Reablement Service

You might contact us yourself or on behalf of a friend or family member who may be finding it hard to cope at home.

Our team is made up of social workers, occupational therapists, nurses, physiotherapists and rehabilitation workers.

You might need our support because you:

• are returning home after a period in hospital or residential care
• have new physical disabilities
• are recovering from a period of illness
• need some support to remain living in your home
• want to regain daily living skills and confidence to live independently

If you are eligible, we will work with you to develop an individual support plan, including goals to help you regain your independence. Your personal plan will include a range of support and could include: occupational therapy, telecare, help preparing meals or support for getting out and about in the community.

If you still have some longer term care and support needs after completion of the service, we can arrange for a reassessment to allow us to plan and implement suitable long term support.

We can still provide you with information and advice about preventative services that can help you stay independent and prevent your situation from worsening.

Intermediate care services are provided free of charge, up to a maximum of six weeks.

This is a placement within a 24-hour care setting and is generally for people who have experienced a crisis at home which has resulted in them needing further support following a hospital admission or to avoid a hospital admission.

The length of stay is determined by the individual needs and the aim is to offer a reablement service based on those needs.

An assessment will be completed by the Dudley Integrated Health Care Team to determine if this service is suitable for that individual prior to admission. There is no charge for this service.

If you need further support at home following a stay in hospital, before discharge and while you are still in hospital, patients and/or carers should ask the ward staff to contact the Hospital Social Care Team.

You will then be referred to the Hospital Social Care Team who will work closely with the Dudley Group of Hospitals, patients and/or their carers offering support, advice, and guidance.

The ward will refer you to the appropriate discharge pathway dependent on current care and support needs.

• Pathway 1 is a supported discharge home with a package of care in place
• Pathway 3 is a discharge to assess bed within a Residential or Nursing home to assess your ongoing care needs

If you require further rehabilitation in a bedded facility, you will be referred to the Intermediate Care Team, who assess for these beds; these are referred to as Pathway 2.

Reablement is a free service, available for up to six weeks, for adults who need help regaining or maximising their independence to enable them to continue living in their own homes. The service is also sometimes known as rehabilitation, or intermediate care at home.

Reablement is an intensive service using a 'doing with' approach, which involves supporting you to do things for yourself. Reablement workers stand back to encourage and allow you the time to complete a task on your own. This may involve being shown a different way to carry out the task to achieve independence.

The service can help you to regain your independence, perhaps following a period of illness, or to maximise it if you are struggling with living independently at home. You might need support from the service because you:

• Are returning home after a period in hospital or residential care
• Have new physical disabilities
• Are recovering from a period of illness
• Need some support to remain living in your home
• Want to regain daily living skills and the confidence to live independently

The Reablement Service is made up of social care assessors, social workers, occupational therapists, physiotherapists, assistant care coordinators and rehabilitation support workers. You will be contacted by a member of the team to complete an assessment of your needs. From this, together we will develop a care plan which will aim to help you become independent. The plan will be tailored to your needs, your abilities, and goals that we will agree with you – exactly what you want to achieve from the service.

The service is for adults aged 18 and over who live in Dudley Borough and who are felt to be at risk of losing their independence.

A needs assessment for the service will take place to decide if you are eligible for it. If you do not qualify for support from the Reablement Service, then we can still provide you with information and advice about preventative and community-based services that can help you stay independent and prevent your situation from worsening.

The service provides short term intensive support, lasting up to a maximum of six weeks. Generally, the length that the service is provided for depends upon individual needs. You will be encouraged to set regular goals and review your progress along the way, with the support of our staff. Often people regain their independence within a few short weeks, and we will work with you and family members or carers to achieve your goals as soon as is practically possible.

For some people it could be encouraging with personal care or to prepare meals, while others may need help to get out of the house and get involved in social activities. Some people may benefit from having telecare home alarms installed in their home, adaptations to their home, or other assistive technology to support in living independently as possible, while others may find occupational therapy or physiotherapy useful. Whatever your needs our staff will work with you to design a service that works best for you.

We offer a flexible service to suit your needs, the aim being to help you to regain your confidence and independence, to enable you to do things for yourself again.

Dudley MBC work in conjunction with Dudley Integrated Healthcare Trust (DIHC) to provide a reablement service for people following a crisis in their life, which has resulted in a hospital admission. The Aim of the service is to avoid premature admissions into long term care setting and maximise the persons independence.

An assessment is undertaken in hospital by a Nurse assessor working for DIHC. Tiled House is an Intermediate care facility, offering 47 residential beds for people identified as having rehab/reablement goals. The facility is based on a residential setting, with a Multidisciplinary team consisting of Therapists, Nurses, Senior Care Officers, Care and Domestic staff all who work in conjunction with each other to provide a high standard of care and assist each individual to reach their goal.

We aim for the length of stay to be between 3-4 weeks, however this can vary depending on the individuals progress and their identified rehab goals. This service is free of charge to the individual if they are registered with a Dudley GP and have identifiable rehab goals.

Following completion of the individuals rehab programme, if a social care assessment is required, we have a dedicated team of social workers that work as part of the MDT.

At the end of the service your needs will be reviewed and hopefully you will have regained your confidence to live independently at home. Our aim is that the intensive short-term support provided will result in you being able to continue living independently. Most people who have used the service are able to regain their independence.

If you still have some long-term care and support needs after the service has ended, then we will arrange for a reassessment of your needs to identify if you are eligible for a personal budget to meet your agreed long-term outcomes.

A financial assessment will be completed to determine if you are required to make a contribution towards the cost of your support.

The Living Independently Team support adults aged 18 years and over who are eligible for an assessment if they appear to require care and support, regardless of their likely eligibility for state-funded care.

Under the Care Act 2014, if a person has eligible needs, they will be entitled to a package of care to suit their individual needs, to promote independence and positively impact on their wellbeing.

LIT provide an assessment-based service focusing on a holistic approach to care and reablement; identifying people’s strengths to determine their needs achieving their desired outcomes.

Carers of adults who meet the LIT Service Criteria are entitled to a carer’s assessment as part of the assessment process.

The aims and objectives of the service are:

• To enable an adult to become independent through reablement services; empowering the person to reach their potential
• If we assess you as having long term care and support needs, we will identify if you are eligible for a personal budget to meet your agreed outcomes
• Working with carers to achieve best outcomes for the person while keeping the cared for safe and within their home
• To provide a seamless service across internal and external services, including greater integration with NHS, housing, mental health, public health, and the voluntary sector
• To enable a consistent and personalised approach to care and support for adults within Dudley who access statutory social care services
• Contribute to improve future planning and work collaboratively with commissioning to provide a range of responsive local services
• We will undertake reviews with the person to ensure the care plan is meeting identified outcomes
• Provide a proportionate, timely, professional, and ethical response to vulnerable adults with care and support needs who may be experiencing abuse or neglect and are unable to protect themselves

For further information please contact our access to adult social care helpline:

Telephone 0300 555 0055 (Monday to Friday - 9am to 5pm)

An emergency duty team is available on 0300 555 8574 at all other times

Web: www.dudley.gov.uk/asc

Email: accessteam.dachs@dudley.gov.uk

Post: Brierley Hill Health & Social Care Centre, Venture Way, Brierley Hill, DY5 1RU

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