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Intermediate Care and Reablement Support Policy

1. Purpose

At {{org_field_name}}, we are committed to providing high-quality, person-centred intermediate care and reablement support to individuals who require short-term assistance to regain independence following illness, injury, or hospital discharge. This policy ensures that our service supports individuals effectively in achieving their recovery goals, enhancing quality of life, and promoting self-care in compliance with CQC regulations, the Care Act 2014, NICE guidelines, and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Our approach is designed to ensure early intervention, prevent unnecessary hospital admissions, and support timely discharge through a structured, outcome-focused reablement programme.

2. Scope

This policy applies to all staff, individuals receiving intermediate care and reablement support, healthcare professionals, and external care partners. It covers:

• Assessment and goal-setting for reablement
• Short-term care planning and interventions
• Multi-disciplinary working and collaboration
• Monitoring progress and reviewing outcomes
• Transitioning to long-term support where necessary

3. Related Policies

• SL07 – Person-Centred Care Policy
• SL12 – Safe Care and Treatment Policy
• SL08 – Dignity and Respect Policy
• SL21 – Medication Management and Administration Policy
• SL16 – Infection Prevention and Control Policy
• SL34 – Confidentiality and Data Protection (GDPR) Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy

4. Definition and Objectives of Intermediate Care and Reablement

4.1 Intermediate Care

Intermediate care provides time-limited, structured support to help individuals regain lost skills, mobility, and independence after a period of ill health, surgery, or hospitalisation. It includes:

• Rehabilitation after an acute illness or hospital stay
• Support to prevent hospital admissions
• Assistance following a decline in mobility or self-care abilities

4.2 Reablement Support

Reablement is an outcome-focused, short-term intervention designed to help individuals regain confidence and functional abilities in daily living. It focuses on:

• Promoting independence in personal care, meal preparation, and mobility
• Building confidence in using assistive equipment and adapting to new routines
• Reducing reliance on long-term support services

5. Person-Centred Assessment and Care Planning

5.1 Initial Assessment

• A comprehensive assessment will be conducted upon referral by a qualified healthcare professional.
• The assessment will cover:
  • Physical and mental health needs
  • Daily living activities and mobility levels
  • Cognitive function and emotional well-being
  • Risk assessments and safeguarding considerations
  • Personal goals and aspirations for reablement

5.2 Developing a Reablement Care Plan

• A personalised reablement plan will be developed based on the assessment, setting clear, achievable goals.
• Plans will include:
  • Therapeutic interventions (e.g., physiotherapy, occupational therapy)
  • Daily activities and self-care routines
  • Use of assistive devices and mobility aids
  • Support with medication, nutrition, and hydration
• Regular reviews will be scheduled to adjust goals and interventions as needed.

6. Delivering Effective Intermediate Care and Reablement

6.1 Multi-Disciplinary Approach

• Our service will work in collaboration with GPs, physiotherapists, occupational therapists, district nurses, and social workers.
• Regular multi-disciplinary team (MDT) meetings will ensure coordinated care planning and progress monitoring.

6.2 Support with Activities of Daily Living (ADLs)

• Individuals will be supported in regaining skills and confidence in:
  • Personal hygiene and dressing
  • Meal preparation and nutrition management
  • Mobility and fall prevention strategies
  • Medication adherence and management

6.3 Use of Assistive Technology and Equipment

• Individuals will be introduced to assistive devices and technology to promote independence, such as:
  • Grab rails, mobility aids, and hoists
  • Adaptive cutlery and kitchen tools
  • Telecare systems for safety monitoring

6.4 Emotional and Psychological Support

• Our approach recognises the emotional impact of illness and reduced independence.
• Individuals will be supported through therapeutic engagement, social activities, and mental health referrals where necessary.

7. Monitoring Progress and Reviewing Outcomes

7.1 Ongoing Assessment

• Daily progress notes will be maintained to monitor recovery milestones.
• Staff will assess:
  • Improvements in mobility and self-care
  • Ability to manage daily activities independently
  • Effectiveness of interventions and support plans

7.2 Reviewing and Adjusting Support Plans

• Weekly care reviews will be conducted with the individual and MDT professionals.
• Adjustments will be made based on:
  • Goal attainment and progress reports
  • Individual feedback and preferences
  • Emerging health or social care needs

8. Transitioning to Long-Term Support

• If the individual achieves full independence, reablement support will be phased out gradually.
• If ongoing support is needed, referrals will be made for long-term care services, domiciliary care, or community support networks.
• All discharge planning will be conducted in consultation with family members and external healthcare providers.

9. Safeguarding and Risk Management

9.1 Safeguarding Adults

• All staff must be trained in safeguarding procedures and report concerns immediately in line with SL13 – Safeguarding Policy.
• Any concerns about an individual’s well-being, mental health, or capacity must be raised with the MDT.

9.2 Risk Assessments

• Comprehensive risk assessments will be conducted to:
  • Prevent falls and injuries.
  • Ensure safe medication management.
  • Identify and mitigate home hazards.
  • Promote infection control and hygiene standards.

10. Staff Training and Competency

• All staff delivering intermediate care and reablement must complete:
  • Specialist reablement training covering rehabilitation principles.
  • Manual handling and falls prevention training.
  • Person-centred care and mental capacity training.
  • Competency assessments reviewed annually.

11. Record-Keeping and Data Protection

• Detailed records of assessments, care plans, and progress notes will be maintained.
• All records must be stored securely in line with GDPR and SL34 – Data Protection Policy.

12. Monitoring and Continuous Improvement

• Quarterly audits will ensure service effectiveness and compliance with reablement best practices.
• Feedback from individuals and families will be actively sought to refine service delivery.
• Lessons learned from outcome evaluations and MDT case reviews will inform future improvements.

13. Policy Review

This policy will be reviewed annually or sooner if required due to:

• Changes in NICE or CQC guidelines.
• Updates in best practice for intermediate care.
• Feedback from staff, individuals receiving support, or healthcare professionals.

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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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