{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Intermediate Care and Reablement Support Policy

1. Purpose and Commitment

The purpose of this policy is to set out how {{org_field_name}} delivers safe, effective, person-centred intermediate care and reablement support. The service will support people, where appropriate, to regain, maintain or improve their independence, confidence and functional ability following illness, injury, hospital discharge or a deterioration in their health or wellbeing.

Intermediate care and reablement will be delivered in a manner that promotes the person’s independence, wellbeing, dignity, choice and control while protecting them from avoidable harm, abuse and improper treatment. Support will be based on assessed need, agreed outcomes and the person’s individual circumstances and preferences.

{{org_field_name}} will provide intermediate care and reablement in accordance with applicable legislation and regulatory requirements, including:

• the Health and Social Care Act 2008;
• the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended;
• the Care Act 2014 and associated statutory guidance, where applicable;
• the Mental Capacity Act 2005 and its Code of Practice;
• applicable safeguarding legislation and statutory guidance; and
• relevant Care Quality Commission requirements and guidance.

Care and support will be planned and delivered in accordance with the Fundamental Standards applicable to the regulated activity, including requirements relating to person-centred care, dignity and respect, consent, safe care and treatment, safeguarding, complaints, good governance, staffing and the duty of candour.

Intermediate care and reablement will normally be outcome-focused and time-limited where this reflects the person’s assessed needs and the arrangements agreed with the relevant commissioner or funding body. No person will have support reduced or withdrawn solely because a predetermined period has expired without consideration of their current needs, risks, outcomes and any arrangements required for the safe transition or continuation of care.

2. Scope

This policy applies to all employees, including care staff, administrative staff, volunteers, and contractors involved in intermediate care and reablement. It covers:

• Assessment and care planning.
• Delivery of intermediate care and reablement services.
• Monitoring progress and evaluating outcomes.
• Collaborative working with healthcare professionals and families.

The policy applies to all domiciliary care settings where service users require short-term, outcome-focused support aimed at regaining independence.

3. Policy Statement

{{org_field_name}} is committed to delivering intermediate care and reablement services that:

• Promote independence and self-care.
• Support recovery from illness, injury, or hospitalisation.
• Empower service users to achieve personal goals.
• Reduce reliance on long-term care services.

We achieve this through comprehensive assessments, tailored care plans, multi-disciplinary collaboration, and continuous progress monitoring.

4. Understanding Intermediate Care and Reablement

4.1 What is Intermediate Care?

Intermediate care provides short-term support to individuals recovering from illness, surgery, or hospital discharge. It bridges the gap between hospital and home, promoting recovery and preventing unnecessary readmission.

4.2 What is Reablement Support?

Reablement focuses on helping individuals regain skills, confidence, and independence in daily activities. It involves:

• Personalised goal-setting.
• Time-limited, intensive support.
• Promoting self-care and resilience.

Reablement differs from traditional care by encouraging active participation rather than passive care delivery.

5. Roles and Responsibilities

5.1 Care Staff Responsibilities

Care staff involved in intermediate care and reablement must:

• provide care and support only within the limits of their role, training, competence and authorisation;
• follow the person’s current care and support plan, risk assessments and agreed reablement goals;
• involve the person in decisions about their care and support and respect their choices, preferences, dignity, privacy and independence;
• obtain and respect valid consent before providing care or support and follow the Mental Capacity Act 2005 where there is reason to believe that the person may lack capacity to make a particular decision;
• encourage and enable the person to undertake activities for themselves where this is safe and consistent with their assessed needs, abilities, wishes and agreed outcomes;
• follow all risk-management measures relating to the person’s care, mobility, environment, equipment, medicines and other identified risks;
• use equipment only where they have been trained and assessed as competent to do so and in accordance with the person’s care plan and relevant instructions;
• follow the organisation’s infection prevention and control requirements;
• remain alert to signs of abuse, neglect, self-neglect, exploitation, improper treatment or avoidable harm and report safeguarding concerns immediately in accordance with the organisation’s safeguarding procedures;
• report deterioration, significant changes in need, accidents, incidents, near misses, equipment concerns, medicines concerns and any inability to deliver planned care without delay;
• seek emergency medical assistance where required;
• maintain accurate, complete, legible and contemporaneous records of the care and support provided, the person’s progress, significant observations, decisions and actions taken; and
• participate in training, supervision, competency assessment and professional development required for their role.

Staff must not undertake a task for which they have not received appropriate training or for which they have not been assessed as competent.

5.2 Manager Responsibilities

The Registered Manager, or a person formally delegated by the Registered Manager, is responsible for ensuring that:

• people receive care and support that is appropriate, person-centred, safe and consistent with their assessed needs and preferences;
• assessments, care plans, risk assessments and reablement goals are completed, implemented, reviewed and updated when needs or risks change;
• valid consent is obtained and recorded and the requirements of the Mental Capacity Act 2005 are followed where applicable;
• safeguarding concerns are recognised, reported, escalated and managed in accordance with applicable legislation, local safeguarding procedures and organisational policy;
• sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed;
• staff receive appropriate induction, training, supervision, appraisal, competency assessment and continuing support;
• staff receive learning disability and autism training appropriate to their role;
• care is coordinated safely with commissioners, health professionals, local authorities, families, representatives and other providers where responsibility for care is shared or transferred;
• accidents, incidents, complaints, safeguarding concerns, medicines incidents, missed or late care, deterioration and other risks are reviewed and appropriate action is taken;
• applicable statutory notifications are made to the Care Quality Commission and other relevant authorities where required;
• the statutory duty of candour is complied with where applicable;
• records are accurate, complete, contemporaneous, secure and available when required; and
• systems are operated to assess, monitor and improve the quality and safety of the service and to identify and mitigate risks.

5.3 Service Users, Families and Representatives

People receiving the service will be supported and encouraged to participate actively in assessment, care planning, goal-setting and review.

Families, carers and representatives may be involved with the person’s consent or where there is another lawful basis for their involvement.

A family member or informal carer must not be treated as having legal authority to consent to care or make decisions on behalf of an adult solely because of their relationship to that person. Where the person lacks capacity to make a particular decision, decision-making must take place in accordance with the Mental Capacity Act 2005 and any applicable lawful authority, including a valid and applicable Lasting Power of Attorney or Court of Protection deputyship.

6. Assessment and Care Planning

6.1 Initial Assessment

Before intermediate care or reablement support begins, or as soon as reasonably practicable where immediate care is necessary, {{org_field_name}} will ensure that the person’s needs and risks relevant to the service are assessed.

The assessment will consider, as applicable:

• the person’s physical health and functional abilities;
• mental health and emotional wellbeing;
• cognition and any known impairment of decision-making ability;
• mobility, transfers and falls risks;
• personal care needs;
• nutrition and hydration needs where relevant;
• medicines support requirements;
• skin integrity and other relevant health risks;
• communication needs and preferred methods of communication;
• sensory impairments;
• environmental risks within the person’s home;
• equipment, aids and adaptations;
• the person’s ability to undertake daily living activities;
• existing professional assessments and treatment or rehabilitation plans;
• the person’s preferences, routines, cultural needs, religious needs and protected characteristics;
• any safeguarding concerns;
• informal support available from family members or carers;
• risks associated with promoting independence;
• the person’s desired outcomes and reablement goals; and
• arrangements for foreseeable deterioration, emergencies or changes in need.

Assessments must be proportionate to the person’s needs and must distinguish between risks that require control and positive risks that can be managed in a way that supports independence and personal choice.

6.2 Individualised Care and Reablement Plan

An individualised care and reablement plan will be developed from the assessment and agreed with the person wherever they have capacity to participate in that decision.

The plan must clearly identify:

• the person’s assessed needs;
• their preferences and wishes;
• agreed reablement outcomes and goals;
• what the person is able and wishes to do independently;
• the support staff are required to provide;
• actions staff should encourage or enable the person to undertake;
• identified risks and agreed measures for managing those risks;
• equipment or aids required;
• relevant medicines support arrangements;
• communication requirements;
• responsibilities of other professionals, providers, family members or carers where applicable;
• escalation arrangements if the person’s condition, needs or risks change; and
• review arrangements.

Care plans and risk assessments must be reviewed whenever there is a significant change in the person’s condition, abilities, needs, wishes, circumstances or risks and at other intervals appropriate to the person’s care.

Changes must be documented and communicated promptly to staff and other relevant persons involved in the person’s care.

6.3 Consent, Mental Capacity and Involvement

Care and support must only be provided with the consent of the relevant person unless there is a lawful basis for providing it without that person’s consent.

Consent must be:

• informed;
• given voluntarily;
• obtained before the relevant care or support is provided;
• sought in a manner that meets the person’s communication needs; and
• treated as an ongoing process rather than a single event.

The person must be given information about proposed care and support in a form they can understand, including relevant risks, benefits and reasonable alternatives where applicable.

Staff must not assume that a person lacks capacity because of their age, disability, diagnosis, appearance, behaviour or because they make a decision that others consider unwise.

Where there is reason to doubt the person’s capacity to make a particular decision, capacity must be assessed in accordance with the Mental Capacity Act 2005. Capacity is decision-specific and time-specific.

Where a person lacks capacity to make a particular decision, any decision made or action taken on their behalf must comply with the Mental Capacity Act 2005, including its best-interests and least-restrictive principles.

Any applicable advance decision, Lasting Power of Attorney, Court of Protection deputyship or court order must be identified, verified where necessary and respected within the scope of the authority granted.

Consent, capacity assessments, best-interests decisions and the involvement of representatives must be recorded appropriately.

7. Delivery of Intermediate Care and Reablement Services

7.1 Person-Centred and Safe Reablement

Care and reablement support will be delivered in accordance with the person’s current care plan, assessed needs, preferences, abilities, risks and agreed goals.

Staff will promote independence by enabling the person to undertake activities for themselves wherever this can be done safely and consistently with their wishes.

Staff must not pressure or compel a person to undertake a reablement activity because it appears within their care plan. Where a person declines care or an activity, staff must respect a capacitous decision, identify and respond to any immediate risk, record the refusal and action taken, and report repeated or significant refusals in accordance with the person’s escalation plan.

The person’s dignity, privacy and autonomy must be maintained throughout all care and reablement activities.

7.2 Risk Management

Risks associated with care and reablement must be assessed, documented and managed. Risk management must support the person’s independence while reducing avoidable harm.

Staff must follow identified control measures and report:

• new hazards;
• deterioration in health or functional ability;
• falls or increased falls risk;
• changes affecting safe mobility or transfers;
• unsafe or damaged equipment;
• medicines concerns;
• changes in cognition or behaviour affecting safety;
• signs of abuse or neglect; and
• any situation in which the agreed care plan can no longer be delivered safely.

Risk assessments must be reviewed following relevant incidents, significant changes or information indicating that existing control measures may no longer be effective.

7.3 Equipment and Mobility Support

Equipment used during the provision of care must be suitable for its intended purpose, available when required and used safely.

Staff must use moving and handling equipment, mobility aids and other care equipment only where:

• its use is included within the person’s assessment or care plan, where appropriate;
• they have received appropriate instruction or training; and
• they have been assessed as competent where competency assessment is required.

Any defect, damage or concern about the safety or suitability of equipment must be reported immediately and unsafe equipment must not continue to be used.

7.4 Medicines

Where {{org_field_name}} provides medicines support as part of the regulated activity, medicines must be managed safely and in accordance with the person’s assessed needs, care plan, medicines records and the organisation’s Medicines Policy.

Staff involved in medicines support must have received appropriate training and have been assessed as competent for the tasks they perform.

Any medicines error, omission, refusal, discrepancy, adverse effect or other concern must be recorded, reported and escalated in accordance with organisational procedures.

Reablement objectives must not result in a person being expected to self-manage medicines where assessment shows that doing so would expose the person to avoidable harm.

7.5 Infection Prevention and Control

Staff must follow the organisation’s infection prevention and control procedures and apply appropriate precautions according to the activity being undertaken and the risks identified.

Relevant infection risks must be identified and managed as part of safe care delivery.

7.6 Multidisciplinary Working and Transfer of Care

Where responsibility for a person’s care is shared with, or transferred to, another person or organisation, {{org_field_name}} will work with the person, relevant professionals, commissioners, providers and representatives to support continuity and safety.

Relevant information necessary for the safe delivery of care must be communicated accurately and without avoidable delay, subject to applicable confidentiality and data-protection requirements.

Changes in professional instructions, equipment, medicines, mobility status, health needs or other information affecting the safe delivery of care must be incorporated into the care plan promptly.

8. Monitoring Progress and Evaluating Outcomes

8.1 Monitoring and Review

The person’s progress towards agreed reablement outcomes will be monitored at intervals appropriate to the duration, intensity, risks and objectives of the service.

Monitoring will include, as applicable:

• progress towards agreed goals;
• changes in functional ability;
• changes in the person’s health or wellbeing;
• changes in risks;
• the person’s experience of the service;
• whether current levels of support remain appropriate;
• whether equipment, aids or adaptations remain suitable; and
• information received from relevant health and social care professionals.

A care plan or risk assessment must not remain unchanged until a scheduled review where staff become aware of information indicating that the person’s needs, abilities or risks have materially changed.

Significant changes must be escalated promptly and reassessment or professional review arranged where required.

8.2 Outcome Evaluation

Outcomes will be evaluated according to the person’s individual goals and assessed needs rather than solely by whether care hours have reduced.

Evaluation may include:

• achievement or partial achievement of agreed goals;
• improvement or maintenance of functional ability;
• increased confidence or independence;
• changes in the level or type of care required;
• outstanding risks or unmet needs; and
• the person’s own views about their progress and future support.

Relevant outcomes and recommendations will be recorded and communicated to the person and, where authorised or otherwise lawful, to relevant representatives, commissioners and professionals.

9. Transition and Discharge Planning

9.1 Preparing for Discharge

As service users achieve their goals, we develop a discharge plan, including:

• Final progress assessment.
• Recommendations for ongoing support.
• Guidance on self-care and community resources.

9.2 Follow-Up Support

We provide follow-up support to ensure sustained independence and well-being.

10. Safeguarding and Risk Management

10.1 Protection from Abuse and Improper Treatment

{{org_field_name}} will protect people receiving intermediate care and reablement from abuse, neglect, exploitation, avoidable harm and improper treatment.

Staff must remain alert to safeguarding concerns, including:

• physical abuse;
• sexual abuse;
• psychological or emotional abuse;
• financial or material abuse;
• neglect and acts of omission;
• discriminatory abuse;
• domestic abuse;
• organisational abuse;
• modern slavery;
• self-neglect; and
• any other behaviour or circumstance that may constitute abuse or improper treatment.

Any safeguarding concern, allegation, disclosure or suspicion must be reported immediately in accordance with the organisation’s Safeguarding Policy and local safeguarding procedures.

Where there is an immediate risk of serious harm, staff must take appropriate emergency action, including contacting emergency services where necessary.

Safeguarding records must be factual, accurate, contemporaneous and handled securely.

Staff must preserve potential evidence where appropriate and must not conduct their own investigation where doing so could compromise a statutory safeguarding or criminal investigation.

10.2 Restraint, Restrictions and Deprivation of Liberty

Care and reablement must be delivered using the least restrictive approach compatible with the person’s safety and lawful care.

Staff must not use restraint or other restrictive practices unless their use is lawful, necessary and proportionate to the risk of harm and is permitted within the staff member’s role, training and the person’s authorised care arrangements.

No person may be deprived of their liberty for the purpose of receiving care or treatment without lawful authority.

Any concern that a person’s care arrangements may amount to a deprivation of liberty must be reported immediately to the Registered Manager so that appropriate legal advice, assessment or application can be pursued through the relevant lawful process.

10.3 Safeguarding and Positive Risk-Taking

Safeguarding must not be used as a reason to remove a person’s lawful choices or independence unnecessarily.

Where a person with capacity chooses to take a risk, staff must seek to understand the person’s decision, provide relevant information, consider reasonable measures for reducing foreseeable harm and record the decision and agreed risk-management arrangements.

Where there is reason to believe that the person lacks capacity to make the relevant decision, the Mental Capacity Act 2005 must be followed.

11. Training and Competency

11.1 Training Requirements

{{org_field_name}} will ensure that staff receive the support, induction, training, professional development, supervision and appraisal necessary to enable them to carry out their duties safely and competently.

Training relevant to intermediate care and reablement will be determined by each staff member’s role and responsibilities and the needs of people using the service.

This will include, where relevant to the role:

• person-centred care and reablement principles;
• safeguarding adults;
• Mental Capacity Act 2005 and consent;
• moving and handling;
• medicines;
• infection prevention and control;
• health and safety;
• emergency procedures;
• recognising deterioration;
• equipment used by the service; and
• other training identified through assessment of staff competency and the needs of people receiving care.

All staff working for the purpose of the regulated activity must receive training on learning disability and autism that is appropriate to their role.

The organisation will determine the appropriate level and content of learning disability and autism training having regard to legal requirements and applicable national guidance.

11.2 Competency

Training attendance alone will not be treated as evidence of competence where the activity requires staff to demonstrate practical competence.

Competency must be assessed, recorded and reviewed where appropriate to the task being undertaken.

Staff must not undertake duties beyond their training, competence or authorised scope of practice.

Where a competency concern is identified, the staff member must receive appropriate support, supervision, retraining or reassessment and must not undertake the relevant activity unsupervised where doing so could expose a person to risk.

Managers will maintain appropriate records of staff training, supervision, appraisal and competency.

12. Record-Keeping and Documentation

{{org_field_name}} will maintain accurate, complete, contemporaneous and secure records relating to each person receiving intermediate care and reablement.

Records must include, where applicable:

• assessments;
• care and reablement plans;
• risk assessments;
• consent records;
• mental capacity assessments and best-interests decisions;
• daily care records;
• progress towards agreed goals;
• changes in health, needs, abilities or risks;
• medicines records;
• incidents, accidents and near misses;
• safeguarding concerns and actions;
• communication with health and social care professionals;
• reviews and reassessments;
• refusals of care where relevant;
• discharge or transition arrangements; and
• significant decisions and the reasons for them.

Staff must record care and support as soon as reasonably practicable after it has been provided.

Records must accurately reflect what occurred and must not be falsified, retrospectively altered without an appropriate audit trail, or completed in advance of care being provided.

Records must be maintained securely, protected against unauthorised access, alteration, loss or destruction and made available only to persons who are authorised or otherwise lawfully entitled to receive them.

Any sharing of personal information must comply with applicable confidentiality and data-protection requirements.

13. Communication and Collaboration

Effective communication ensures continuity of care. This includes:

• Regular updates to healthcare providers.
• Collaboration with service users and families.
• Participation in multidisciplinary team meetings.

14. Complaints and Feedback

{{org_field_name}} will operate an effective and accessible system for identifying, receiving, recording, handling, investigating and responding to complaints about the care and support it provides.

People receiving the service and persons acting on their behalf will be given information about how to make a complaint and will be supported to raise concerns in a manner appropriate to their communication needs.

A person must not experience discrimination, victimisation, withdrawal of care or any other adverse treatment because they have made or supported a complaint.

Complaints will be:

• acknowledged and handled in accordance with the organisation’s Complaints Policy;
• investigated proportionately;
• responded to within applicable organisational timescales;
• recorded together with the findings, outcome and action taken; and
• used to identify learning and opportunities to improve the service.

Where an investigation identifies that action is necessary to address a failure, reduce risk or prevent recurrence, that action will be implemented and monitored.

Complaint information and associated correspondence will be retained in accordance with applicable requirements and made available to the Care Quality Commission where the Commission is lawfully entitled to request it.

Where a complaint also raises a safeguarding concern, safety incident or other matter requiring separate statutory action, the relevant procedure must be commenced without waiting for completion of the complaints process.

15. Quality Assurance and Continuous Improvement

15.1 Governance and Audit

{{org_field_name}} will establish and operate effective systems and processes to assess, monitor and improve the quality and safety of intermediate care and reablement services.

Governance arrangements will include, as appropriate:

• auditing care records, assessments and care plans;
• monitoring whether agreed care and reablement outcomes are being addressed;
• reviewing accidents, incidents and near misses;
• reviewing safeguarding concerns;
• reviewing medicines incidents where medicines support is provided;
• monitoring complaints and feedback;
• monitoring missed, late or incomplete care visits where relevant;
• reviewing staff training, competency, supervision and appraisal;
• identifying changes in risk;
• checking whether actions identified through audits and reviews have been completed; and
• obtaining and acting upon feedback from people using the service.

15.2 Risk Management and Improvement

The Registered Manager will ensure that risks relating to the health, safety and welfare of people using the service are identified, assessed, monitored and mitigated.

Where an audit, incident, complaint, safeguarding concern, feedback, staff concern or other review identifies a shortfall, the organisation will:

• identify the cause and extent of the concern;
• take proportionate action to protect people from harm;
• establish any corrective or improvement action required;
• allocate responsibility for completing actions;
• monitor completion and effectiveness; and
• share relevant learning with staff.

Governance records must provide sufficient evidence to demonstrate how the organisation monitors compliance and responds to identified risks or shortfalls.

16. Duty of Candour

16.1 Openness and Transparency

{{org_field_name}} will act in an open and transparent manner with people receiving care and support and with relevant persons acting lawfully on their behalf.

Staff must report accidents, incidents, omissions and safety concerns promptly so that the organisation can determine whether further action is required under the statutory duty of candour.

16.2 Notifiable Safety Incidents

Where an incident meets the statutory definition of a notifiable safety incident under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, {{org_field_name}} will comply with the statutory duty of candour.

The relevant person will be notified as soon as reasonably practicable after the organisation becomes aware that a notifiable safety incident has occurred.

The notification will:

• be given in person by an appropriate representative of {{org_field_name}};
• provide a true account of all facts known at the time that are relevant to the incident;
• advise the relevant person of any further enquiries that the organisation considers appropriate;
• include an apology; and
• be followed by written notification containing the information required by the regulation.

Reasonable support will be provided to the relevant person in relation to the incident.

The organisation will maintain a secure written record of the notification and other steps taken to comply with the duty.

Where the relevant person cannot be contacted or declines to speak to the organisation, reasonable attempts to make contact must be documented.

Compliance with the duty of candour does not replace any separate requirement to notify the Care Quality Commission, safeguarding authority, commissioner, police, coroner or any other relevant body where such notification is required.

17. Compliance and Review

This policy will be reviewed at least annually and sooner where necessary following:

• a relevant change in legislation or statutory guidance;
• a change in Care Quality Commission regulatory requirements or guidance materially affecting this policy;
• a significant incident or safeguarding concern;
• findings from complaints, audits or regulatory activity indicating that the policy requires amendment; or
• significant changes to the service or the manner in which intermediate care or reablement is provided.

Compliance with this policy will be monitored through appropriate governance arrangements, including:

• care-record and care-plan audits;
• review of risk assessments;
• review of incidents, safeguarding concerns and complaints;
• staff training and competency records;
• supervision and appraisal;
• service-user feedback;
• outcome monitoring; and
• management review of identified risks and improvement actions.

The Registered Manager is responsible for ensuring that this policy is implemented in practice and remains consistent with the requirements applicable to the regulated activity, including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended.

Staff must be informed of relevant changes to this policy and must receive additional instruction, training or competency assessment where a change affects their duties.

---

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.