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Intermediate Care and Reablement in Care Homes (Scotland) Policy


This policy is for care homes providing intermediate care in line with the Scotland intermediate care national framework, which encompasses a range of services available to:

  1. people who are leaving hospital to assist their recovery
  2. to others who are at risk of hospital admission, which might be prevented by timely and appropriate intervention.

The emphasis of all intermediate care is on promoting independence through active recovery as it aims to help to move a person receiving care from medical dependence to being more independent by providing a supported pathway between social, primary and acute care. The aim is to avoid unnecessary or inappropriate hospital stays.

Such care can be provided in a wide range of different settings, ranging from hospitals to care homes to people’s own homes. It is accepted that intermediate care is only appropriate where older people are medically stable and no longer need specialist medical support on hand. This provides the major difference between intermediate care and traditional rehabilitation services in that rehabilitation services usually have specialist clinical support on site.

Policy Statement

This policy sets out the values, principles and procedures underpinning {{org_field_name}}’s approach to its intermediate care services, where it is contracted to provide them.

It seeks to:

The Home’s Approach to Residential (Bed-based) Intermediate Care

{{org_field_name}} recognises intermediate care as carried out in our home to be a dedicated form of service that:

{{org_field_name}}’s Approach to Intermediate Care

{{org_field_name}}’s main aim is to assess and facilitate a person’s transition from hospital care so that an individual can return to their usual place of residence within a predefined time (step-down service).

It might also use the facility to assess and prevent the need for admission to hospital (step-up service).

It is the home’s policy and view that residential (bed-based) intermediate care is intended to be built around active rehabilitation and is not appropriate for people with longer term continuing care needs.

The Home’s Intermediate Care Admission Criteria

It is important that those admitted into intermediate care at the home will benefit from the programme. To enable this, a comprehensive assessment, including risk assessment, appropriate selection and clear care planning are vital.

The home insists that in each case of proposed admission for intermediate residential care there must always be clear clinical and managerial accountability for each new person receiving care.

Admission to our intermediate treatment service will be based on individual need in line with the following criteria.

  1. The home will appoint an intermediate care lead with the required qualifications and competence to be responsible for organising and coordinating the individual’s care plan in partnership with other professionals involved.
  2. All contracts for intermediate residential care will be time limited and that time should be specified at the entering of an agreement.
  3. The person receiving care must be registered with a GP, which could be their usual doctor.
  4. No significant acute changes in medical management should be anticipated within the contracted period of intermediate care provision.
  5. The assessed requirement for care must indicate that the person’s care can be safely and effectively provided outside of an acute hospital.
  6. The assessed requirement for care should indicate that maximum independence is most likely and can be safely achieved in a residential setting, with ready access to care staff for assistance or reassurance.
  7. The person receiving care should initially be assessed as being likely to return home within four to six weeks of admission unless exceptional circumstances apply.

The home considers that an agreed assessment approach established by the local integrated health and care partnership is crucial to the success of the contracting process for intermediate care and that whatever assessment process is used should be agreed with the person receiving care.

Intermediate Care Procedures (To be Adjusted for Local Service — Delivery)

  1. {{org_field_name}} will appoint an intermediate care lead with the required qualifications and competence to be responsible for organising and co-ordinating the intermediate care service.
  2. Intermediate care staffing arrangements will reflect the ethos of a therapy-led service and staff will have relevant experience of a rehabilitative care environment.
  3. The home will be responsible for:
  4. – proving the agreed, adequate levels of appropriately qualified staff
  5. – maintaining staff competencies through regular training and review
  6. – checking that all qualified staff have current registration with the relevant professional registration bodies.
  7. The physical environment of the home will reflect the purpose of the intermediate care programme and the distinctive needs of people admitted for intermediate care.
  8. The home will:

a. provide intermediate care facilities which are separate from long stay, standard accommodation so as not to cause disruption to permanent residents
b. provide dedicated accommodation for residential intermediate care users together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable people to return home at the end of their stay
c. designate therapy, kitchen and lounge areas for the sole use of people receiving intermediate care and to provide them near to their bedroom areas
d. have décor and furniture that is of a domestic style in those areas to be used for residential intermediate care
e. be person-centred in its care practice as described in the national health and care standards My Support, My Life
f. have therapists and other specialists available with adequate facilities and support to undertake their work
g. employ staff who are qualified and/or trained and appropriately supervised to use techniques for rehabilitation including treatment and recovery programmes, promotion of mobility, continence and self-care
h. check an individual’s progress daily with weekly review meetings attended by all involved in the individual’s plan of care
i. notify the care plan co-ordinator where a person is making better progress than anticipated so that an early review of suitability for discharge can be undertaken, enhancing the opportunity for an early and successful return home
j. make suitable and immediate arrangements, where, in the judgment of the home staff, a person requires emergency treatment or admission to hospital
k. notify the case manager or clinical lead of any re-admitted emergency action at the earliest opportunity
l. immediately notify the case manager or clinical lead in the event of a significant deterioration in a person’s health status
m. arrange admission/readmission to acute care if necessary through a locally agreed acute admission/readmission policy.


All staff appointed to work on the home’s intermediate care programme receive appropriate training to enable them to provide a dedicated service and to work effectively as members of a multidisciplinary enterprise.

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Copyright ©2024 {{org_field_name}}. All rights reserved

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