Agenda item

Intermediate Care and Reablement Update

To receive an update in respect of intermediate care and reablement.


Consideration was given to an update presentation on the Intermediate Care and Reablement Place Project. The report provided a definition of the various services and requirements; illustrated the rationale for the recent changes; identified current aims, objectives and milestones; described the COVID-19 response; and gave detailed information about the variety of care services offered. These services are designed to keep people living at home independently for as long as they can. When appropriate, people can be discharged from hospital to continue their recovery at home with the right care in place. Several case study examples were also provided. Workforce challenges and anticipated next steps were also described.


In discussion, Members requested clarification of whether during COVID, limited numbers of community beds has limited service delivery in any way. The response noted that available funding has allowed a bed-based discharge where appropriate. National guidance had moved assessment out of the hospital and into the community; therefore, for some people coming out of hospital, upon further assessment, an adjustment is warranted.


Members expressed interest in hearing more about the cases that were not quite as successful and the learning that has been taken forward. Quite a lot of people were very poorly coming out of hospital, some with COVID, some without, so some of these have had to go back into a 24 hour care arrangement, but it was appropriate for them. It is a balance to do the best at the time with the resources available. The service always tries to learn and improve.


Clarification was requested regarding the 1.8% increase in the rate of patients being seen, and how that translated to numbers of patients. The answer was offered after the meeting.


Further clarification was requested around the 10% of urgent KPIs for integrated rapid response that were not met, and the reasons for these not being met. It was noted in the response that the demand on the service has been greater, and staff sickness has also been greater. The data regarding staff sickness was requested to be circulated as part of the next update.


Further information was requested about how the needs of people who want to go into residential care are considered. The response from officers provided assurances that learning would be taken from an upcoming customer satisfaction survey.


Members also requested to know which services had high KPI performance. The response from officers noted these are the Therapy teams and Occupational Therapy teams which are divided into acute and long term care teams. It was noted that generalised KPIs would be implemented as part of the next steps, so that all services have some shared KPIs.


Members requested more details around the waiting time to be seen for therapy after discharge. The response from partners noted that the assessment would normally be conducted within 24 hours. Joining up staff communication in the next phase will therefore be very important. It was requested that therapy data following discharge be included in the next update.


Assurances were requested around the mitigation of the skills shortage and other service delays. In terms of skills shortages, the response noted that recruitment teams and in-house training programme would be able to support new staff coming in who need new levels of training, and it is necessary to make reablement care an attractive career of choice. In terms of delays, the need to implement the pathway across the community—not just for those leaving hospital but for all people who need to step up their care—embed learning and changes to have easier access to reablement and care, so working with the Community Hub triage is still underway.


Members also requested more information about how the vaccination programme delivery affect the delivery of intermediate and reablement care? The response provided assurances that most staff have already taken up the vaccine and the key groups have been given access to the vaccine. Therefore, access to the vaccine had not yet caused any delays to the provision of intermediate or reablement care, and all staff have been supported to access the vaccine in a timely manner.




1.    That the next update be submitted in 12 months’ time, with this update including performance data.


2.    That a briefing on the data regarding discharge therapy be provided to the Commission as soon as this can be made available.

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