DCW98-Intermediate Care and Reablement Support Policy
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Intermediate Care and Reablement Support Policy
1. Purpose
The purpose of this policy is to ensure that {{org_field_name}} provides high-quality, person-centred intermediate care and reablement support to individuals recovering from illness, surgery, or hospital discharge. The policy aims to facilitate independence, functional recovery, and improved quality of life, reducing the need for long-term care or hospital readmission.
Our objectives are to:
- Enable individuals to regain skills and confidence in daily living activities.
- Promote independence, preventing unnecessary hospitalisation or long-term care dependency.
- Support individuals in transitioning from hospital to home safely.
- Provide a structured, time-limited reablement programme tailored to service users’ needs.
- Ensure a multi-disciplinary approach, working with health and social care professionals.
- Meet Care Inspectorate Wales (CIW) regulations and national standards for reablement care.
2. Scope
This policy applies to:
- Service users receiving intermediate care and reablement support.
- All employees, including reablement care workers, supervisors, and managers.
- The Registered Manager and Responsible Individual, ensuring compliance and oversight.
- Healthcare professionals, including physiotherapists, occupational therapists, and GPs.
- Families and carers, who support service users in regaining independence.
- Local authorities and social services, involved in intermediate care planning.
3. Legal and Regulatory Framework
This policy aligns with, and must be implemented in accordance with, the following legislation, regulations and statutory guidance (as amended from time to time):
- Regulation and Inspection of Social Care (Wales) Act 2016.
- Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended), including requirements relevant to domiciliary support services such as: provision of information and a written guide, service agreements, meeting language and communication needs, duty of candour, handling concerns/complaints, whistleblowing, governance and quality assurance, record keeping, and required notifications.
- Welsh Government Statutory Guidance for providers of care home and domiciliary support services (last updated 27 March 2024).
- Social Services and Well-being (Wales) Act 2014.
- Mental Capacity Act 2005 (including best interests decision-making and lawful restrictions where applicable).
- Equality Act 2010 and a human-rights based approach to care and support.
- Social Care Wales Codes of Professional Practice and associated practice guidance (as applicable to the service and workforce).
- Relevant evidence-based guidance, including NICE guidance on intermediate care and reablement (where applicable to service delivery).
4. Duty of Candour and Openness
We act in an open and transparent way with individuals receiving care and support and, where appropriate, their representatives when things go wrong. This includes:
- being open and honest about what happened and the impact;
- offering a sincere apology where appropriate;
- explaining what will be done immediately to keep the person safe;
- sharing the outcome of any review or investigation and what will change as a result; and
- taking action to prevent bullying, victimisation, or obstruction of any person who raises concerns or who acts in line with their professional duty of candour.
Where concerns indicate a possible breach of the professional duty of candour by a Social Care Wales registered worker, we will address this through supervision and/or disciplinary processes and, where appropriate, make a referral to the relevant professional body.
All staff must understand and follow our duty of candour arrangements and must record actions taken within the individual’s records and within our governance/quality systems.
5. Defining Intermediate Care and Reablement
5.1 What is Intermediate Care?
Intermediate care is a short-term, targeted intervention designed to:
- Support hospital discharge and prevent unnecessary admissions.
- Facilitate recovery from illness, surgery, or injury.
- Help individuals regain independence in daily living activities.
5.2 What is Reablement Support?
Reablement focuses on:
- Restoring functional ability, such as mobility, cooking, and personal care.
- Encouraging service users to develop self-care skills.
- Reducing reliance on long-term care services.
How we manage this efficiently:
- Each service user has an individualised reablement plan.
- Care staff are trained in promoting independence, rather than doing tasks for the individual.
- Regular progress assessments ensure timely goal adjustments.
6. Language, Communication and Welsh Language
At assessment and throughout reablement support, we identify, record, and review each person’s communication needs and preferred language, including any aids or adjustments required to communicate meaningfully.
Information and support will be provided in a way the person can understand, including in an appropriate language, style, presentation and format. Where required, we will support access to communication aids and reasonable adjustments (for example: large print, pictorial prompts, hearing or visual support, interpretation support, or other assistive technology).
Where Welsh is the person’s preferred language, we will take reasonable steps to meet Welsh language needs and to provide an active offer in line with our statement of purpose and service arrangements.
7. Eligibility and Assessment for Reablement Support
7.1 Identifying Suitable Service Users
Intermediate care and reablement are suitable for individuals who:
- Have been recently discharged from hospital and require temporary support.
- Are recovering from illness, injury, or surgery.
- Need assistance regaining mobility, self-care, or daily living skills.
- Would benefit from short-term interventions to prevent deterioration.
7.2 Initial Assessment and Goal Setting
Each service user will receive:
- A comprehensive assessment by a multi-disciplinary team, including social workers, physiotherapists, and occupational therapists.
- A personalised care and reablement plan, setting specific, measurable goals.
- Risk assessments, ensuring safety in the home environment.
How we manage this efficiently:
- Collaboration with hospital discharge teams to ensure smooth transitions.
- Regular case reviews to monitor progress and adjust care plans accordingly.
8. Information for Individuals, Written Guide and Service Agreement
Before reablement support starts (or as soon as practicable), we provide the individual and, where appropriate, their representative with clear information about the service in a format that meets their communication needs.
This includes access to a written guide that explains, as a minimum:
- how the service works and what to expect;
- how to raise concerns or make a complaint;
- how to access advocacy and support to express views;
- key contacts (including the Registered Manager and Responsible Individual);
- how to access CIW inspection information (where applicable); and
- how the person can access their own records and how information is handled.
We also provide a service agreement/contract and support the individual to understand it. The agreement sets out what care and support will be provided, planned visit times (where relevant), costs/charges (where applicable), how changes will be agreed and communicated, and how and when the service may end (including any notice arrangements).
9. Developing Personalised Reablement Plans
Each service user’s reablement plan includes:
- Clearly defined independence goals (e.g., dressing, cooking, walking).
- Strategies for regaining skills and adapting to limitations.
- Support for medication management and nutrition.
- Psychological and emotional support to boost confidence.
How we manage this efficiently:
- Plans are developed in collaboration with the service user and healthcare professionals.
- A key worker is assigned to oversee each individual’s progress.
10. Delivering Reablement Support
10.1 Encouraging Independence
Care workers will:
- Support, rather than do tasks for the service user.
- Use verbal cues and prompts to encourage self-care.
- Implement adaptive techniques and assistive devices where needed.
10.2 Promoting Physical Recovery and Well-being
- Support physiotherapy-led exercises to regain strength and mobility.
- Encourage healthy nutrition to aid recovery.
- Monitor and manage medication adherence.
How we manage this efficiently:
- Staff receive specialised reablement training.
- Regular progress meetings ensure adjustments to support strategies.
11. Scheduling, Travel Time and Visit Length
Where reablement support is delivered as a domiciliary support service, we will provide each domiciliary care worker with a schedule of visits that clearly sets out:
- the time allocated for each visit;
- the travel time allocated between visits; and
- rest breaks where applicable.
We will ensure travel time allocations are sufficient having regard to distance and factors reasonably expected to affect travel (for example, traffic and parking).
We will ensure visit time allocations are sufficient to deliver care and support in line with the person’s plan and are not less than 30 minutes unless the relevant legal conditions apply.
We will keep appropriate records of time spent on visits, travel time and rest breaks and use this information as part of supervision, audit and quality monitoring.
12. Monitoring Progress and Adjusting Support
12.1 Weekly Progress Reviews
- Regular evaluations track service users’ progress against their goals.
- Adjustments are made if additional support is required.
12.2 When to Transition to Long-Term Care
- If reablement goals are met, the service user is discharged from the programme.
- If further support is needed, referrals are made to long-term care providers.
How we manage this efficiently:
- Data-driven decision-making ensures service users receive the right level of care.
- Care teams work closely with social workers to determine next steps.
13. Preventing Hospital Readmission
13.1 Identifying Early Signs of Deterioration
- Regular health checks monitor signs of relapse.
- Care staff report concerns to healthcare professionals promptly.
13.2 Crisis Prevention Planning
- Emergency care plans are in place for high-risk individuals.
- Proactive medication management prevents avoidable complications.
How we manage this efficiently:
- Emergency response procedures are built into reablement plans.
- Rapid response teams ensure quick intervention when needed.
14. Staff Training and Competency in Reablement Care
14.1 Mandatory Training Includes:
- Techniques to promote independence and self-care.
- Mobility support and falls prevention.
- Psychosocial approaches to building confidence.
- Infection control and medication management.
- Social Care Wales Codes of Professional Practice and associated guidance, including understanding and applying duty of candour expectations where relevant to the role.
14.2 Competency Assessments
- Care workers must demonstrate practical skills in reablement techniques.
- Annual refresher training ensures up-to-date knowledge.
How we manage this efficiently:
- A reablement lead oversees staff training and competency checks.
- Peer coaching supports continuous learning and development.
15. Multi-Agency Collaboration and Communication
- Work in partnership with physiotherapists, occupational therapists, and district nurses.
- Ensure open communication with GPs and hospital discharge teams.
- Regular care coordination meetings review service user progress.
How we manage this efficiently:
- Digital care records enable seamless information sharing.
- Regular case discussions enhance multi-agency collaboration.
16. Concerns and Complaints
Individuals and/or their representatives can raise concerns or make a complaint verbally or in writing. All concerns and complaints will be taken seriously, responded to respectfully, and handled in line with our complaints process and timescales.
We will:
- acknowledge complaints (unless anonymous);
- investigate proportionately and fairly;
- keep the complainant informed of progress; and
- provide a written outcome where appropriate, including any actions taken and learning identified.
Individuals will not suffer disadvantage, withdrawal, reduction of service, or unfair treatment as a result of raising a concern or complaint.
If a person is not satisfied with our response, we will provide information on further routes, including (as relevant):
- the commissioning authority’s complaints process (where the service is commissioned);
- the Public Services Ombudsman for Wales; and
- the Citizen Voice Body (Llais) for support to express views and access advocacy.
17. Related Policies
This policy aligns with:
- Hospital Discharge and Transition to Home Care Policy (DCW26).
- Falls Prevention and Mobility Support Policy (DCW37).
- Medication Management Policy (DCW21).
- Safeguarding Adults Policy (DCW13).
18. Policy Review
This policy will be reviewed at least annually and sooner where required by changes to legislation, statutory guidance, CIW frameworks/requirements, or learning from incidents, safeguarding, whistleblowing and complaints; the Registered Manager and Responsible Individual will ensure governance systems monitor quality and safety, including audit of records and analysis of trends, and that learning is shared with staff and translated into service improvements. The Registered Manager and Responsible Individual are responsible for ensuring compliance.
19. CIW Published Inspection Ratings
Where CIW published inspection ratings apply to this service, we will comply with requirements on displaying and communicating our rating, including displaying the rating in a prominent location at the service office and maintaining accurate digital display where used.
We will ensure staff understand what the rating means, how it is generated, and how learning from inspections, action plans and improvement work is implemented and monitored through governance processes.
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}}
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