using reablement services: feedback from older people in ... · using reablement services: feedback...

Using reablement services: feedback from older people in

Norfolk

Please contact Healthwatch Norfolk if you require an easy read; large print or a translated copy of this report.

Postal address: Healthwatch Norfolk, Suite 6 – Elm Farm, Norwich Common, Norfolk NR18 0SW

Email address: [email protected]

Telephone: 0808 168 9669

August 2016

mailto:[email protected]

Contents

Section Page

Who we are and what we do 1

Summary 2

Why we looked at this 4

What is a reablement service? 5

What's so special about reablement? 6

How we did this 7

Stakeholder and service user engagement 7

Methods we used 9

Engagement and participation outputs 14

Participants 15

What we found out 16

Part A: Reablement services in Norfolk 17

Part B: Service user survey results 25

Part C: Service user views and experiences 29

What this means 40

Reccomendations 43

Appendix 44

Who we are and what we do

Healthwatch Norfolk is the local consumer champion for health and social care in the county. Formed in April 2013, as a result of the Health and Social Care Act, we are an independent organisation, with statutory powers. The people who make decisions about health and social care in Norfolk have to listen to you through us.

We have five main objectives:

1. Gather your views and experiences (good and bad)

2. Pay particular attention to underrepresented groups

3. Show how we contribute to making services better

4. Contribute to better signposting of services

5. Work with national organisations to help create better services

We are here to help you influence the way that health and social care services are planned and delivered in Norfolk.

Acknowledgements

Healthwatch Norfolk is fortunate to work with many partners in Norfolk. We gratefully acknowledge and offer thanks to the following people and organisations for their support of this project:

‣ Denise Forder, Norfolk First Response County Manager, Norfolk County Council

‣ Katherina Brady, Norfolk First Response County Manager, Norfolk County Council

‣ Bob Russell, AgeUK Norwich

‣ Lynn Matthews, AgeUK Norfolk

‣ Annie Coomber-Briggs, Unit Manager, Henderson Unit, Norfolk & Norwich University Hospital Trust

‣ Dr Tim Winters, Head of Public Health Information, Norfolk County Council

Feedback on reablement services �1

Summary

Reablement services aim to support people to regain daily living skills that might have been lost through illness, injury or ageing. Reablement services are designed to help people regain their independence, for example after a stay in hospital. Reablement provides help with personal social care, activities of daily living and other practical tasks for a limited time. This is done in such a way as to enable the service user to develop and regain both the confidence and practical skills to carry out these activities independently. Specially trained staff work with service users to ensure that they are supported in their own home and safely practice what they need to do with someone at hand, to help grow confidence. There’s a lot of good evidence to show that reablement services are very effective and provide good value for money, helping people when they need it most. Between 50% and 60% of people receiving reablement don’t need any further formal care service and carry on living independently in their own homes.

This project is about reablement services for adults - intermediate in nature and provided by Norfolk County Council. Healthwatch Norfolk is taking a special interest in Norfolk First Support; the service it provides and what service users say about it. This project has a specific focus on protecting the provision of reablement services within the current financial climate and in equitable access to reablement by users. In Norfolk, almost 5,000 people are having a reablement service every year and that number is increasing. In the year 2015-2016, gross expenditure on the county’s reablement services amounted to £6,728,000.

The aim of this project was to gather feedback from a sample of older people aged 65 years and older living in Norfolk about their views and experiences of using adult social care reablement services. Specifically, the primary objective was to find out more about what it is like for older people using the Norfolk First Support reablement service as provided by Norfolk County Council and to identify what works well and and areas for improvement.

At the onset, individuals and organisations who were routinely involved in providing information, advice and support services for older people were consulted. The reason for doing this was to learn from local experts on the best ways to engage with older people and find out about their reablement experiences - everyone said a ‘light touch’ was the best way to go. Between August 2015 and July 2016 over 62 meetings, events, social clubs and activities were attended to spread the word about the work of Healthwatch Norfolk and this project in particular. Along the way, 340+ stakeholders gave their views and support along with 730+ members of the public, including 410+ older people and their carers using services. During this time, older people were asked if they would volunteer to share their experiences of reablement services in Norfolk; this included their stories of hospital discharge, the support they received from local reablement


services and their needs and expectations beyond that. A total of 52 people participated in informal interviews and focus group discussions. Participants were aged between 65 and 83 years of age, 40 were older people using services and 12 were their family carers. Transcripts of the conversations were analysed with themes emerging as people talked about their reablement journey.

To complement this information, some different desk-based research activities were carried out to look into the commissioning and funding arrangements for reablement services in the county, local figures on hospital discharge and the outcomes that reablement services are having. This was done was attending meetings such as those held in public by the Norfolk County Council Adult Social Care Committee, scrutinising council papers and reports and also by asking for help and information from the managers of the Norfolk First Support service. Every year the Norfolk First Support service conducts a survey of service users. In the two years between April 2014 and March 2016, feedback on service experiences were collected from 3,282 people. Service users rated their satisfaction very highly with 81% of people saying the service they received was “excellent” and a further 17% saying it was “good’.

Through our conversations with older people, we learnt that many described a period of isolation with deteriorating health prior to an illness or event which led to their reablement needs. Many described losing confidence in being able to do daily routine tasks and a loss in their mobility which had quite a significant effect. We found three quarters had received a level of reablement support which was described as a strongly positive and helpful service. A small minority hadn’t received a service because a reablement worker wasn’t available at the time of their needing support. People had many positive things to say about the reablement workers; they were cheerful, they were reliable and they helped people to look at problems in a new way by breaking things down into manageable chunks and setting clear goals.

In general, awareness of the availability of reablement services prior to encountering them was low. Older people described a need for good-quality timely information at key points such as leaving hospital. People felt that others should know about the service but also we learnt that not everyone would benefit from a reablement type of service. Promoting the service to all might mean raising false expectations and lead to people being disappointed. Some said they felt that reablement was over a bit too quickly and they didn’t feel confident enough to manage their needs on their own. Others wanted more home care support, and some were willing and able to pay for this themselves. This work has culminated in some key insights and two recommendations are made. One is to improve access to good quality timely information on support services upon is discharge from hospital and the other to better manage expectations for ongoing support on discharge from the reablement service.


Why we looked at this

As an organisation, we receive many comments from the general public who share their experiences of a wide variety of health and social care services. The decision to gather feedback on reablement was made on the basis of comments from the public about adult social care provision at the time of creating the Healthwatch Norfolk Strategy for 2015-2017. At that time, all local authorities were facing substantial cuts to their government budgets and there was concern as to how this might impact upon care services, particularly those for people aged 65 years or older.

Local people described knowing little about reablement service provision and how to access it. Whilst a person may have been identified as having a reablement need, there wasn’t always capacity within the service to offer them a reablement service when they needed it most, for example on discharge home from hospital. This prompted us to take a closer look at this service.

This project is about reablement services for adults - intermediate in nature and funded by Norfolk County Council. Healthwatch Norfolk is taking a special interest in Norfolk First Support; the service it provides and what service users say about it. This project has a specific focus on protecting the provision of reablement services within the current, challenging financial climate

and in equitable access to reablement by users who would benefit from it.

The aim of this project was to gather feedback from a sample of older people aged 65 years or over living in Norfolk, about their views and experiences of using adult social care reablement services. Specifically, the primary objective was to find out more about what it is like for older people using the Norfolk First Support reablement service as provided by Norfolk County Council and to identify what works well and and areas for improvement.

A secondary objective was to explore experiences of hospital discharge and the type of support that older people want and need to help them to remain living independently in their own home.

This project provides Healthwatch Norfolk with further information relating to older peoples’ reablement experiences and explains how Healthwatch Norfolk might be able to make a difference.


What is a reablement service?

Reablement services aim to support people to regain daily living skills that might have been lost through illness, injury or ageing. Reablement services are designed to help people regain their independence, for example after a stay in hospital.

The key thing about reablement services is that they help people to do things for themselves including 1

helping people self-care, rather than the conventional home care approach of others doing things for them. Local authorities provide this type of adult care service (known as an intermediate service); a person may receive a period of reablement care funded by their local authority. In Norfolk, this could be for up to 6 weeks.

Reablement provides help with personal social care, activities of daily living and other practical tasks for a limited time. This is done in such a way as to enable the service user to develop and regain both confidence and practical skills to carry out these activities independently. Specially trained staff work with service users to ensure that they are supported in their own home and safely practice what they need to do with someone at hand, to help grow confidence. Reablement can help with a range of tasks including:

• Personal care tasks such as washing, dressing and toileting

• Domestic skills such as food and drink preparation, shopping, organising and planning daily routines, using transport and doing laundry

• Encouraging the necessary confidence to move around. This would include getting up and out of a chair, getting in and out of bed and getting on and off the toilet

First, a Personal Support Plan is agreed with the user, based upon the referral by the Occupational Therapist and other professionals (e.g. social workers). Reablement staff help people to set achievable goals based on what the individual expects to achieve by the end of the reablement programme. Reablement workers help people to understand and accept that there may be risks to living in the community but work towards minimising these and try to ensure that all risks are acceptable. The plan is kept in person’s home so that they, their family members and care staff can monitor achievements and identify new goals to work towards.

Social Care Institute for Excellence (March 2012) Reablement: key issues for commissioners of adult 1

social care


What’s special about reablement?

There is strong evidence to say that reablement leads to improved health and wellbeing and supports people to do things for themselves. Research studies elsewhere have shown that compared with home care, reablement can deliver improvement in physical functioning and reduce the need for ongoing support services . The best 2

available research evidence demonstrates savings of around 60% on social care spend following a period of reablement . An implicit aim of 3

reablement is to reduce the number of care hours required to support a person at home and develop their independence so that they can remain living in they own home instead of being admitted into residential care . 4

Nationally, there are different models of reablement and those where occupational therapists have a key role in the provision of reablement can produce good outcomes in ongoing reablement for people with long term and complex health conditions. Occupational therapists have the skills and expertise to assist in the reablement of people with complex needs as well as strengths in

assessment and goal planning . 5

Reablement care workers also benefit greatly from the advice and training opportunities that occupational therapists can provide. Service users report high degrees of satisfaction with reablement services but understanding the aims of reablement are key. Some users have concerns regarding the 6

handover after reablement, about their need for some kind of ongoing support. Research suggests that the evidence on service users across the country needs to be strengthened . 7


social care Glendinning et al (2010) Home care re-ablement services: investigating the longer term impacts 3

(prospective longitudinal study) York/Canterbury: SPRU, PSSRU. Lewin, G. (2010) Submission to inquiry into caring for older Australians. Canberra: Caring for Older 4

Australians Productivity Commission. Social Care Institute for Excellent (October 2011) Reablement: a key role for occupational therapists.5

Wilde, A. & Glendinning, C. (2012) “if they’re helping me then how can I be independent?”. The 6

perceptions and experiences of users of home-care reablement services. Health & Social Care in the community 20: 6: 583-590 Francis, J., fisher, M. & Rutter, D. (April 2011) Reablement: a cost-effective route to better outcomes. 7

Social Care Institute for Excellence.


How we did this The Reablement Service Project commenced in August 2015 and a project plan was created that contained a number of key lines of enquiry. These were:

‣ Is information about reablement services readily available at the point when it is needed most - do people know what to ask for?

‣ Is it easy for people to access reablement services?

‣ Do all users who would benefit have the same equality of opportunity to access reablement services?

‣ What works well about reablement services – what do people like?

‣ Are people satisfied with the service they received? If not, what could be improved?

‣ What are the current commissioning arrangements for reablement services and how are they funded?

‣ What does the data on trends in emergency re-admissions for people aged 65 years+ tell us about quality of care and readiness for discharge?

‣ When health and social care commissioners work collaboratively, are the right packages of care in place for those who need it?

‣ What does the data on the proportion of older people still at home 91 days after discharge tell us about reablement outcomes?

The progress of the project -including discreet reports on each of the key lines of enquiry - has been reported on

a month-by-month basis to the Healthwatch Norfolk Quality Control Panel.

Stakeholder and service user engagement

Engaging with and listening to local people and service providers are at the heart of what a local Healthwatch does. At the beginning of the project an Engagement and Participation Plan was created and this guided the engagement activities undertaken as part of the project, with slight changes made along the way in response to opportunities and challenges.

Reference groups

A variety of local groups around the county have been consulted in relation to the reablement project. Such groups provide information, advice and social activities for older people - especially those living alone and those who are housebound and socially isolated. Some provide social contact and support for people with long term and degenerative health conditions, adults and older people with mental ill-health and physical and learning disabilities, plus their carers, for example:

‣ Meals on Wheels ‣ Older People’s Forums ‣ ‘Knit & Knatter’ Groups ‣ Support Groups ‣ Carers Groups ‣ ‘Good Neighbour’ schemes ‣ Drop-in cafes ‣ Community lunches


research

consult

ask

listen

check

report

action

Engaging in partnership with AgeUK Norwich

A higher proportion of reablement servicer users were understood be older people living in low-income households in the city of Norwich. With this in mind,

AgeUK Norwich were approached for expertise and support in will facilitating a small number of community events for older people in Norwich. The aim was to raise awareness of the reablement project and encourage people to share their views and experiences of reablement services. AgeUK Norwich advised on the best means to engage with older people living in disadvantaged communities in Norwich. Three low-key events took place between March and April 2016 and were attended by over 160+ older people. Views and experiences of reablement services were gathered from people attending the events and from workers of the agencies who were present.


CATTON GROVE Over 50s Cafe

Warm + Well Slipper Swap

1MILE CROSS

Norwich Older People’s Forum, Keeping Active

2LAKENHAM Lakenham & Tuckswood

Inequalities Project

3

Aim

To engage with older people living in Norwich and listen to their views.

Activities

The events offered information and advice, ‘taster’ sessions, entertainment and a light lunch.

Evaluation

Feedback on the events was gathered.

Methods we used

A mixed-methods approach was taken which included stakeholder engagement and desk-based research to source and collate quantitative data, along with public engagement and participation to gather qualitative views and experiences of reablement services.

Gathering service data from local sources

To better understand how our local reablement services are planned, funded and delivered, information was sought from local services through:

‣ seeking out and engaging with stakeholders, informing them of the work of Healthwatch Norfolk and the focus on reablement services for older people

‣ meeting senior officers within Norfolk County Council, with commissioning responsibility for reablement services

‣ meeting the County Managers for Norfolk First Support and Norfolk Swift Response (Norfolk County Council) and requesting data on reablement service users, provision and outcomes

‣ seeking advice on the best ways to engage with older people and past users of the reablement service

‣ requesting data on service user feedback from the County Managers

‣ attending council meetings i.e. Adult Social Care Committee for papers and associated reports on planning, expenditure and forecasts for adult care services including prevention services and reablement

(see Appendix 1)

Desk research

A desk-based approach was taken to sourcing and collating published articles on the efficacy of reablement services. An initial rapid review of evidence on reablement services and their outcomes was carried out, using sources promoted by reputable organisations such as the Social Care Institute for Excellence Institute and the Association of Directors of Adult Social Care.

Desk-based research was also used to source and collate data on hospital discharge (delayed transfers of care), offers of a reablement services and medium-term outcomes and independence following a period of reablement (90-day data). This was done to answer our questions on the availability of reablement services and any changes to be observed in recent years. Advice on the best available sources of social care outcomes data was sought from a information specialist and simple data sets were sourced from the Health & Social Care Information Centre. These were comprised of a number of outcome indicators for both social care and health services (see Appendix 2). The data was plotted to show recent trends and to compare Norfolk’s services with


those of other, similar local authorities.

Gathering feedback from service users

Decisions on the most appropriate and effective ways to gather feedback from older people were made based on consultation with voluntary and community sector organisations providing support services to older people, the county’s older people’s forums and with officers of Norfolk County Council. All suggested that a “light touch” would be the best approach to engaging with older people leading to informal conversations with individuals and small groups. Holding structured, facilitated discussions with larger groups of older people (i.e. 12 +), conducting very formal, structured interviews and lengthy, complicated questionnaires were all methods reported to be off-putting for older people and possibly less productive too.

The general approach to initial engagement with older people, their carers and with those providing support services included:

‣ attending a number and variety of ‘reference group’ type meetings and forums for older people, people with mental ill-health, physical disabilities and learning disabilities - all around the county

‣ speaking at events for older people, informing people about the work of Healthwatch Norfolk,

disseminating leaflets describing the work of Healthwatch and info-sheets describing the reablement project

‣ seeking and recruiting older people and their carers with experiences of reablement services and/or hospital discharge interviews and focus group discussions

‣ working in partnership with AgeUK Norwich to engage in a number of themed events for older people living in the Norwich area

‣ visiting the Henderson Unit at the Julian Hospital in Norwich to view the unit and meet with staff from the multi-disciplinary team

‣ attending the Henderson Unit Patient & Public Involvement Forum

Sampling

An opportunistic sampling approach was adopted through informal conversations with older people in addition to those who were facilitating, leading or volunteering with groups, activities or events. There was also a ‘snowballing’ effect at times when group leaders would introduce the project officer to volunteers, carers or older people who would know of a person who had recently had a period of illness and received reablement support.

Recruitment

Following an introduction or informal conversation, older people were invited to participate in an interview or focus group. This was conducted either at the time if appropriate or rearranged for a mutually convenient


time and location. For the purposes of interview and focus group selection, older people - and a carer if desired - were recruited who:

‣ described an injury or episode resulting in a need for emergency care of some nature (e.g. NHS 999 call/paramedic attendance, Community First Responders, Norfolk Night Owls or Swifts) and/or

‣ described a period of illness requiring medium to long term care at home e.g. care from community nursing team or reablement service and/or

‣ described an illness or injury resulting in a hospital admission, followed by a description of hospital discharge with admittance to the Henderson Unit (reablement ward) and/or

‣ described a referral to reablement/Norfolk First Support and/or

‣ and/or had used a reablement service within the last 18 months or so

Interviews

Interviews were employed to gather in-depth views and experiences of services from a service user perspective. Interviews were conducted on a one-to-one basis (project officer and older person) or a paired interview basis (project officer with older person and their carer). Interviews took place in a variety of settings, followed a Discussion Guide (see Appendix 3) and lasted between 15 and 30 minutes. The project officer asked for permission to record the

interview, seeking written consent. Where consent was not given, detailed notes were made.

Focus groups

Focus groups were employed for the purpose of discussing differing views and experiences and to allow participants to prompt each other with pertinent questions and comments. In addition, focus groups were used to validate key themes and run a sense-check on key observations. Focus groups were comprised of between 3 and 6 individuals with a mix of service users and carers in attendance. Focus group discussions took place in a variety of settings following the Discussion Guide (see Discussion Guide) and lasted between 20 and 40 minutes. The project officer asked for permission to record the interview, seeking written consent. Where consent was not given by all group members, detailed notes were made.

Analysis

Recordings of interviews and focus groups were transcribed using TranscribeME into clean verbatim script. The analytical software package NVivo v.11 was used to hold, organise and analyse materials. A conceptual coding model (see Figure 1) was developed based on initially on the structure of the discussion guide and later refined to resonate with the content of the transcripts and notes. In addition to sense-checking the key themes and coding model during a service user focus group, key findings were also discussed and validated with service providers.


Figure 1. Model for categorising and coding content

afterthe event

beforethe event, illness

or injury

Norfolk First

Support

VCS* services

beyond reablement

home care

Norfolk Swift Response

Information, advice and support

Family and carers

* VCS - Voluntary and community sector

Limitations of this work

This project has attempted to capture stories of reablement services from people who’ve used the service. Some people wanted to have a carer or family member with them during an interview or focus group. It is acknowledged that the sample of service users and carers who participated are not a representative sample of reablement service user population.

Norfolk County Council administers a service user feedback form prior to discharging a person from their service and the number of returns gives a sound indication of service user satisfaction. The duration of reablement support can vary between service users, depending on their needs. For some reablement service users the duration of reablement can be quite brief and a proportion may become ill again or move to a different care setting. As such, it was not considered appropriate or good use of resources to repeat this survey through the administration on an independent survey, either at the same time or subsequent to a period of reablement.

During the planning stages of this project, it was both recognised and advised that meeting with, and interviewing, older people who were housebound (and likely to be living alone) presented a number of risks which outweighed the practical considerations of the project. It is

acknowledged that our sample includes people who are elderly and housebound but who also have someone who supports them to get out of the house and therefore doesn’t include older people who don’t have this kind of support, or choose not to use it.

Our participants, with an average of 70 years, are acknowledged to be in the younger age group of ‘older’ service users: the average age of a Norfolk First Support service user in 2015-2016 was 81 years. This was not intentional and is a further reflection of the challenges of reaching elderly, unwell, housebound service users.

Initially, the intention was to establish a Project Reference Group for the reablement project. Very early on, it became apparent that this wouldn’t be an effective way to represent the diversity and geographical spread of ex-service users of reablement service users. It seemed particularly unlikely that this was a feasible way to reach any number of housebound ex-service users in particular. To this end, it was decided that the project officer would visit and engage with as large a number of existing service user and carer groups as possible, in order to ensure involvement of local people and organisations providing services to older people.


Engagement and participation outputs

Stakeholder and service user engagement and participation in the project were logged as the project progressed; this included the number of meetings and forums attended, the numbers of stakeholders the project officer spoke to and the numbers of older people encountered along the way. When meeting members of the public and users of older people’s services, an information sheet about the reablement project and further information about Healthwatch Norfolk (a standard leaflet) was offered. An overview of project engagement and participation outputs are shown in Table 1.

Table 1

Stakeholder and service user engagement and participation (Aug 2015 to July 2016)

As can be observed from the figures in the table, the most concentrated activity took place in the late spring and early summer. This is because the early months of the project were spent generally engaging with older people’s forums and services in order to listen and consult with people on the best approaches and understanding the important issues.

Month Meetings, events & forums

attended

Stakeholders informed about the

project

Service users & carers informed the

project

People given verbal or written

information about Healthwatch Norfolk

Aug 3 10 0 0

Sep 5 39 60 72

Oct 4 13 15 60

Nov 9 52 22 72

Dec 4 12 32 64

Jan 5 12 32 70

Feb 9 24 16 40

Mar 10 90 50 74

Apr 3 73 126 199

May 3 10 21 31

Jun 3 5 24 24

Jul 4 8 18 24

Total 62 348 416 730


Participants

In total, 52 people participated in either a focus group or an interview. Forty of these were users of older people’s services and 12 were carers (ten family cares and two paid carers). More information about the participants is shown in Figure 2. Those who agreed to be interviewed or participate in focus groups were also asked to complete an ‘equal opportunities’ form used by Healthwatch Norfolk when gathering comments from the public. Forty one of the 52 participants completed this (see Appendix 4), 11 declined.

52 participants 40 service users, 12 carers

25 people 27 people

6 focus groups 11 one-to-one interviews, 8 paired

19 men 33 women

Figure 2. Participants

The average age of participants was 70 years (the youngest carer was 52 years old and the oldest service user was 83 years old). The age profile of Norfolk First Support service users for the year 2015-2016 reveals an average age of 81 years and that the oldest person receiving reablement was 102 years. This means that our sample sits towards the younger end of the 65 years+ age spectrum of reablement service users (see Page 13).


What we found out

This section describes our findings by grouping information together in three ways, based on the different approaches taken. Each section provides the highlights, with further, or supporting, information on the topics to be found in the Appendix.

Part A. Reablement services in Norfolk

What we found out through engaging with our partners, desk-based research and working with service providers

Part B. Reablement service user survey results

What we found out through looking at the results of the service user survey and the quality audit administered by Norfolk County Council

Part C. Service user views and experience

What we found out through engaging and listening to older people and their carers through interviews and focus group discussions


Part A. Reablement services in Norfolk

During the course of this project we learnt that a hospital-based reablement service is provided to eligible patients prior to discharge home by the Henderson Unit of the Norfolk and Norwich University Hospital Trust on the Julian Hospital site in Norwich. It was announced that the unit will close from 21 October because of a lacks of funds and further information about the Henderson Unit can be found in Appendix 5.

Avoiding costly and undesirable hospital readmissions

There have been several national initiatives aimed at reducing the numbers of people who are inappropriately discharged from hospital and are readmitted again within a matters of hours or days. These are called “emergency readmissions”. Another part of the picture is those people who are waiting to be discharged from hospital but are unable to be, due to an appropriate package of community care being unavailable to them at the time. These are called ‘delayed transfers of care’. Such occurrences are costly for local services and impact upon people’s wellbeing and recovery. Targets for both reducing emergency readmissions and delayed transfers of care have been set for each local area and are accompanied by a collection of incentives and penalties.

When health and social care commissioners work collaboratively, it is possible to arrange sufficient community care packages to receive patients who are discharged from hospital as well as ensuring the care is appropriate and effectively supports that person to remain at home. As part of this project, we looked at data on emergency readmissions and delayed transfers of care for the Norfolk area. It was interesting to note that Norfolk’s social care sector is responsible for less than 2% of hospital discharge delays (2014-2015 figures). Further information on this topic can be found in Appendix 6.

Prevention and independence

Adult social care services for unplanned and planned needs make a contribution towards supporting older people to remain living independently in their own homes and to maintain their health and wellbeing.

In Norfolk, reablement services are called “Norfolk First Response”. Unlike many other adult social care services in Norfolk, the reablement service is not a ‘commissioned service’. It is led, managed and provided by Norfolk County Council staff, as opposed to being tendered out and contracted with a provider organisation. A brief explanation of the current commissioning and funding arrangements for the reablement service can be found in Appendix 7.


The Norfolk First Response service incorporates two services; Norfolk Swift Response and Norfolk First Support. Together, these services are designed to provide for both unplanned and planned adult social care needs. Norfolk Swift Response is an unplanned response service, and Norfolk First Support is a planned needs service providing assessment and reablement. Managers and teams within the Norfolk First Support service are employees of the county council. The overall service model for Norfolk, incorporating planned and unplanned needs and the roles that social care and health services have within it, can be found in Appendix 8.


Norfolk Swift Response (also called “Swift and Night Owls”) is a service which aims to provide care and support to a person in their own home for up to 72 hours, helping to avoid an admission to hospital or residential care. The service is available 24 hours a day,

seven days a week and is co-located with community nursing teams. This allows for the most appropriate response to a person’s initial crisis, preventing admission to hospital or a residential placement whenever possible and helping to stop people’s situation or condition from getting worse.

In the year 2015 - 2016, there were 14,750 referrals to the Norfolk Swift Response service. Each month on average, 1,229 people were referred to the service. The service contributes to a reduction in the number of calls to NHS 999 emergency services and community health teams along with helping to prevent admissions to hospital.

Prevention figures for the years 2014-2015 and 2015-2016 are shown below in Table 2. Demand for this service is increasing; in the year 2015-2016, Norfolk Swift Response saw a 5% increase on 2014-2015 in the number of referrals to the service.


Table 2.

Norfolk Swift Response prevention outcomes

Calls and admissions prevented 2015 - 2016 2014-2015

Community health call 5,019 4,233

% of total calls 34% 30%

Emergency services call 7,227 6,386


Hospital admission 3,220 2,719


Total referrals 14,750 14,275

People are referred to the Norfolk Swift Response service for a number of different reasons and/or needs. Figure 3 below displays the reasons why 14,750 people were referred to the service and shows clearly that around a third of people have had a fall and a third have a personal care need. Many different individuals and services are making referrals to Norfolk Swift Response. The source of referrals received by the service is shown below in Figure 4. Agencies providing community alarms, family members and neighbours, along with other county council services are the source of a majority of referrals.

Figure 3. Reasons for referral to Norfolk Swift Response (2015-2016)

Figure 4. Source of referrals to Norfolk Swift Response (2015-2016)


1%

1%2%

31%

2%9%

7%2%

1%

30%

14%Welfare checkPersonal carePalliative careNutritionNo responseMobility issuesMedicationFallEmergency household taskCatheter or stoma careBreakdown in formal service

42%

2%

2%3%1%

3%2%

16%

1%

22%

6% Self-referralRelative/neighbourPoliceNorfolk County Council internalOther providerOther health providerGPCommunity NurseCare agencyAmbulanceHome alarm providers

Table 3 above lists the areas of the county where service users are living. A slightly higher proportion of service users are living in the Norwich area. When planning for project engagement in summer 2015, initial research suggested that a greater proportion of older-person households with very low incomes, for example in local authority and social housing, are to be found in the Norwich area of the county. Together, these figures tell us something about the prevention and care needs in this group of people.

Norfolk First Support is a reablement service which enables people to regain functional skills and confidence lost through injury or illness (see Appendix 9 for the current service leaflet). It is also a type of preventive service, as service users are supported to ‘do things for themselves’ such as self-care, thus reducing the need for further social care or health service intervention.

Norfolk First Support provides reablement support in a person’s own home for up to six weeks. The service provides assistance with long or short term needs including onward referrals to other adult care services and advice and information to support people to choose the right help or service for themselves.

In the year 2015 - 2016, there were 4,929 referrals to the Norfolk First Support service. Each month on average, 410 people were referred to the service. Demand for this service is growing as well; in the year 2014-2015 there were 4,566 referrals. A slightly higher proportion of the service user’s are living in the Norwich locality, as show in Table 4 overleaf.

People are referred to the service via adult social care’s ‘front door’ or directly from health care workers e.g community nurses. A breakdown of the source of referrals to Norfolk First Response is shown overleaf in Table 5.


Table 3.

Percentage of total referrals to Norfolk Swift Response by locality

Locality [Clinical Commissiong Group]

2015 - 2016 2014-2015

Great Yarmouth & Waveney 13% 14%

West Norfolk 19% 20%

Norwich 32% 29%

South Norfolk 18% 18%

North Norfolk 16% 20%

If there is a need for either an assessment to work out precisely which tasks the person requires assistance with, or there is any possibility that that the person would benefit from an opportunity to improve their levels of independence, they are passed to a reablement scheduling team.

This reablement scheduling team book a team of reablement workers to visit and if appropriate book a reablement practitioner as well. In most cases the team are able to tell the referrer at the first point of contact when the service will begin and when a reablement practitioner will visit to discuss their individual support plan.


Table 4.

Total referrals to Norfolk First Support by locality

Locality 2015 - 2016 Number (%)

2014-2015 Number (%)

East 545 (11%) 552 (12%)

West Norfolk 1,017 (21%) 923 (20%)

Norwich 1,407 (28%) 1,294 (28%)

South Norfolk 978 (20%) 904 (20%)

North Norfolk 982 (20%) 893 (20%)

Total 4,929 4,566

Table 5.

Sources of referrals to Norfolk First Support

Source of Referral Number Percentage

Acute hospital 2,528 51%

Community hospital 379 8%

Community Locality team 379 8%

Adult care ‘front door service’ 778 16%

Norfolk First Response/Swifts 43 1%

Health providers 454 9%

Virtual Ward 183 4%%

Henderson Unit 171 3%

Help at Home 14 < 1%

The team reablement workers will visit for up to six weeks without charge to the customer. If the person appears to need ongoing support they will have a social care assessment and options will be considered to help meet any needs (if there are still unmet eligible social care needs the person will have a Personal Budget Questionnaire). All service users are given a leaflet with details on how to contact Norfolk County Council in future.

Examples of the tasks that staff will support with are:

‣bathing and showering, dressing ‣making drinks and washing up ‣making beds and doing laundry ‣bringing in coal for the fire ‣preparing meals ‣liaising with other services e.g. to order equipment or home adaptations

People receive a financial assessment during the reablement period to assess their contribution to any ongoing services provided. If they are self-funding they are sign posted towards

an appropriate service to provide on-going support needs.

Reablement outcomes

As part of the reablement project, we took a closer look at some of the data on reablement outcomes (for further information, please see Appendix 10). This included the percentage of older people being offered a period of reablement following their discharge from hospital and the percentage of older still living independently in their own home 91 days following reablement.

In common with the England average, approximately 3% of older people aged 65 years or over in Norfolk are offered reablement services following discharge from hospital. The trend over time reveals that the proportion of older people in Norfolk being offered reablement services doubled between 2010-11 and 2014-15 (from 1.2% to 2.8%).

In 2014-2015 in Norfolk, 84% of older people aged 65 years or older remained living independently at home 91 days after being discharged from hospital (see Figure 5 overleaf). On average, services in Norfolk perform well in terms of supporting older people to remain living independently at home after discharge from hospital, when compared to its’ peers, to the East of England and England figures.


Figure 5. Proportion of older people aged 65 and over who were still at home 91 days after discharge from hospital into reablement/rehabilitation services

(2014-2015) 8

Figure 6. Outcomes of reablement for 4,570 users of the Norfolk First Support service (2015-2016) 9

Locally, the immediate and longer term outcomes of our reablement service are good: half of all those people who receive reablement care

from the Norfolk First Support service are re-abled and require no further care (see Figure 6 above).

Health & Social Care Information Centre data, Adult Social Care Outcomes Framework, 2014-2015 8

Data provided by County Mangers, Norfolk County Council9


0%

20%

40%

60%

80%

100%

Northamptonshire

Gloucestershire

Suffolk

Worcestershire

Lincolnshire

Lancashire

Leicestershire

Norfolk

Cumbria

Derbyshire

North Yorkshire

Somerset

Warw

ickshire

Staffordshire

Devon

Nottinghamshire

7%10%

1%2%

9%

20%

50%

Re-abled (no further service)Referred for needs assessmentSelf-funding servicePerson cancelled careFurther service declinedPerson deceasedHospital admissionPending resolution

Expanding the service

At the time of starting this project, it was reported that

the service could only take 76% of the referrals made to it, due to limited capacity. The additional investment of £1.3 million by Norfolk County Council in November 2015 was intended to fund the expansion of the service. Recruitment for an additional 47 reablement support part-time posts has started and once the positions are filled, the service should be able to support up to an additional 1,500 people a year.

A summary of key findings

From all the information gathered as part of this project, we know the following things about reablement services:

• In Norfolk, service users who are deemed to benefit from reablement may receive up to six weeks of reablement free of charge

• the public can find information on Local Authority services and care on

the Norfolk County Council's website. There is also information on those services which are free of charge following hospital discharge, including reablement, equipment and adaptations, at NHS Choices

• the total budget that Norfolk’s Adult Social Care Services allocated to Norfolk First Support for 2015-2016 was £2,822,000

• Gross expenditure on reablement services (excluding Norfolk Swift Response) in 2015-2016 was £6.728 million; this is jointly funded (50/50) between Norfolk County Council and Norfolk’s five Clinical Commissioning Group

• the council report spending £2,558,000 on Norfolk First Support reablement in the financial year 2015 - 2016

• within the Re-imagining Norfolk consultation document, the proposed budget changes for reablement were to spend more on reablement services with the aim of achieving £3,200,000 net savings (after increased costs) in the longer term

• a 2% council tax social care precept was adopted by Norfolk County Council following a vote by councillors on 22 February 2015

• demand for reablement services is increasing all the time

• Forty-nine per cent (49%) of people receiving a reablement service from Norfolk First Support in 2015-2016 were re-abled and required no further service


https://www.norfolk.gov.uk/care-support-

http://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/local-authority-funding-for-care.aspx%22%20%5Cl%20%22reablement

Part B. Reablement service user survey results

At the end of each Norfolk First Support intervention, the Reablement Practitioners will encourage the service user or their advocate to complete and return a Quality Assurance Feedback Form. In 2016, a total of 1,079 surveys were returned during the sixth month period from January to July. Service users were asked the question “How likely are you to

recommend our service (Norfolk First Support) to friends and family if they need similar care or support?”. Ninety eight percent (98%) of Norfolk First Support service users said they would be extremely likely or likely to recommend the service to family and friends (see Figure 7). Eighty percent (80%) of service users said that they felt the service and advice offered was either “excellent” and a further 17% said it was “good” (Figure 8).

Figure 7. Likelihood of recommending the service to friends and family

Figure 8. How service users felt about the service and advice offered


1%13%

86%

Extremely likelyLikelyNeither likely nor unlikelyUnlikelyExtremely unlikelyDon't know

2%17%

81%

ExcellentGoodOKBadVery bad

Table 6.

Feedback from 1079 users of the Norfolk First Support reablement service (January - July 2016)

The survey responses show that 1054 out of 1079 - 98% - service users said they felt involved in the discussions and decisions the advice and support given to them, shown in Table 6 above.

The information in the table also demonstrates that 99% of uses felt that had been treated with dignity and respect.

A sub-set of users (192) were asked two further questions about being involved in changes to their support and being offered support and signposting:

“Were you able to contribute and be fully involved when changes to your support were suggested/made?”

‣Yes - 191 users out of 191

‣No - 1 user

“Do you feel staff offered and/or arranged the level of support and signposting that you needed?”

‣Yes - 189 users out of 191

‣No - 1 user

In all, service users have very positive things to say about their experiences of Norfolk First Support.

In 2014-2015, Norfolk First Support received 4,570 referrals and 2,203 service users completed a Quality Assurance Feedback Form (which constitutes a 48% return). Service users rated their satisfaction very highly. In Table 7 overleaf, the results from the Annual Quality Assurance Report April 2015 - March 2016 are displayed. These results also show that service users have very good experiences of reablement with Norfolk First Support.

Question Number (%) saying YES

Number (%) saying NO

Did you feel involved in the discussions and decisions regarding advice and support?

1052 (97.7%)

15 (1.39%)

Did you feel you were treated with dignity and respect by the staff that visited you?

1070 (99.2%)

3 (0.28%)


Table 7.

Feedback from 2,203 users of the Norfolk First Support reablement service (2014-2015)

“It was easy for me to arrange the Reablement Service to visit me”

‣Yes, I contacted the Social Services myself to arrange - 43%

‣Yes, somebody else arranged it on my behalf - 57%

‣No - 1%

“Staff discussed with me whether additional equipment or adaptations were thought to be required to support time living at home”

‣ Yes - 63%

‣ No, this was not necessary - 35%

‣ No, but I would have liked them to - 1%

Statement Number (%) saying YES

Number (%) saying NO

I was visited within a reasonable timescale and was kept informed of approximately when the service would commence

2182 (99.5%)

7 (0.32%)

I had trust and confidence in the staff treating or supporting me

2177 (98.8%)

1 (0.05%)

I was treated with dignity and respect by the staff that visited me

2192 (99.5%)

1 (0.05%)

The staff that visited showed their identity badges and wore a uniform

2192 (99.5%)

1 (0.05%)

I felt involved in decisions about my care and support 2184 (99.1%)

8 (0.4%)

Overall, I felt I was fully satisfied with the visit from the team

2173 (98.6%)

8 (0.36%)

I would definitely use this service again if I had a change of circumstances

2170 (98.5%)

4 (0.18%)

I would tell others about the service I received, so if they ever had a change in circumstances and required some support at home, they could contact Social Services to activate Norfolk First Support

2158 (97.9%)

6 (0.27%)


“Staff discussed with me whether I had any further health or social care need after they finished supporting me ”

‣ Yes - 66%

‣ No, this was not necessary - 33% ‣ No, but I would have liked them to - 1%

Overall, 98% said they were fully satisfied with the visit from the team.

Ninety-nine percent of users completing a feedback form said that they were visited within a timescale that was reasonable to them with 99% also saying they were treated with dignity and respect and were involved with decisions about their care and support.

Service users were reporting that reablement staff had worn a uniform and an identity badge when they had visited - with almost 100% of users saying this.

Regarding initial access to the service, 43% of users said that they had contacted adult social care service themselves to arrange a visit and 57% said that someone else had arranged it on their behalf. It is interesting to note that just less than two-thirds said that reablement staff had discussed their needs for additional equipment or adaptations to their home to support them living at home.

A third said they hadn’t needed staff to discuss any further health or social care support once the reablement period had finished and two thirds said that staff had discussed ongoing needs with them.


Part C. Service user views and experiences

This section sets out the strongest and recurring findings gained through listening to older people and their carers tell their stories and describe their experiences of reablement services. These findings are set out in a way which attempts to follow an older person’s story (or journey) from just before something happened such as an illness or event, through reablement and the period just after reablement.

Before (the event, illness or injury)

Older people were asked to describe the things that happened before and in the lead-up to their reablement.

Older people, especially those living alone, can be isolated

Often a period of intense loneliness preceded an event or illness that resulted in a reablement need. Older people talked about a gradual decline in social and daily interactions with others in their neighbourhood and local community and for some a distancing from relationships with family members and friends. People said that they were often aware that their physical health and mental wellbeing were deteriorating but they didn’t have anyone around at the time they could tell or someone to approach for help in the first instance. People were


afterthe event

beforethe event,

illness or injury

Norfolk First Support

VCS services

beyond reablement

home care



Family and carers

alone for many different reasons; some had recently experienced the death of their spouse or partner, some had families who had moved away, others had a house or partner move into residential care.

Mobility can decline

Many reported a decline in their mobility, describing how it became increasingly difficult for them to get around safely and confidently in their own home as well as outside their home.

This was something that seemed to take people by surprise, in that they weren’t expecting to become quite so immobile or unstable in their own home environment. Several older people described a fall as the incident which led to their hospital admission and subsequent interaction with reablement services. For some experiencing a fall at home, this was the time when they encountered the Norfolk First Response service’s ‘Night Owls’ or ‘Swifts’ (which operates 24 hours a day, 365 days a year) if the fall took place in the evening, at night or during a weekend, or a Community First Responder.


“I feel lonely when I wake up in the morning. I don’t like mornings

because you wake up and want to talk to somebody about something that has happened or something like an

ache or pain that is starting to worry you. I get worried going to bed and when maybe the night before when something’s happened in the night

and it’s scared you and you don’t have anyone there, because you are on

your own, and there’s no-one around to get hold of in an emergency

situation. That’s the sort of thing that worries you”

“When you’re on our your own, it’s nice when you go out. But you walk

into the house and you want to tell somebody what you’ve

been up to and there’s nobody to tell”

“…he ended up going in a home. He wasn’t there for very long before he died but I didn’t get to see him much when he was in there, I had nobody to take us up there you see…we did a lot of things together, we managed things

together and I was having to do everything and I just couldn’t”

“Oh, I can't go out in the cold weather. I can't breathe in the cold.

It's because the cold air goes into your lungs, and the lungs are near

my damaged heart, and so I do dread the winter. I can’t get out. I’m

frightened of slipping over, even in my own back garden. I don’t feel

safe. I started hanging on to things to get around!”

Whilst some older people reported a decline in their mobility before their incident or illness, all reported an improvement in their mobility after reablement.

After (the event, admission to hospital, illness)

Older people were asked to describe the things that happened after they were unwell and how they heard doubt and first encountered reablement services. Around two thirds of the older people we spoke to had spent a short time in hospital prior to receiving reablement. The reasons for admission to hospital were described as including a fall, fainting or a black-out, worsening of a existing condition such as diabetes or high blood pressure and a serious infection such as flu. Others said that they hadn't been admitted to hospital but had, for example, had fall in their home or when out shopping, had a minor accident at home resulting in an injury or had become very run-down (after recovering from flu or a severe stomach bug).


“telling me that mum had had a fall ….Because she has this thing, you see…a pendant…well it’s an alarm really. But she wears it

around her neck, even when she goes to bed and that…all the time. She’d got up in the night to go for

a wee and had fallen – I think – between the bed and the wall in

her bedroom, and she hadn’t been able to get up again. She’d hurt her side and I think of course as well she was very, very scared.

When she pressed her alarm they sent someone to go check up on

her”

“The ambulance still arrived but someone else got to her first, the First Aiders I think? They are in the local area and they are like volunteers. They are sort of like paramedics but local volunteers from the surrounding areas and I think they get sent ahead to save calling an ambulance. As an extra

check that sort of thing”

“there was a pair of them who arrived together…they work together at night and call

themselves night owls. So…these two came together but they’d also called the ambulance out as well…well I’m not sure who did that as I

wasn’t there at first and dad himself was pretty upset by it all…

and…I don’t think he can remember it all very clearly

anyway…”

“I had the flu and was quite poorly over Christmas and the New Year, for a couple of months actually, I couldn’t

get out at all”

“… they put me in the [James] Paget [hospital], something to do with my

diabetes. Both my legs swelled up and they didn’t really know what was

going on”

Hospital discharge feels rushed

One common theme in the conversations with older people who had been admitted to hospital was the ‘rushed’ nature of their discharge home. People felt they are discharged home from hospital in a hurry and family members described their surprise at the short length of time their relative spent on the hospital ward. Both older people and their carers said they felt they hadn’t had enough time to get well enough to go home.

People also felt under pressure to make decisions that they may have to live with for a long time such as agreeing to a period of respite or even considering residential care. Older people said they did not want to have to make a hasty decision about going into a care home or nursing home, especially when they weren’t fully

themselves as they were still recovering.

Awareness of reablement services is low

With the exception of two people who had previously used the reablement service and a further four who had known others receive a reablement service, the majority of older people we spoke to had not been aware of reablement services prior to receiving them. The same was true of their family members and carers; whilst they were aware an older person may sometimes qualify for help from social care services, they didn’t know about the reablement service in Norfolk.

Most thought others could be made more aware that the service is available.


“I was no sooner in there then I was coming home again”

“Dad wasn’t ready to come home. Not on his own”

“… Hmmm…they were so ready to send her home. I mean, from day one they seemed anxious to send her back home….I did feel they were putting

pressure on my mum to go home before she ready but they didn’t half

mess about when the time came”

“I hadn’t heard of reablement before. I wasn’t sure what

reablement meant”

“It wasn’t something I’d come across before”

“…A lady down the road had the people come in when she came out

of hospital. She couldn’t cope on her own, her family live away”

“So useful and so helpful, people should know about this, if they can

get it”

Reablement experiences

Throughout the engagement activities undertaken for this project, it would seem that not many people i.e. the ordinary person or member of the public, are familiar with the word ‘reablement’. It is a term used, however, by health and social care workers and those people (including volunteers) who are running support services for older people and their carers.

Based on conversations with people and using what we know about reablement services, it would seem that at least 30 out of the forty older people we spoke had definitely encountered reablement services.

Some did not refer to ‘Norfolk First Support’ or to ‘reablement’ but described events, assessments and people in such a way it would indicate that they probably had received a service.

Most didn’t always know what to expect and most thought, at first, that the reablement worker would be coming to do things for them as opposed to helping and encouraging people to do things for themselves. This expectation was expressed by both older people and their carers.

For a small minority, the opportunity for reablement had passed them by.


“I wasn’t aware that you could get this kind of service but now I’ve had it I think it’s marvellous. It makes so much more sense to help people get

back on their feet and get a bit stronger before they even go home

and then make sure…they can do the things they really need to do to stay in their own home. People need help

to do that sort of thing and not everyone has someone like family to

help them anyway” (older person who had stayed on the Henderson Unit in addition to

receiving reablement support at home)

“I had never heard of reablement”

“…I was a bit…disappointed myself at first…because I thought they were

coming to help him you know actually give him some practical help

but they way he described it, they said they were there to help him

plan things and set goals for himself as doing things for him wouldn’t really help him in long run…It

worked out well in the end and he seemed pretty pleased which is all

that matters”

“From what I remember I think the social worker in the hospital tried to set this up for me but there wasn’t anyone who could come out when I actually got out of hospital…they

said there wasn’t anyone available in the area at that moment in time”

About two thirds of older people we spoke to had never thought about making changes to their home environment to make mobility or handling household tasks easier. The majority could see afterwards how useful it is to make even small, practical changes to their physical environment; this was often raised as part of the reablement goal planning.

Reablement staff helped with discussing home adaptations. For a small number of participants, the reablement practitioner had arranged a piece of equipment or adaptation with the community equipment service, or put the service user in touch with another organisation or agency that could help them.


Interviewer: “Can you think of anything else the reablement practitioner gave help with?”

Carer: “Someone else did come, I don’t remember their name but they came out to the house and helped go through a checklist of things to look at, to go over, to make sure mum didn’t fall again. They weren’t a reablement worker, I don’t think. I think the reablement lady asked them to come. They sorted out mum’s carpets, her fire alarm and some other things. I think it might have helped if I had been at the house but I couldn’t be there because of work. It might have been someone from Norwich council or the housing association, I don’t know”

“They helped with all sorts of different things…something they did

was help with cooking which I’d found very difficult before I went

into hospital, so I was worried about not being able to do things for

myself. I couldn’t get into my kitchen very easily. There is a step up into it you see. The carers arranged for my ramp to go in there - it took some

time for it arrive - but eventually it did…it helps me get up into the

kitchen so I can make myself something to eat. They stayed with me while I practiced heating food

and serving it up. I still can’t get up into my pantry because there is a

door step but my son moved everything out into the kitchen so I can get what I need there instead”

“the reablement carer arranged for me to have a chair in my bathroom to help me sit at the sink to shave and

to wash - it’s a white metal and plastic one - it’s got arms on it which I can use to help lower myself down and stand back up again easily. It

doesn’t matter if it gets wet”

What people liked about the reablement service

We asked people to say what they liked best about the reablement service. The good elements of the service most frequently referred to included:

‣ people got the service at the time when they needed it most

‣ reablement staff were patient and cheerful

‣ reablement staff helped people to look at problems in new ways and find solutions

‣ staff introduced themselves by name ‣ reablement gave people confidence ‣ reablement staff didn’t tell people

what to do, they made helpful suggestions

Feedback on the quality of the service and reablement staff was very positive indeed.


Interviewer: “What did you and your mum like best about the reablement service you received?”

Carer: “For me, I liked knowing that someone was going in to see her especially during the day when I was at work and couldn’t get over. And my mum liked…well we should ask her shouldn’t we, what she liked? Did you like the reablement lady coming in to see you mum?”

Service user: “Yes, I did. I liked her very much. She was a very helpful girl. And very cheerful”

“…it got me back on my feet and they helped make my home feel

safe again”

“I just liked the company of them, having them come into my house. I liked knowing that they would come. I looked forward to

it breaking the day up a bit”

“An absolutely dependable service. I have no complaints whatsoever

about the standard of care I received”

Matching expectations

There were two areas where older people report being disappointed; on a few occasions staff appeared to be rushed and that for a proportion of people, the reablement service ended before some people felt ready for it to end.

People said that the reablement workers had explained to them the nature of the support at the first visit. Some acknowledged they had forgotten that and that they had got used to the level of support the reablement practitioners were providing. Some felt that the reablement support was over too quickly, especially those who didn’t feel quite so confident when their reablement support ended. Some family carers said that they had probably over-estimated their ability to support the person who’d had reablement but in reality, once the support had finished they had to re-adjust their expectations.


“The personal one-to-one visits were much appreciated. I looked forward to them coming every day and was treated with respect and courtesy throughout”

“the carer was super reliable”

“It’s not a surprise as such, when a person gets old all the conversations about the future inevitably seem to graduate towards dying and death. The carers spoke a lot

about the future and after a while I began to grow some confidence in thinking I could still manage on my own, look after myself, enjoy life still”

“Sometimes the carer seemed to be in a bit of rush. She had a lot to pack into her day I think”

“the visits were over quite quickly and there was quite a lot to pack in to them anyway”

“We don’t qualify for any help now. The Norfolk First Support workers were really great when they were coming. Everything was quite hectic at the time and my health wasn’t so good so we appreciated the support we got, at the time we did. When it came to end…it wasn’t quite a month I don’t think…it all seemed to go very quiet after that. I was managing and my wife was managing and we were using the bathroom equipment that had been provided for us. I felt, and my wife certainly felt, we could have done with more. They did explain to us why the support was coming to an end - and they’re right, it’s not as thought my wife has got any better or any worse. We just thought it would go on a bit longer than it did”

Beyond reablement

Ten out of the forty older people we spoke to had some form of ongoing, regular help with personal care, household tasks or help with garden and pets. Some of those who didn’t have help, wanted on-going help with household tasks and personal care going forward and would have liked a bit more information on how to go about getting it.


Many participants said they would not think of contacting the council to find out if they were able to get support from adult social care services. Few older people’s service users said that they were online and using the internet to find information on services and social activities. It seemed that family members, including adult children and grand-children, carry out a lot of online research on their behalf. Printed materials are still preferred by the majority of older people and carers that we spoke to ; local press and 10

radio, leaflets and handbooks remain popular as a source of information on where to get advice and support services. Word of mouth is also considered the best source of recommendation.

What is quite clear from engaging with older people and listening to their views and experiences, is the role that the community and voluntary organisations have in providing older people with information, advice and support.

These are the preferences of the sample of older people who participated in this project; it is 10

recognised that many older people are regular, competent and happy users of information technologies (see comments on limitations on Page 13).


Interviewer:Have you ever thought about contacting Norfolk County Council?

Service user G: No, not really. No I haven’t.

Service user M: I got my carer through the council so it sounds like a common sense thing to do.

G: Who’d you speak to at the council, to get this sort of thing arranged?

M: They’ve got a helpline. You can ring that.

Service user A: “Do you know, that’s a bit funny because I have seen that number now I come to think of it but it’s never really occurred to me that you could call that number to ask about social workers, or home carers. I had always thought it was for, well, I don’t know what I thought it was for…libraries, council meetings, building works on the roads, town planners…”

Interviewer: “Do you think that perhaps for other people it wouldn’t be the first thing that comes to mind?”

Service user C: “If you don’t already have a carer I don’t think people will ring the council to get one…”

Some people report being prepared to pay for ongoing help at home if they needed it and some thought that social

care services should do more to help people beyond their period of reablement.


Interviewer: “Do any of you use the internet to look for information? Would you go online and perhaps look at the county council’s website for example?”

Service user R: “I don’t have the internet so I couldn’t anyway.”

Service user G: “I don’t have the internet at home much to my daughter’s annoyance but she has the internet and the wi-fi at home so she’s often looking up things”

Interviewer: “What about you, M?”

Service user M: “I do have it well my son set it all up for me and got me an i-pad to use but I’m not really well I’m not very good at it and I don’t what to do really. I’ve got g-mail that he got for me and put it on the i-pad but I can’t say in all honesty I know what I’m doing and I’m always getting it wrong! My g-mails don’t send. Some of my carers speak to me about it and they will tell me what to do and what it’s possible to do with it but I’m not really interested in all that. Not at my age”

Service user L: “I don’t have the internet. I couldn’t afford it every month because I’m on my own I don’t get that much money every week and I wouldn’t have a clue how to do about setting it all up and what you do with it”

Service user G: “It would certainly help people who say they are very lonely and don’t see anyone but it can… I’m sure it is… expensive and it’s not always easy to understand these things and how they work. And what to do when it goes wrong!”

Service user R: “Sometimes the cost of such things can be a real barrier. Retired folk in particular just don’t have that kind of money to spend, unless perhaps you have children – and remember not everybody does – or grand-children, who can help you organise things like getting the internet set up or getting an email address. In Great Yarmouth lots of older people are on really very basic incomes and once you’ve got a pension you have got a fixed amount of money coming in every week or every fortnight and that’s it, there isn’t any more money. What you spend on your telephone bills or the internet has got to come from somewhere and at the end of the day it’s money you won’t spend on something just as important. Like gas or heating fuel”

During a stay at the Norfolk and Norwich Hospital, an older person described an encounter with a support worker from AgeUK Norfolk that had been particularly enlightening. The support worker had visited the ward to speak with patients, to listen to their concerns and to assist by providing the relevant information or information that would signpost to someone else who could help. In this instance, the older person had used the information to find a personal carer for themselves when they were discharged, arranging for them to visit and funding this service themselves. Their family carer considered this a very good idea.

Something else that comes out clearly in the conversations with older people is that social activities in a local community are highly valued, people like the opportunity to see and speak to other people, to do some practical and creative, to have a hot lunch and for some, the opportunity for an “occasion" and a chance “to dress up a bit”. For some of our participants, the return to isolation following a period of reablement was keenly felt:


“I wasn’t there myself when this person came onto the ward. Mum

would get a bit confused about who had spoken to her over the course of the day - there were so many - and what they had told her…because I

wasn’t able to get in till the evening…but the person who I presume came

from AgeUK…because of the literature she left for mum afterwards…seemed

to be very good and left some information which we used…we found someone to come in and see to mum,

do whatever she wants to do that day…We pay for that…mum pays for that herself. It’s fine. It works out

well”

“…after all the attention and the chatter and the laughter on the [Henderson] ward, then with the reablement carers coming in every day once I got home…afterwards…it went back to being so quiet. I

missed the company. If there is a way to keep that going, that would be wonderful”

What this means

Reablement services in Norfolk

Drawn from data we've gathered from various sources, some key findings about the service can be summarised as followed:

‣ there is good evidence that reablement is cost-effective, is preventive in nature and reduces the need (and costs) of ongoing care support

‣ Norfolk First Support is our local reablement service, offering up to six weeks of reablement support free of charge, handling 4,929 referrals in the year 2015 - 2016 and 4,566 in 2014 - 2015

‣ gross expenditure on reablement services in Norfolk in the year 2015-2016 was £6.728 million (jointly funded between Norfolk County Council and the five Clinical Commissioning Groups)

‣ Norfolk County Council reported spending £2,558,000 on the Norfolk First Support reablement service in the financial year 2015 - 2016 also investing a further £1.1 million in November 2015, aiming to recruit another 47 part-time reablement workers so that a further 1,500 people could benefit from the service

‣ within the Re-imagining Norfolk consultation document, the proposed budget changes for reablement were to spend more on reablement services with the aim of achieving £3,200,000 net savings in the longer term

‣ a 2% council tax social care precept was adopted by Norfolk County Council following a vote by councillors on 22 February 2015

‣ demand for reablement services is increasing all the time

‣ forty-nine per cent (49%) of people receiving a reablement service from Norfolk First Support in 2015-2016 were re-abled and required no further service

These findings tell us that reablement services continue to feature highly within early intervention and prevention adult care services and that extra resources have been spent and allocated to reablement services in Norfolk.

What people say about the service

In the two years between April 2014 and March 2016, feedback on service experiences were collected from 3,282 people that demonstrates that:


‣ service users report high levels of satisfaction with reablement service they’ve received

‣ users feel they are treated with dignity and respect

‣ people said they felt involved in discussions and decisions about their care and support

‣ 81% said the service was “excellent” and a further 17% said it was “good”

From our conversations with older people and their carers we are aware that:

‣ older people say they can become very isolated in the period leading up to their reablement need

‣ mobility can decline affecting people’s ability to care for themselves safely at home

‣ hospital discharge can be rushed and people feel under pressure to make decisions in a hurry

‣ awareness of reablement services is low prior to receiving this kind of support

‣ people like reablement staff, they find them cheerful and patient and help people to find new ways to solve problems and gain confidence in doing things for themselves

‣ sometimes expectations don’t match up; people thought reablement staff

were going to help them more or that they’d help for longer

‣ some people did not feel fully confident to manage their needs when their period of reablement ended

‣ for some, the duration of the service feels too brief, some would like ongoing help at home with practical household tasks and personal care. Some are able and willing to pay for this themselves

‣ people expressed a sense of a ‘return to loneliness’ following the positive interaction with reablement services

‣ older people retain their preference for printed materials (leaflets, brochures) and for word of mouth recommendations on support services

‣ the community and voluntary sector in Norfolk is providing a great many opportunities for older people to get information and advice they find helpful and to take part in social activities they find enjoyable


What could be improved?

Drawing from the insights that people have shared with us, Healthwatch Norfolk has an opportunity to feed back to Norfolk County Council and the managers of the reablement services, sharing the positive feedback as well as influencing some areas where service users said things could be better.

Awareness coupled with good, timely information meeting expectations

Few people are aware of reablement services, however the service is not appropriate for everyone and some may be ineligible for a number of reasons. Therefore, it does not seem prudent for Healthwatch Norfolk to advocate that the reablement service

be widely promoted to all older people; this could raise false expectations and lead to disappointment. Older people and their carers do value good quality, timely information about the kids of help and support available upon discharge from hospital as well as support with ongoing care needs at home. Good quality timely information and signposting could be strengthened at the point of discharge from hospital and from the reablement service.

Support beyond reablement

A proportion of older people said they didn’t quite feel ready to move on from the service and that they would like ongoing support beyond reablement. This links to the points made above about awareness and availability of ongoing support.


Recommendations Drawing from our findings on what works well and what can be improved, the table below sets out the recommendations arising from this work.

Table 7.

Recommendations

Evidence Recommendation For Follow- up Action “HWN will…”

Awareness of reablement services is low however not everyone is appropriate for reablement. People want good quality, timely information about support services on discharge on hospital and about ongoing personal care at home.

Consider collaborative commissioning of a ward-based, visiting proactive information service for older people on all elderly care wards of the Norfolk & Norwich, James Paget Hospital and Queen Elizabeth Hospitals e.g. an expansion of the existing services by VCS organisations (including AgeUK)

Norwich CCG North Norfolk CCG South Norfolk CCG West Norfolk CCG Great Yarmouth CCG

In January 2017, HWN will ask the five CCGs to provide a progress update on actions taken.

Service users’ expectations do not always match their needs and the duration of reablement care provided. All service users are given a booklet providing contact details for Norfolk County Council but some did not know how to get support from other agencies.

Norfolk First Support will compile a locally focused factsheet with voluntary organisations information that will be discussed with service users, as a means to hep people feel more supported after their period of reablement.

Norfolk First Support reablement service

In January 2017, HWN will ask the Norfolk First Support reablement service to provide an update on steps taken to implement the new factsheet at the end of the reablement period.

Future system changes may impact upon the capacity of reablement service provision

Review reablement provision, including the impact of closing the Henderson Unit in a year’s time

Healthwatch Norfolk Board

Review expenditure and provision on reablement services in Sept 2017


Appendix

No. Page

1.1 Methods to investigate commissioning and funding arrangements for adult social care reablement services in Norfolk

45

1.2 Sources of information on service and financial planning 46

2.1 Methods to investigate hospital re-admissions and reablement outcomes

48

2.2 Social care and health outcomes indicators 49

3 Discussion Guide 50

4 Equal opportunities data 51

5 NHS hospital-based reablement - the Henderson Unit 52

6 Hospital discharge and delayed transfers of care 54

7 Reablement commissioning and funding arrangements 57

8 Service model: meeting planned and unplanned reablement needs 59

9 Norfolk First Support Service leaflet 60

10 Outcomes of reablement 62


Appendix 1.1 Methods to investigate commissioning and funding arrangement for adult social care reablement services in Norfolk

* The Adult Social Care Committee is responsible for the commissioning and quality standards of adult social care services for people in Norfolk. It incorporates all those services, from protection to residential care, that help people live fulfilling lives and stay as independent as possible as well as overseeing the protection of vulnerable adults. Papers presented to the Adult Social Care Committee of Norfolk County Council within this time frame (including those papers reporting on historical data and trends previous to August 2015) were included. It was not thought necessary to include the papers of other committees or full council, as these would only contain papers and figures that had previously been presented to the Adult Social Care Committee and any revisions would need to go back again to the Adult Social Care Committee for consideration.

Question (key line of enquiry)

Method

“What are the current commissioning arrangements for reablement services and how are they funded?”

Timeframe Aug 2015 - May 2016 Face-to-face fact finding and meeting attendance* Desk-based review of written formal reports, board papers, web content In reviewing the sources of information and documentation, the following scope was applied:

a) Any reports describing the commissioning cycle, process and arrangements for Reablement Services b) Any reports containing figures on the financial allocation or expenditure against Reablement Services c) Any reports containing a description of, or referral to, strategies or activities to decrease, maintain or increase the financial allocation or expenditure on Reablement Services d) reports and papers describing the outcome of the most recent consultation on the county council’s adult care services, drawn from the responses of service users and public e) web content describing the funding of reablement services locally (with regional or national comparators)


Appendix 1.2 Sources of information on service and financial planning

Information or document owner/author

Source of information/Title of document (in order of oldest to most recent

HM Government Social Care Spending Efficiency Tool 2013-2014 https://www.gov.uk/government/publications/adult-social-care-efficiency-tool

East of England Local Government Association

Cecilia Tredget, Managing Director (August 2015, verbal communication)

Norfolk Health and Wellbeing Board Norfolk County Council West Norfolk CCG Norht Norfolk CCG Norwich CCG South Norfolk CCG Great Yarmouth & Waveney CCG

Health & Wellbeing Board papers: September 2014 - Better Care Fund Planning Template (submitted to Local Government Association & NHS England 18th September 2014) (submitted to Local Government Association & NHS England, 18th September 2014) 11th November 2016 - Norfolk Better Care Fund Plan – Progress Update 2015/16 and Planning 2016/17 16th February 2016 - Integration in Norfolk and the Better Care Fund Plan May 2016 – Norfolk Health and Wellbeing Board Update

ADASS (Association of Directors of Adult Social Care)

ADASS Budget Survey 2015 Report http://www.adass.org.uk

Norfolk County Council departments and staff

Harold Bodmer, Executive Director of Adult Social Care Sera Hall, Head of Integrated Commissioning Janice Dane, Assistant Director of Prevention & Transformation Denise Forder, County Manager Norfolk First Support Katerina Brady, County Manger Norfolk First Response (Sept & Oct 2015, verbal communication) Jeremy Bone, Delivery Manager Business Intelligence Tony Harrison, Information Exploitation Officer (Sept 2015, telephone and email communication) Jeremy Bone & Chris Kirk, Business Intelligence and Performance Service (Sept 2015, email communication)

Norfolk County Council

Re-imagining Norfolk Budget Consultation 2016-2019 https://norfolk.citizenspace.com/consultation/re-imaginingnorfolkbudget Your Norfolk Issue 51 Spring 2016 P.3


https://www.gov.uk/government/publications/adult-social-care-efficiency-tool

http://www.adass.org.uk

https://norfolk.citizenspace.com/consultation/re-imaginingnorfolkbudget

Adult Social Care Committee Norfolk County Council

Adult Social Care Committee papers: 8th June 2015 - The new approach to social care – promoting independence in Norfolk 7th Sept 2015 – Adult Social Care Finance Monitoring Report Period 4 (July) 2015-2016 7th Sept 2015 – Strategic and Financial Planning 2016-2019 – Re-imagining Norfolk 7th Sept 2015 – The cost of care in Adult Social Services – Interim Report 12th October 2015 - Re-imagining Norfolk: Service and Financial Planning 2016-17 to 2018-19 9th November 2015 – Adult Social Services Transformation Programme 9th November 2015 – Adult Social Care Finance Monitoring Report Period 6 (September) 2015-16 25th January 2015 – Adult Social Care Finance Monitoring Report Period 8 (November) 2015-2016 7th March 2016 - Adult Social Care Finance Monitoring Report Period 10 (January) 2015-16 26th May 2016 - Adult Social Care Finance Outturn Report Year End 2015-16

Norfolk Reablement First Response

“Norfolk First Response Service – for Healthwatch Norfolk” – Katherina Brady- County Manager – Western (QEH), Eastern (JPH) and the referral hub Denise Forder – County Manager – Norwich, Southern, Northern (NNUH) Janice Dane, Assistant Director of Prevention & Transformation

Social Care Institute for Excellence

Jennifer Francis, Mike Fisher and Deborah Rutter (April 2014) Reablement: a cost effective route to better outcomes. Research Briefing No 36.

The Financial Times

Sally Gainsborough & Sarah Neville. The Financial Times 19th July 2015. Austerity’s £18bn impact on local services. www.#.com


http://www.ft.com

Appendix 2.1 Methods to investigate hospital re-admissions and reablement outcomes

In order to answer some of the questions about how well our local services are doing, the following methods were used.

Question (key line of enquiry) Method

“What does the data on trends in emergency re-admission within 2 days and 30 days for people aged 65+ tell us about quality of care and readiness for discharge?”

- Desk based research; retrieval, plotting and analysis of health and social care outcome indicators - Interrogation of available data on unplanned readmissions to hospital within 2 days and within 30 days of discharge - Focus on trends over time - Selection of three key events likely to

be more common in people aged 65 years and older: stroke, acute myocardial infarction (heart attack) and hip replacement

“Are health and social care commissioners working collaboratively to ensure the right packages of care will be in place for those who need it?”

- Desk based research; retrieval, plotting and analysis of health and social care outcome indicators - Interrogation of available data on delayed transfers of care (DTOC) - Selection of variables: DTOC

attributable to NHS; DTOC attributable to social care

“What does the data on the proportion of older people still at home 91 days after discharge tell us about reablement outcomes?”

- Desk based research; retrieval, plotting and analysis of health and social care outcome indicators; stakeholder meetings - Interrogation of available data on discharge to reablement services - Selection of measures: offer of

reablement and proportion of people aged 65 years and over still at home 90 days after discharge from hospital


Appendix 2.2 Social care and health service outcome indicators

To explore the outcomes of local adult social care and health service outcomes indicators, the following indicators were selected.

Source Domain Indicator name Release date

NHS England Delayed transfers of care NHS England Acute Trusts

Number of delayed days Proportion of delayed (by reason)

Monthly

Adult Social Care Outcomes Framework

Delaying and reducing the need for care and support

Permanent admissions to residential and nursing care homes, per 100,000 population

Dec-15

ASCOF 2B(1) Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services

Dec-15

ASCOF 2C(2) Delayed transfers of care from hospital, and those which are attributable to adult social care

Dec-15

NHS Outcomes Framework

Helping people to recover from episodes of ill health or following injury

ASCOF 2B(1) Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services

Feb-15

3b Emergency readmissions within 30 days of discharge from hospital

Feb 15

ASCOF 2B(2) Proportion of older people (65 and over) who were offered rehabilitation following discharge from acute or community hospital

Feb-15


Appendix 3. Discussion guide

Before •Can you tell me a little bit more about what happened to you? •[Prompt: a fall at home, period of illness, GP visit, out-of-hours

contact, emergency e.g. ambulance called or Norfolk Swift Response]

After •Can you describe what you remember most about your recovery/

discharge from hospital? •What sort of support were family, friends or neighbours able to help

with? •What sort of information about help did you have?

Experience of reablement services •Who first mentioned a reablement service to you? What did they say

about it ? [Do you remember if you were “referred” by someone such as a Nurse, Social Worker, Occupational Therapist?. Did you hear about it from a charity e.g. AgeUK? ]

•Who came to see you, once you started to get better, or when you had got home from hospital?

•How often did the reablement workers come? •What sorts of things did the reablement workers help you with? •Was it what you expected? If not, can you explain why?

What worked well? •What things, in your opinion, worked really well for you? •What did you like best about the reablement service you received?

What needs to be improved? •What could have been better? •What would you suggest could improve the service you received?


Reablement Discussion Guidefor focus groups and interviews

Appendix 4. Equal opportunities data

Summary information on the characteristics of participants is shown below.

Table A4.1 Table A4.2

Gender Religion and beliefs


Ethnic origin Marital status


Sexual orientation Disability

How participants described their ethnic origin

Number

White British 34

White European 4

Black Caribbean 1

Traveller/Irish Heritage 1

Prefer not to disclose 2

Did not answer 10


How participants described their religion or beliefs

Number

No religion 11


Jewish 2

Christian 19

Other 1

Did not answer 10

How participants described their gender

Number

Male 19

Female 22


Did not answer 10

How participants described their marital status

Number

Single 7

Cohabiting 4

Marrried 16

Separated 1

Divorced 5

Widowed 6

Prefer not to say 3

Did not answer 10

How participants described their sexual orientation

Number

Heterosexual 29


Did not answer 10

“Do you consider yourself to have a disability?”

Number

Yes 22

No 17

Did not answer 13

Appendix 5. NHS hospital-based reablement

Henderson Unit

The Henderson Unit opened in November 2014 using funds made available to help the local NHS system cope with the added pressure upon services during the winter months. These added ‘winter pressures’ are often caused by spells of cold weather which can particularly affect older people and adults with long terms conditions.

The Henderson Unit contains 24 beds in total. Referrals are made to the Henderson Unit by staff at the Norfolk & Norwich University Hospital (NNUH), when a person is considered to be medically fit for discharge but assessed as potentially benefiting from reablement support. The unit has a mixed-model approach, combining a social care, therapy-led model of reablement and also a medical model of rehabilitation. Many of the staff are employees of Norfolk First Support. Most patients arriving at Henderson Unit are there “to get a bit stronger before I go home”.

What care is offered?

Some people stay for a few days, others stay for a couple of weeks, depending on their needs. The ethos of care provided on Henderson Unit is reablement support, helping people to help themselves and adjust to the consequences of an event (such as a fall), an injury and/or disabling condition. A patient will be assessed on the ward at the main hospital site prior to arriving at the Henderson Unit. At this point, the patient is given a leaflet about the unit, questions answered and

the expectations of coming to the unit discussed.

Upon arrival, a personalised and tailored package of reablement will be put in place, according to the person’s needs. This could include a mix of physiotherapy, occupational therapy, speech therapy, nursing care and personal wellbeing. The average length of stay is about 10 days and between March 2015 and September 2015, 117 patients were referred onto Norfolk First Support for ongoing reablement at home.

What do patients say?

The unit staff hold a quarterly Patient & Public Involvement Forum which ex-service users and their families are encouraged to attend. Feedback is also gathered through a patient audit, and used by the staff to make improvements:

‣ “after a long hospital stay where I was mostly in bed it was great to have the support to become mobile again. I felt that the hospital looked after my medicals needs well but Henderson looked after my welfare needs”

‣ “It was a surprise when I arrived, bit I settled down and began to follow my helpers who were very good”


‣ “I had a pleasant stay on the Henderson unit. Staff always very nice and seemed very happy”

‣ “care was generally good. More physio - this seemed patchy”

‣ “I liked Henderson very much but I would have liked more therapy”

‣ “I personally was looked after very well. The food was good and although tiring, the exercises helped to keep me agile. Incidentally, I am 93”

The future of the Henderson Unit

The subject of a possible closure of the Henderson Unit was discussed at the July 2016 meeting of the Healthwatch 11

Norfolk Board and it was proposed that a watching brief be maintained on the impact of the closure upon readmissions and the percentage of people who remain living independently at home following hospital discharge.

On the 27th September 2016, an announcement was made by the Norfolk & Norwich University Hospital that it’s Governing Body had taken the decision to close the Henderson Unit from 21 October 2016.

The reason for the closure was cited as being a result of a lack of funds to continue to operate the unit. The hospital has been placed in ‘financial special measures’ since July this year and must make significant financial savings of around £20 million.

Three of Norfolk’s Clinical Commissioning Groups responsible for commissioning care for people living in the central area of the county (Norwich, South Norfolk and North Norfolk Clinical Commissioning Group) were reportedly approached by the hospital and asked to provide further funds for the unit. The request was declined, with the three organisations citing their own requirements to make significant savings as a barrier to provide funds for the unit.

On Wednesday 28th September the Chief Executive of Healthwatch Norfolk was interviewed by BBC Radio Norfolk on the subject of the closure of the Henderson Unit. On that day, neither the Norfolk & Norwich University Hospital nor the county council would agree to comment on the closure of the Henderson Unit. A statement on the closure was released by the hospital.

Healthwatch Norfolk anticipates that services and interventions such as reablement, which are ‘preventive’ in nature, will be a key feature of the forthcoming Sustainability and Transformation Plans , for which there 12

will be one overall plan for the Norfolk and Waveney area setting out the actions that need to be taken by the leaders of the NHS organisations in Norfolk, in consultation with patients and the public.

Minutes of the meeting of the Healthwatch Norfolk Board July 2016 11

http://www.healthwatchnorfolk.co.uk/wp-content/uploads/2016/04/Combined-set-Board-Papers-Part-I.pdf

http://www.healthwatchnorfolk.co.uk/reports-and-papers/sustainability-and-transformation-plan/ 12


http://www.healthwatchnorfolk.co.uk/reports-and-papers/sustainability-and-transformation-plan/

http://www.healthwatchnorfolk.co.uk/wp-content/uploads/2016/04/Combined-set-Board-Papers-Part-I.pdf

Appendix 6. Hospital discharge and delayed transfers of care

The information on delayed transfers of care has been sourced from the Adult Social Care Outcomes Framework (ASCOF) held in the Health and Social Care Information Centre . This indicator measures the impact of hospital services 13

(acute and non acute) and community based care in facilitating timely and appropriate discharge from all hospitals for all adults. This measures the ability of the whole system to ensure appropriate discharge from hospital for the entire adult population, and is an indicator of the effectiveness of the interface between health and social care services. How well Norfolk compares to its nearest neighbours on delayed transfers of care from hospital are shown below in Figure A6.1.

Figure A6.1. ASCOF 2C(1) All delayed transfers of care - average daily rate per 100,000 population 2014/2015

Health and Social Care Information Centre (http://www.hscic.gov.uk/catalogue/PUB18657) and NHS 13

England


http://www.hscic.gov.uk/catalogue/PUB18657

The overall Norfolk health and social care system performs reasonably well in comparison the majority of local authorities in it’s cluster but Figure A6.1 still shows however, that just over 10% of hand-overs of care in the county are delayed. That means in real terms that there can be delay for every one in ten individuals. The trends in delayed transfers of care are shown below in Figure A6.2 which reveals that at times the proportion of delays can drop down to 6% (from an 2015 average of 10%) but increase to as much as almost 17%). This suggests that there is the capacity (volume) and capability within our services for delayed transfers of care to be reduced however, the factors involved in contributing to that are numerous and could include, for example, the overall number of people waiting for a transfer of care and stresses or blocks in a particular service area which impact on these figures overall.

Noted: on average, one in every ten people leaving a hospital in Norfolk might experience a delay in the transfer of their care from one service to another.

Noted: the trends in delayed transfers of care show that the proportion of people experiencing a delay can be as high as 17% and as low as 6%.

Figure A6.2 ASCOF 2C(1) Delayed transfers of care in Norfolk patients - trend over time (April 2014 – Dec 2015)

Delayed transfers of care attributable to social care

When approaching delayed transfer of care to examine which component of the system might be contributing to the issue, it is interesting to note that Norfolk’s social care sector is responsible for less than 2% of delays (see Figure A6.3).


Figure A6.3 ASCOF 2C(2) delayed transfers of care attributable to social care or

jointly social care and the NHS (2014/15)

Noted: Less than 2% of delayed transfers of care attributable to social care.

It is also interesting to note that the health and social care system in Norfolk is performing slightly better – and consistently slight better - than the England average in respect of delayed transfers of care (see Figure A6.4).

Figure A6.4. ASCOF 2C(2) delayed transfers of care over time


Appendix 7. Commissioning and funding arrangements

Commissioning arrangements

In Norfolk, the accountable local authority officer for reablement service provision is the Executive Director for Adult Social Care Services, Norfolk County Council. The Assistant Director of Adult Social Care is the responsible officer for the oversight, development and management of the service structure.

Unlike many other adult social care services in Norfolk, the reablement service is not a ‘commissioned service’. It is led, managed and delivered in-house as opposed to being tendered out and contracted with a provider organisation. Managers and teams within the Norfolk First Support service are employees of the county council. Many local authorities have an in-house reablement service , to ensure a good 14

understanding of the costs involved before outsourcing.

In Norfolk, those people who are to deemed to benefit from a reablement service may receive up to six weeks of reablement free of charge (this is not always the case elsewhere in the county). The public can find information on Local Authority services and care on the Norfolk County Council's website . There is also information on those services which are free of charge following hospital

discharge, including reablement, equipment and adaptations, at NHS Choices .

Funding for reablement

When we met with the Executive Director for Adult Social Care, we were told that in Norfolk reablement services are 50% funded by the county council and 50% funded by the county’s five Clinical Commissioning Groups.

The total budget that Norfolk’s Adult Social Care Committee allocated to Norfolk First Support for 2015-2016 was £3,923,000 (£2,823,000 for the year plus an additional investment of £1,100,000 in November 2015). The actual expenditure on Norfolk First Support reablement in the financial year 2015 - 2016 was £2,558,000. Gross expenditure on reablement services in Norfolk in 2015-2016 was £6,728,000 million jointly funded between Norfolk County Council and the five Clinical Commissioning Groups.

As a preventive service, reablement services have been included within the planning for Norfolk’s Better Care Fund which contains an element of funded protection for adult social care services, payable by Norfolk’s CCGs. Publicly available data on the actual financial contribution of CCGs to


social care


https://www.norfolk.gov.uk/care-support-

http://www.nhs.uk/Conditions/social-care-and-support-guide/Pages/local-authority-funding-for-care.aspx%22%20%5Cl%20%22reablement

reablement services could not be found.

Norfolk spends more on residential packages of adult care compared to other similar local authorities (residential care is relatively expensive type of care provision). Reablement services aim to promote independence and reduce admissions to permanent residential care. There is strong evidence to suggest an increased investment in reablement type service could reduce spend on residential care.

Within the Re-imagining Norfolk consultation document, the proposed budget changes for reablement were to spend more on reablement services with the aim of achieving £3,200,000 in the longer term.

A 2% council tax social care precept was adopted by Norfolk County Council following a vote by councillors on 22 February 2015 and a large public consultation exercise to gather views and opinions.


Appendix 8. Definition of reablement, unplanned and rehabilitaiton needs (Source: D.Forder & K.Brady, Norfolk County Council)

Reduce acute bed stays Trained CQC-‐registered Managers

Trained, skilled, CQC-‐registered staff Short-‐term intervention up to 6 weeks

Feeds into assessment process Restore daily living skills, physical capabilities

& confidence at home Prevention – independence, confidence to

remain at home Provision of equipment

Safeguarding

Led by skilled therapists* Treatment to facilitate recovery

Can reverse many disabling conditions Restore physical, sensory & mental capacities Inpatient units, outpatient settings & patient’s

own home Provision of equipment/prosthetics

Delivered by registered staff or delegated to assistants

Reduces ambulance response CQC-‐registered staff with enhanced training to deal with unplanned requirements such as falls Non-‐assessed urgent, unplanned intervention One-‐off intervention Falls

Non-qualified staff Functional assessment

Formal assessment process Maximise independence

Support hospital discharge

Prevent hospital or residential admission

Therapists: Doctors, nurses, occupational therapists, physiotherapists, dieticians, psychologists, podiatrists, speech & language therapists, social workers

Reablement Social Care Services

Unplanned Health & Social Care

Crisis Support/Rapid Response Rehabilitation

Health Services





To contact Norfolk First Support tel. 0344 800 8020

Our promise to you

The Norfolk First Support team will always:

• Show their identity cards when they visit you for the first time

• Be dressed in the team uniform

• Behave professionally and politely and respect your privacy and dignity

• Ensure you receive prompt, appropriate support and notify you if there is a delay

• With your agreement and if appropriate, make ongoing referrals to other support

agencies

You can contact our Customer Service Centre on 0344 800 8020

• For social care information and advice

• To find out about the support we can offer

• To access services

• For leaflets in different formats or languages

• For urgent help at any time – not just office

hours

Email [email protected]

Minicom 0344 800 8011

Mobile phone text 60046

www.norfolk.gov.uk/firstresponse

Norfolk First Support is monitored, regulated and

inspected by the Care Quality

Commission



To contact Norfolk First Support tel. 0344 800 8020

Your needs are at the heart of our service and our priority is to help you remain

independent in your own home. We can provide assistance with short or long term

needs, onward referrals, advice and information to help you choose the right help

or service for you.

This service provides intensive support in your own home for up to six weeks. If,

for example, you have been in hospital and need support when you return home,

Norfolk First Support is there to help you regain as much independence as

possible.

After an initial assessment of your needs, the Norfolk First Support team will work

with you to develop a personal plan designed to help you regain the skills and

confidence to remain independent in your own home.

Case Study

Cyril (76) was taken ill and spent three weeks in hospital. When he came home

Norfolk First Support staff helped him to regain his independence, supporting him

as he went about everyday tasks such as making himself a drink, preparing his

own lunch and making his bed. Cyril was soon feeling confident again and is now

living independently – preparing all his own meals, bringing in coal for his fire and

enjoying a spot of gardening. He’s even been lending a helping hand to his

neighbour

Who can get assistance from Norfolk First Support?

Adults living in Norfolk

How much does it cost?

We will discuss with you how much Norfolk First Support care you need and if you are eligible for this service, then it is provided free for up to six weeks. Our aim is to help you remain independent in your own home avoiding costly, long-term support.

Appendix 10. Outcomes of reablement

Supporting people to regain skills lost due to illness or injury in order maintain their independence in living at home is a primary goal of reablement. The measure of reablement outcomes is through use of two-part indicators (Adult Social Care Outcome Framework) that capture the collaborative work of social services and health staff and services commissioned by joint teams, as well as adult social care reablement. The rationale for a two-part measure is to capture the volume of reablement offered as well as the success of the reablement service offered. The measure includes social care-only placements: • Indicator ASCOF 2B(1) - The proportion of older people aged 65 and over discharged

from hospital to their own home or to a residential or nursing care home or extra care housing for rehabilitation, with a clear intention that they will move on/back to their own home (including a place in extra care housing or an adult placement scheme setting), who are at home or in extra care housing or an adult placement scheme setting 91 days after the date of their discharge from hospital.

• Indicator ASCOF, 2B(2) - The proportion of older people aged 65 and over offered reablement services following discharge from hospital.

Offer of reablement services

It seems to make sense to start with the proportion of older people actually offered reablement services following discharge from hospital, which for Norfolk is slightly less than 3% (2014-2015 data) - see Figure A10.1 – and just slightly above the average for Norfolk’s nearest neighbours. It is interesting to note that our local services are broadly aligned to the regional and national picture and that the proportion of older peole being offered reablement services has effectively doubled since 2010-11 (see Figure A10.2).

Figure A10.1 ASCOF 2B(2) proportion of older people aged 65 offered reablement services following discharge from hospital 2014/15


Figure A10.2. ASCOF 2B(2) proportion of older people aged 65 offered reablement services following discharge from hospital trend over time

The trend over time reveals that the proportion of older people in Norfolk being offered reablement services doubled between 2010-11 and 2014-15 (from 1.2% to 2.8%). In common with the England average, just less than 3% of older people aged over 65 years in Norfolk are offered reablement services following discharge from hospital. Looking at the proportion of older people in Norfolk who were still at home 91 days after discharge from hospital in the year 2014-2015, we can see that 84% of people were still living at home and had not been readmitted to hospital (see Figure A10.3).

Figure A10.3 ASCOF 2B(1) proportion of older people aged 65 and over discharged from hospital still at home 91 days after discharge 2014/15


In terms of avoiding a re-admittance to hospital and continuing to live independently at home after discharge from hospital, Figure A10.3 shows that over 84% of older people do this. Also, we can see from Figure A10.4 that Norfolk has performed well in this indicator over a period of years between 2010-2015, on average doing better than most of its nearest neighbours, the East of England average and the England average. A times, the yearly figure reaches almost 90% and we can see that the best performing local authorities in Norfolk’s cluster are reaching this mark (i.e. Nottinghamshire and East Sussex).

Figure A10.4 Trends in the proportion of older people aged 65 and over who were still at home 91 days after discharge from hospital (2010/11 - 2014/15)

In 2014-2015, 84% of older people aged 65 years over remained living independently at home 91 days after being discharged from hospital. On average, services in Norfolk perform well in terms of supporting older people to remain living independently at home after discharge from hospital, when compared to its nearest neighbours, the East of England and England.


using reablement services: feedback from older people in ... · using reablement services: feedback...

Documents