Intermediate Care and Reablement in Care Homes (Wales) Policy

Introduction

This policy is for care homes providing intermediate care in line with the requirements of the Social Services and Well-being (Wales) Act 2014, and to comply with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (in force from April 2018).

Intermediate care encompasses a range of services available to people who are leaving hospital or who are at risk of hospital admission, which might be prevented by timely and focused intervention.

The emphasis of 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 people are medically stable and no longer need specialist medical support on hand. People living with dementia are not excluded from receiving an intermediate care service.

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 treatment provision. It seeks to:

establish clarity of roles and expectations between the home and intermediate care purchasers
ensure that the home provides a high quality, safe and appropriate service with areas of risk addressed
provide the basis for a sound contractual agreement which delivers value for money
provide a service that is consistent with the intermediate care provisions set out in the Social Services and Well-being (Wales) Act 2014.

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

The home considers its intermediate care service to be provision that:

is targeted at older people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long-term residential care or continuing NHS in-patient care
is provided after a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery
aimed at maximising independence and typically enabling people who have been receiving treatment to resume living at home
is time-limited (normally four to six weeks or less)
involves cross-professional working, with a unified assessment framework, single professional records and shared protocols.

The Home’s Intermediate Care Policy

The objective of {{org_field_name}}’s intermediate care service is to facilitate the transition from hospital care so that an individual can return to their usual place of residence within a predefined time.

It is the home’s policy and view that residential 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 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 using services.

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

The home will appoint an intermediate care lead with the required qualifications and competence to be responsible for organising and co-ordinating its programmes.
All contracts for intermediate residential care should be time limited and that time should be specified at the entering of an agreement.
The person receiving care must be registered with a GP, which could be their usual doctor.
No significant acute changes in medical management should be anticipated within the contracted period of intermediate care provision.
The assessed requirement for care must indicate that the person’s care can be safely and effectively provided outside of an acute hospital.
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.
The person receiving care should initially be assessed as being likely to return home within six weeks of admission unless exceptional circumstances apply.

Intermediate Care Assessment

The home considers that an agreed assessment approach is crucial to the success of the contracting process for intermediate care and that whatever assessment process is used should be agreed between all parties. {{org_field_name}} has agreed to use local social services assessment tools.

Intermediate Care Procedures (Adjust for local situations)

{{org_field_name}} will appoint a named intermediate care lead with the required qualifications and competence to be responsible for organising and co-ordinating the programme.
The home will ensure that staffing arrangements reflect the ethos of a therapy-led service and that staff have relevant experience of a rehabilitative care environment.
The home will be responsible for:
– providing agreed, adequate levels of appropriately qualified staff
– maintaining staff competences through regular training and review
– checking that all qualified staff have current registration with the relevant professional registration bodies.
The home will ensure that the physical environment of the home reflects the purpose of the intermediate care programme and the distinctive needs of the people admitted for intermediate care.
The home will:
provide intermediate care facilities which are separate from long-stay, standard accommodation so as not to cause disruption to permanent residents
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
designate therapy, kitchen and lounge areas for the sole use of intermediate care and to provide them near to their bedroom areas
provide décor and furniture of a domestic style in those areas to be used for residential intermediate care
be person-centred in its care practice
have therapists and other specialists available with adequate facilities and support to undertake their work
employ intermediate care 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
check individual progress daily with weekly review meetings attended by all involved in the individual’s plan of care
notify the local intermediate 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 early and successful return home
make suitable and immediate arrangements, where, in the judgment of the home staff, a person requires emergency treatment or admission to hospital
notify the case manager or local intermediate care co-ordinator of any readmitted emergency action at the earliest opportunity
immediately notify the case manager or local intermediate care co-ordinator in the event of a significant deterioration in a person’s health status
arrange admission/readmission to acute care if necessary through a locally agreed acute admission/readmission policy.

Training

All staff involved in intermediate care programmes receive specialist training in line with their roles and responsibilities. Training follows the (NICE), Intermediate Care Including Reablement (NG74) and Wales NHS guidance.

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}}

WCH156. Intermediate Care and Reablement in Care Homes