, run in partnership with T&W PCT.

4. The development of this service has certainly been one of the factors that have helped us improve significantly, our performance around admissions to residential/nursing home care, helping people to live at home and delayed discharges.

5. In 2007 enablement/rehabilitation was identified as a critical element in the “rethinking community care” efficiencies programme. Work has commenced on this programme and

9. Plannign to re-model the service to increase the number of people ot requiring ongoing care.

10. Reviewing reporting systems.



will be linked to PCT commissioned review of Intermediate Care.

6. FACS applied according to level of need on exit of the service, when substantial or critical levels will receive funding. However lower levels of need may be supported if the input is one of prevention and supporting independence e.g. the purchase of small pieces of equipment to enable a service user to dress independently

7. In 2008, T&W Putting People First programme established with specific work streams. Re-ablement and rehabilitation in the community is one of the work streams. Work will be carried out to refine the re-ablement services, increase capacity of the service to include all adults over 18, and ensure the personalisation agenda is supported throughout

8. T&W intermediate care service (ICS) functions to prevent avoidable admissions to hospital or residential care and facilitates discharge. The service supports planned and unplanned episodes of re-ablement and care T&W ICS is a joint team with health, social care and mental health under one team manager

Walsall Council

(Metropolitan)

(updated Jun 2010)

See CSED Assessment


Surveys Document

Intake and Assessment Service Model: de-selective Funding: with health Provision: in-house service


1. Commencing planning and testing an initial re-ablement model from July 2010

Warwickshire County Hospital Discharge Support (solely or primarily) (but see notes below) Model: de-selective Funding: by the Council



Council

(updated Mar 2008)



1. Small pilot scheme in operation 2. Offers 6 weeks at direction of SW / OT 3. Have hospital discharge scheme covering ¼ county taking

referrals from acute hospital and ICT 4. Fast response team aimed at preventing admissions to

residential care or hospital

5. Warwickshire has been running a small pilot Re-ablement scheme for some time and is currently planning to re-configure it's internal homecare service as an "Intake" Re-ablement service.

6. It is intended to phase the introduction of Re-ablement across the County and to integrate the existing hospital discharge and fast response service within the Re-ablement service. The speed of introduction of the service will be influenced by the ability of the Private Sector to take up the service currently provided by the internal homecare service.

7. A project board including local and strategic commissioning in addition to Locality Provider Services is being put in



place to ensure the interests of all stakeholders are fully considered.

8. Funding has been identified for six Occupational Therapist posts to be an integral part of the Re-ablement process.

9. A training programme for existing homecare staff will be introduced to re-focus the current service from Homecare to Re-ablement.

10. It is planned that the service will be an "Intake" service with a limited input of up to six weeks.

11. It is intended in the initial introduction of Re-ablement for all referrals to meet the existing FACS criteria. Longer term aims, once the "Intake" service is fully established across Warwickshire, are for the service to link with the PHILLIS (Promoting Health and Independence through Low Level Integrated Support)



service. PHILLIS is an early intervention service aimed at providing support to people over the age of 50 who don't meet the current FACS criteria. It is the view that PHILLIS may identify people who, with the benefit of early intervention from a Re-ablement service, will be able to maintain their level of independence much longer.

12. In addition to the current service Warwickshire has also been operating, through the internal homecare service, a pilot scheme to support people suffering from dementia. The pilot has proved to be very successful and the service will now be "Rolled out" across Warwickshire. Although this is not a Re-ablement service as such, the intention is for care workers to undergo the "Re-ablement" training in addition to the specialised training required for working with people



suffering from dementia.

Wolverhampton City


(updated June 2010)

Intake and Assessment Service (see note 1 below) Model: de-selective (see note 2 below) Funding: by the Council OR with health Provision: in-house service


1. Pilot scheme in operation from community and hospital referrals from June to November 2010 based on 2 districts and covering apporx. 15 to 20% of the older people cohort

2. De-selection criteria based on a screening tool and OT assessment.

3. Multi-skilled team established in one location with OTs and social workers

4. Using a RAS assessment (FACE) at beginning and end of the phase to establish changes.

5. Full roll-out will start in Jan 2011 and be completed by Apl 2011

Worcestershire County

Council

(updated Jan 2012)

Intake and Assessment Service Model: de-selective (see note 2 below) Funding: by the Council (see note 7 below) Provision: in-house service


1. The Promoting Independence Service is a countywide service with central base in Worcester but divided into 4 locality-based teams which each comprise an OT, Physio, Team Leader, Coordinator (Planner), and 11 Promoting Independence Assistants. There is also a Lead therapist, Team Manager and Team support officer.

2. Referrals come directly from the Access centre, from Community Social Work teams, Community Hospitals, Residential Rehabilitation schemes, limited acute hospital discharges

8.



3. Focus is to reduce long term ongoing care requirements including premature admissions to care homes

4. Service lasts for up to 6 weeks. Average length is 4 weeks 5. On average 75% of Service users are discharged with no

ongoing care needs 6. Robust reporting system in place 7. Service is funded by the council but therapists are employed

by Health




YORKSHIRE AND HUMBERSIDE REGION


Barnsley Borough


(Jan 2007)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service FACS: Substantial and above.

1. Service established June 2006 and operated by in-house service

2. Anticipate service will evolve up to 1,000 care hours per week and links to intermediate care and OT teams in health through PCT

3. Main focus will be through older people including those with dementia and mental health needs.

Bradford Council

(Metropolitan)

(updated Feb 2009)

Intake and Assessment Service – see notes below Model: selective / de-selective Funding: by the Council Provision: in-house service FACS: Substantial and above and applied at entry to and exit from re-ablement service.

1. Intake scheme in place covering North Bradford 2. In-take model applied to the whole of North in-house service 3. Introduction of ‘cluster’ arrangements for Home Care Seniors

in order to deliver timely response to new customers who set

8. Planned roll out to all of Bradford by end of April 2009

9. New ‘cluster’ bases



goals to be achieved within 6 weeks 4. Close working with OTs to fast track equipment needs 5. Commissioning evaluation complete:-

• 69% achieved reduced amount of care hours at the end of service

• 14% gained full independence

• 12% increased care hours

• 5% stayed the same

• 31% savings achieved (full figure was 36% but deducted 5% re CSED research finding )

• Worked closely with the independent sector to agree capacity for long term packages

• Full engagement from the Trade Unions 6. Two existing enablement teams cover S&W and City Area –

full integration from Care Management and dedicated OT/Physio input –provision managed through in-house home care.

7. Three x Health in Mind (POPPS) teams provide up to 3 month enablement support to customers with organic and functional MH diagnosis. Two teams in-house, one Methodist Homes.

operational (excepting one outstanding)

Calderdale Council

(Metropolitan)

(updated Sept 2009)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: in-house service FACS: Low and above and applied on exit from the re-ablement service. (see note 3)

1. First phase of implementation started mid Sept 2009 in south

area of Calderdale. 2. Staff trained and shadowing time included with go live due

21st Sept. 3. Care Service Advisors undertake a high level assessment as

4. Immediate remedial actions to be taken over course of 12 weeks with phase 1, followed by 2 week ‘breather’ to



part of single point of contact. Social worker involved in formal review to allow handover and identify ongoing care pathway / RAS,

consolidate changes before commence phase 2 training.

5. Phase 2 due to commence in north area of Calderdale in early November with shadowing, followed by training, etc.

6. Phase 3 due to start In lower area of Calderdale in Jan 2010

7. Finally, phase 4 due to start early Feb 2010 in upper area of Calderdale

Doncaster Council

(Metropolitan)

(updated Aug 2010)

Intake and Assessment Service Model: selective / de-selective Funding: by the council (see note 2 below) Provision: in-house service FACS: Moderate and above and applied on entry to the service (see note 3 below).

1. Doncaster’s re-ablement team is an integrated health and social care team and does include care/intervention traditionally provided by home carers. The team also meet much of the definition being used by the Care Services Efficiency Delivery.

2. STEPs re-enablement team is a Council funded service provided by in-house Home Care. This service is for short term (up to 6 weeks) with a view to service ending or reducing if required beyond. Further provision is outsourced. An alternate Wellbeing service is provided for people who have low level of needs and so are not eligible for STEPS

3. Integration with re-ablement team and Community Intervention Team



East Riding of

Yorkshire Council

(UA)

(updated Apl 2008)


FACS: Upper Substantial and above and applied at entry to and exit from the re-ablement service. (see note 3 below)

1. Existed since 1999 and the ERYC currently works in

partnership with Health providing Intermediate Care. 2. It also provides time limited rehabilitation support to service

users to maximise independence to support them to remain at home.

3. The service provides short term focused assessment and is subject to FACS at entry to the service,. Referrals are also made into the service for the provision of up to six weeks intermediate care and there is no charge for this element of the service

4. A review of Priority Care is taking place which will seek to re-establish a focus.

5. Through careful assessment, identified clients will benefit from a maximum 6 weeks intensive care, with the intention of reducing their care needs for subsequent placement in the independent sector

6. Seeking to start the service Sept 2008

Hull City Council (UA)

(updated Sept 2007)

Intake and Assessment Service – see notes below Model: selective / de-selective Funding: with health Provision: in-house service FACS: Substantial and above.

1. Hull City Council and the Primary Care Trust are in the process of developing a re-ablement team through the integration of our in-house homecare service with the



intermediate health care team. 2. Service will develop as an intake team supporting the acute

services and community teams in both health and social care. Expectation is to have a phased approach to introduce and develop the re-ablement model to other teams and service providers.

3. Joint staff training in progress to support set up and service delivery

Kirklees Council

(Metropolitan)

(updated Apl 2008)

See CSED Assessment


Surveys Document

Intake and Assessment Service – see notes below Model: selective / de-selective Funding: with health Provision: in-house service FACS: Substantial and above and applied at exit from the rapid response and SHDT re-ablement service. (see note 6 below)

1. Supported Hospital Discharge Teams and Rapid Response

Teams are in place. These are joint teams incorporating health staff. Service Users have access to a short intense period of enablement to enhance independence.

2. The in-house service homecare service covers 50% of the market. Block contracts are in place in the independent sector. We have agreed, as part of the service modernisation agenda, that the in-house service will reduce in size to 30% of the market will focus on intake, enablement, palliative care and complex and unstable cases. All work is overseen by the Project Board chaired by the Head of Service.

3. New Job descriptions are due to be put in place to increase the range of low level health tasks undertaken by homecare staff

4. Significant work has been undertaken in liaising with the trade unions

1. Electronic rostering and monitoring to be put in place.

2. Review the role of the brokerage service

3. Plan for reshaping the service to be drawn up

4. Pilot project for joint work with heath to be put in place.

5. Intake model to be developed.



5. A piece of work in currently being undertaken to re-engineer our business processes

6. The service is not subject to FACS criteria and the Rapid Response and Supported Hospital Discharge Teams will continue to see anyone that is considered appropriate for the service by the team

7. The length of time a service user can spend on either service is under review.

Leeds City Council

(UA)

(updated Mar 2008)

See CSED Assessment


Surveys Document

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service OR outsourced service FACS: Substantial and above and applied at entry to Enablement Programme.

1. Action Learning Programme currently rolling out in the South

of the City. The Enablement programme has taken an interdisciplinary approach where social workers, joint care managers, disability services OT’s and community support staff works closely together.

2. There is no specialist enablement teams developed. All community support staff, OT’s & Social work staff are involved in the programme and all receive training. It has changed the way they work with service users during the initial 6-8 weeks period

3. Changed the pathway of assessment. OT’s do an assessment and sometimes intervention prior to SW assessment, so this can inform the care plan and affects the need for community support. There is active care management by SW staff. OT’s support the community support staff in setting up an enablement programme and monitor/adjust this programme on a regular basis. This has been well received by staff and service users/carers

11. Integrating the hospital discharge pathway into the enablement programme.

12. Exploring interfaces with intermediate care team and joint elements in the pathway which could be joint up

13. Exploring if closer working relationship between day services and community support would benefit users and create more options for enablement programme

14. Preparing roll-out for rest of city



4. Focus is on people who are new to the service or those with a significant change in needs. It has also affected the way staff approach people with long term support needs

5. Concept of enablement accepted, and part of the business plan.

6. Line of FACS eligibility is in Leeds at critical to substantial. High dependency & level of need does make it difficult to achieve a reduction in hours of care during the enablement period. The main change in outcomes are:

a. the user participates more in the care and is encouraged to remain active although this not always translates in reduced hours

b. The user is seen by an OT prior to referral for home care support. Some have had no need for community support after receiving equipment or advise.

7. As this is not a specialist service or team – but a change for everyone working with service users who may need home care support – it has been a major challenge to make those changes & create capacity while at the same time still running the ‘old’ service. The roll-out will hopefully make it easier for staff.

8. No extra resources for making the change. All absorbed by services as part of service development.

9. Lessons learned report & 6 month report of action learning programme available.

10. Leeds Metropolitan University currently undertaking an evaluation of the action learning programme. Report expected April 2008.

North East Intake and Assessment Service (see notre 2 below) Model: selective / de-selective Funding: with health



Lincolnshire Council

(UA)

(updated Apl 2008)




Provision: in-house service FACS: Moderate and above and applied at exit from re-ablement service.

1. From September 07 the Adult Social Care service and the

Primary Care Trust joined together to form North East Lincolnshire NHS Care Trust Plus. We are now operating as an NHS organisation, and are starting the long process of integrating services, operations, back room issues, harmonisation etc.

2. From a re-ablement point of view, START has now become the CTP’s Intermediate Care at home service Our aim is offer re-ablement services to all new referrals for home care services across the CTP. We have opened up all the referral routes, which include our care management commissioning group, the Hospital Social work team, older people mental health service, physical disability services and our residential Intermediate Care unit.

3. This has meant that we have a significant shortfall within the service, however it is helping us identify the capacity issues and how large the service will need to be in the future.

4. We are working much more closely with the Intermediate Care Clinical team which includes OT’s, Physios, Nurses and Social Workers, and continue to have a good success rate with 30% of users not requiring services once they leave START.

5. We currently have 40 staff working within START, but the evidence is starting to show that this may need to be doubled. We are looking at developing a generic worker role, which will include health and social care tasks, this will link in with the integration of the two organisations.



North Lincolnshire

Council (UA)

Intake and Assessment Service OR Hospital Discharge Support (solely or primarily) Model: selective / de-selective Funding: by the Council OR with health Provision: in-house service OR outsourced service FACS: Moderate and above.



North Yorkshire

County Council

(updated Aug 2010)

Intake and Assessment Service Model: de-selective Funding: by the Council Provision: in-house service FACS: Moderate and above.

1. The roll out of re-ablement has begun in the Selby area, to be followed by the rest of North Yorkshire, with the first phase to be completed by June 2011.

2. An evaluation of the initial implementation will be completed by December 2010 3.Phase 2 will take place 2011/12, and will be informed by the evaluation.

Rotherham Borough


( Jan 2012)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council and Health Provision: in-house service FACS: Substantial and above and applied at exit from re-ablement service



1. The in-house home service has been radically reconfigured as an Enabling Service and these changes have been rolled out across the Borough. These changes include planned rostering of staff to reduce staff down time and improved work life balance for the staff employed in the service.

2. Referrals to the service are made through our Rothercare Direct Service. Triage arrangements take place at this first point of contact to establish if an individual would benefit from a period of enablement. Once this fact is established a proportionate assessment will be undertaken and service will commence within 48 hours.

3. The service is provided up to a maximum period of 6 weeks at no cost to the customer.

4. A review is undertaken at 4 weeks and if ongoing support is required, a full ISCA is undertaken and ongoing maintenance and support of the customer is then provided by Independent Sector Providers.

5. To achieve further efficiencies within the service a merger has also taken with the Wardens from the sheltered housing schemes. The prime focus/objective of the service is to improve the health, well being and level of independence to the individual in receipt of the service

6. The service has now integrated with the Intermediate Care Community Therapy Team and their prime focus is to facilitate timely discharge from hospital and intermediate care rehab beds. Hospital discharge arrangements are completed within 24 hours of referral to the service. Therapy interventions are applied alongside enabling staff to promote and maintain the independence of individuals in their own home

Sheffield City Council

(Metropolitan)

(updated Feb 2009) See CSED Benefits of

Intake and Assessment Service Model: selective / de-selective Funding: with health (but see note 5 below ) Provision: in-house service FACS: Substantial and above and applied at entry to and exit from the re-ablement service (see note 4 below).




Document 1. Sheffield developed its re-ablement service (Short Term

Intervention Team – STIT) in December 1997 and has continued to increase resources into this service from that time.

2. We are now clear about the size of the service we will provide, which is 3 times larger than it is currently. This acknowledges the success of this type of provision.

3. Also we are very clear that in order for us to make the changes and achieve sustainability, we do have to take a whole systems approach in Sheffield working alongside our commissioning and contracts section for a whole market approach to achieving the rebalance of home support in the city.

4. There is an Assessment and Care Management protocol that sits behind this to ensure the relevant actions are taken and the service user is charged, where appropriate.

5. Some areas of STIT receive part funding from Health but this proportion will reduce as STIT capacity grows in line with the future strategy

6. The strategy for the in-house service is to reconfigure resources, currently in ongoing home care, into the re-ablement service.

7. It is Sheffield’s intention that all new service users and those existing service users, either from hospital or the community, will have a period of 6 weeks within STIT or one of our Resource Centres to enable them to reach optimum independence before transfer to an independent provider for ongoing care where appropriate.

8. This is part of wider strategy on our integrated services, which also includes resource centres for Short Term Intervention Services

Wakefield Council

(Metroplitan)

(updated Mar 2009)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council – see notes below Provision: in-house service FACS: Substantial and above and applied at entry to and exit from re-ablement service.



1. React is a rehabilitation and care assessment team and works as part of family services, social work assessment process. It was initially developed in 2003 to facilitate hospital discharge. Principally it was to support the hospital team to promote timely and appropriate discharges but soon developed into an Intake team for all requests for domiciliary care, taking referrals from all service areas. Re-Act look at all referrals in a multi-disciplinary setting in order to ascertain any rehabilitation potential and sorted accordingly to either rehabilitation or long-term need. If long-term they will move along to a long-term provider, if there is any rehabilitation potential then Re-Act will undertake the assessment programme.

2. Our aim is to work with people up to six weeks, working alongside other professionals to deliver a professional rehabilitation service. We are linked closely to the social work assessment teams, hospital rehabilitation units, resource centres and other health care professionals to stabilise individual packages of care and to encourage services users to reach their optimum level of ability. This could be people being totally rehabilitated to needing no package of care, or a reduced package of care. This will then be passed onto a long-term provider, to suit their assessed needs, thus giving choice, independence and a quality of life. We have found the multi-disciplinary approach to be essential in providing a good quality of care with the service user who is central to the assessment.

3. Re-Act comprises of family services staff and two Occupational Therapists, who obtain supervision from both social services management and by Health's Occupational Therapist Management Team in order to support professional development.



4. Re-Act is district wide and to facilitate this it has two team bases, East and West of the district which provides a more local and personalised service which helps to provide and support both staff and service users throughout the district. The team is heavily involved in integrated networks with health professionals which again gives good close working relationships which has been found to be beneficial to people living within the district.

5. The experience of having occupational therapists has proved to be vital in facilitating rehabilitation to a personalised rehabilitation programme. They have developed the skills and knowledge of all staff within the team through regular training sessions which includes moving and handling plans, aids and adaptations and assistive technology giving an holistic approach to each individuals plan of care. Re-Act continues to develop in line with the governments agenda enabling people to be in control of their lives and the care they receive.

City of York Council

(UA)

(updated Jan 2012)

Intake and Assessment Service Model: selective / de-selective Funding: by the Council Provision: outsourced (see note 2 below) FACS: Moderate and above and applied at entry to re-ablement service.

1. All new referrals except specialist service provision go through Enabling Service.

2. Service was provided In-house but was outsourced with a go live date of March 2012

3. Customers access the service for a maximum 6 weeks for re-ablement etc before moving onto other long-term services if appropriate.



APPENDIX 1 – INTAKE AND ASSESSMENT or HOSPITAL DISCHARGE ONLY

INTAKE AND ASSESSMENT SERVICE HOSPITAL DISCHARGE SUPPORT (solely or primarily)

Barking and Dagenham

Barnet

Bath and North East Somerset UA

Bedford Borough

Bexley

Birmingham

Blackpool UA

Bolton

Bournemouth UA

Bracknell Forest UA

Bradford

Brent

Brighton & Hove

Bristol UA

Bromley

Bury

Calderdale

Central Bedford

Cheshire East

Cheshire West & Chester

City of London

Cornwall

Coventry

Cumbria

Darlington UA

Derby UA

Derbyshire

Doncaster

Dorset

Dudley

Durham

Ealing

East Riding of Yorkshire UA

East Sussex

Essex

Gateshead

Gloucestershire

Greenwich

Hackney

Halton UA

Blackburn with Darwen UA

Camden

Croydon

Enfield

Hammersmith and Fulham

Haringey

Harrow

Hillingdon

Kensington and Chelsea

Lambeth

Leicester UA

Liverpool

North Tyneside

Northamptonshire

Redbridge

Richmond upon Thames

South Gloucestershire UA

Swindon UA

Tameside

Torbay UA

Waltham Forest

Warwickshire



Hampshire

Havering

Herefordshire UA

Hertfordshire

Hounslow

Islington

Kent

Kingston upon Hull UA

Kingston upon Thames

Kirklees

Knowsley

Lancashire

Leicestershire

Lewisham

Lincolnshire

Luton UA

Manchester

Medway UA

Merton

Milton Keynes UA

Newcastle upon Tyne

Newham

Norfolk

North East Lincolnshire UA

North Yorkshire

Northumberland UA

Nottingham City Council UA

Nottinghamshire

Oldham

Portsmouth UA

Reading UA

Redcar & Cleveland UA

Rochdale

Rotherham

Royal Borough of Windsor and Maidenhead

Rutland

Salford

Sandwell

Sefton

Sheffield

Shropshire

Slough Borough Council UA

Solihull

Somerset UA



South Tyneside

Southend-on-Sea UA

Southwark

Staffordshire

Stockport

Suffolk

Sunderland

Sutton

Telford and the Wrekin UA

Thurrock UA

Tower Hamlets

Trafford

Wakefield

Walsall

Wandsworth

Warrington UA

West Berkshire UA

West Sussex

Westminster

Wigan

Wiltshire

Wirral

Wokingham UA

Wolverhampton

Worcestershire

York UA

110 22

In addition, Surrey Council Council currently operate a mix of intake and assessment and hospital discharge across various areas.



APPENDIX 2 – SELECTIVE or DE-SELECTIVE MODEL

SELECTIVE DE-SELECTIVE Intake and Assessment Services

Bedford Borough

Bolton

Ealing

Greenwich

Hampshire

Havering


Lewisham

Luton UA

Medway UA

Newham



Southwark

Sutton

West Sussex

Westminster


Barnet

Bexley

Birmingham

Bournemouth UA

Bracknell Forest UA

Brent

Brighton & Hove

Bromley

Central Bedford

Cheshire East

Cornwall

Coventry

Darlington UA

Derby UA

Derbyshire

Durham

East Sussex

Gateshead

Hackney

Hertfordshire

Hounslow

Islington

Kent

Knowsley

Leicestershire

Lincolnshire

Manchester

Norfolk

North Yorkshire

Nottinghamshire

Oldham

Portsmouth UA


Rutland

Salford

Sefton

Slough Bor. Council UA

Solihull

Southend-on-Sea UA

Staffordshire




Tower Hamlets

Trafford

Walsall

West Berkshire UA

Wigan

Wirral

Wokingham UA

Wolverhampton

Worcestershire

Hospital Discharge Support (wholly or primarily)

Enfield


Haringey

Hillingdon


Lambeth

Leicester UA

Northamptonshire



Camden

Harrow

North Tyneside

Redbridge

Tameside

Waltham Forest

Warwickshire

27 58

In addition, Wandsworth are understood to apply a selective approach for their main service but a de-selective approach for their short term intervention service



APPENDIX 3 – FUNDING OF HOMECARE RE-ABLEMENT SERVICE

FUNDED BY THE COUNCIL FUNDED WITH HEALTH


Barnet


Bedford Borough

Birmingham


Bolton

Bournemouth UA

Bradford

Brent

Brighton & Hove

Bristol UA

Bromley

Bury

Calderdale

Camden

Central Bedford

Cheshire East


City of London

Cornwall

Cumbria

Darlington UA

Derby UA

Derbyshire

Doncaster

Dorset

Dudley

Durham

Ealing

East Sussex

Enfield

Gateshead

Gloucestershire


Hampshire

Bexley

Blackpool UA

Bracknell Forest UA

Cambridgeshire

Coventry


Essex

Greenwich

Hackney

Halton UA

Harrow


Kirklees

Lambeth

Leicester UA

Manchester

Milton Keynes UA


North Tyneside

Oldham

Poole UA

Reading UA


Rotherham


Sandwell

Sheffield

Southend-on-Sea UA

Sunderland


Thurrock UA

Torbay UA

Walsall

Warrington UA

Westminster

Wigan

Wirral



Haringey

Havering

Herefordshire UA

Hertfordshire

Hillingdon

Hounslow

Islington


Kent


Knowsley

Lancashire

Leicestershire

Lewisham

Lincolnshire

Liverpool

Luton UA

Medway UA

Merton

Newham

Norfolk

North Yorkshire

Northamptonshire

Northumberland UA


Nottinghamshire

Portsmouth UA

Redbridge


Rochdale

Rutland

Salford

Sefton

Shropshire


Solihull


South Tyneside

Southwark

Staffordshire



Stockport

Suffolk

Sutton

Tameside

Tower Hamlets

Trafford

Wakefield

Waltham Forest

Wandsworth

Warwickshire

West Berkshire UA

West Sussex

Wiltshire

Wokingham UA

Worcestershire

York UA

92 37

In addition, Surrey are understood to have a mix of council and joint funded services with health across their areas.



APPENDIX 4 – DELIVERY OF HOMECARE RE-ABLEMENT

IN-HOUSE OUTSOURCED (in part of whole)


Barnsley


Bedford Borough

Birmingham


Blackpool UA

Bolton

Bournemouth UA

Bracknell Forest UA

Bradford

Bristol UA

Bromley

Bury

Calderdale

Central Bedford

Cheshire East


City of London

Cornwall

Coventry

Cumbria

Darlington UA

Derby UA

Derbyshire

Doncaster

Dorset

Dudley

Durham

Ealing


Gateshead

Gloucestershire

Greenwich

Hackney

Halton UA


Hampshire

Haringey

Barnet

Bexley

Brent

Cambridgeshire

Camden

Croydon

Enfield

Harrow

Hertfordshire

Lambeth

Medway UA

Oxfordshire

Peterborough UA

Poole UA

Redbridge


Southwark

Westminster

Wirral

York UA

Outsourced (LATC - wholly owned trading companies)

Essex

Sefton

Stockport

Wokingham UA



Havering

Herefordshire UA

Hillingdon

Hounslow

Islington




Kirklees

Knowsley

Lancashire

Leicester UA

Leicestershire

Lewisham

Lincolnshire

Liverpool

Luton UA

Manchester

Merton

Middlesbrough UA

Milton Keynes UA

Newcastle upon Tyne

Newham

Norfolk


North Somerset UA

North Tyneside

North Yorkshire

Northamptonshire

Northumberland UA


Nottinghamshire

Oldham

Plymouth UA

Portsmouth UA

Reading UA


Rochdale

Rotherham


Rutland

Salford

Sandwell

Sheffield




South Tyneside

Southend-on-Sea UA

Staffordshire

Stoke-on-Trent UA

Suffolk

Sunderland

Surrey

Sutton

Tameside


Thurrock UA

Torbay UA

Tower Hamlets

Trafford

Wakefield

Walsall

Waltham Forest

Wandsworth

Warrington UA

Warwickshire

West Berkshire UA

West Sussex

Wigan

Wiltshire

Wolverhampton

Worcestershire

110 25

In addition to the listings above,

• Kent have a mix of in-house and outsourced services

• Solihull have an outsourced service for service after 6pm

• Brighton (pilot started Aug 2010) and East Sussex (pilot started Oct 2011) direct new referrals to their in-house service and people on review are directed to an outsourced provider

• South Gloucestershire are running a pilot with Brunlecare for 43 weeks (started Jan 2012)



APPENDIX 5 - APPLICATION OF FACS ELIGIBILITY CRITERIA

FACS APPLIED AT ENTRY TO SERVICE

FACS APPLIED ON EXIT FROM SERVICE

TOTAL

Low and above

Bracknell Forest UA

Liverpool

Sunderland

Low on entry and Moderate on exit

Derbyshire

Calderdale

5

Moderate and above

Bolton

Brighton & Hove

Derby UA

Doncaster

Dudley

Islington


Kent

Knowsley


Peterborough UA

Portsmouth UA

Rochdale

Rutland

Salford

Sutton

West Sussex

Westminster

York UA

Greater Moderate on entry Moderate for Community


Moderate on entry and Substantial on exit

Medway UA

Nottinghamshire


Darlington UA

Warrington UA


26

Substantial and above


Barnet

Bedford Borough

Bexley

Central Bedford

Cornwall

Coventry

Dorset

90



Birmingham


Blackpool UA

Bradford

Brent

Bromley

Bury

Camden

Cheshire East


City of London

Croydon

Ealing

East Sussex

Essex

Gateshead

Gloucestershire

Hackney

Halton UA

Hampshire

Haringey

Havering

Hertfordshire

Hillingdon

Lambeth

Leeds

Leicester UA

Lewisham

Lincolnshire

Luton UA

Middlesbrough UA

Newcastle upon Tyne

Norfolk

Oldham

Sandwell

Sheffield

Shropshire


Solihull


Southampton UA

Southwark

Staffordshire

Stockport

Enfield

Greenwich

Harrow

Hartlepool

Herefordshire UA

Hounslow

Kirklees

Lancashire

Leicestershire

Manchester

Milton Keynes UA

Newham

North Tyneside

Northamptonshire

Plymouth UA

Poole UA


Rotherham


Sefton

Southend-on-Sea UA

Swindon UA


Tower Hamlets

Walsall

Wigan

Wirral



Stoke-on-Trent UA

Suffolk

Tameside

Trafford

Wakefield

Waltham Forest

Wandsworth

Warwickshire

Wiltshire

Worcestershire

Upper substantial on entry


Critical and above

Northumberland UA

West Berkshire UA

Wokingham UA

3

TOTAL 86 38 124

In addition, it is understood that Somerset apply Moderate on entry to their service for referrals from the community but referrals from hospital are not subject to FACS.



GPA was founded by Gerald Pilkington who has over 26 years of experience working in health and

social care across the independent sector (acute, long-term care and rehabilitation) and NHS.

Gerald was previously Chief Executive of a not-for-profit group that owned care homes and acute

hospitals across England and Wales, and managed others under contract. He has also served as a

Trustee and non-executive Director of a not-for-profit hospital.

More recently Gerald was the national lead for homecare re-ablement within the Care Services

Efficiency Delivery programme at the Department of Health, supporting 152 English local authorities

to achieve their efficiency targets within adult social care.

If you would like to discuss how we might be able to help you to deliver operational and financial

improvements do contact us.


GPA was founded by Gerald Pilkington who has over 26 years of experience working in health and social care across the independent sector (acute, long-term care and

rehabilitation) and NHS.

Gerald was previously Chief Executive of a not-for-profit group that owned care homes and acute hospitals across England and Wales, and managed others under contract. He has

also served as a Trustee and non-executive Director of a not-for-profit hospital.

More recently Gerald was the national lead for homecare re-ablement within the Care Services Efficiency Delivery programme at the Department of Health, supporting 152

English local authorities to achieve their efficiency targets within adult social care. GPA continue to work with councils, LATCs and other providers to help them implement and

enhance their re-ablement services.

If you would like to discuss how we might be able to help you to deliver operational and financial improvements do contact us.

See our website for discussion papers on a range of subjects including homecare re-ablement and extra care

homecare re-ablement cssr scheme directory update april … · • 17% of reported services only...

Documents