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& Reablement Team

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Discharge Home to Assess Service

A live-in care support pathway from hospital to home, promoting independent living

The Agincare Live-in Care service is rated Good by CQC and works with over 20 local authorities throughout England and Wales. We know from experience that each local demographic and geography presents its own combination of challenges and opportunities to commissioners and providers.

Our Discharge Home to Assess Service provides a short term intervention using the live-in care model. It enables safe and timely discharge from hospital; a home based comprehensive assessment and support to achieve re-enablement outcomes for a short period determined by the commissioner. Partnership working across acute and community services is an essential ingredient to achieving the desired outcomes for patients.

Working with commissioners like Portsmouth City Council, we have achieved evidence and outcome based commissioning that flexes with demand. Our service steps in when normal social care commissioning is just not enough, when someone needs more than domiciliary visits or when local providers simply do not have the capacity to deliver a more comprehensive service.

Discharge Home to Assess and Reable Testimonial

Both Dad and I were very impressed with Lisa who came and visited my father in hospital to assess his needs. Throughout the time she spent with Dad she was so empathic, patient and brilliant at drawing out information from him with such ease and showed a deep understanding of the difficulty that he was having coming to terms with losing his independence. She gave both Dad and I confidence in the standard of care we could expect from Agincare and was one of the main reasons we chose your company.

I would like to thank you for the sensitivity that you have shown to my father and to me his daughter in arranging full time live in care for my father.

Both Dad and I were very impressed with Lisa who came and visited my father in hospital to assess his needs. She spent 90 minutes talking to him, his nurse and myself. Then came and visited his home. To me this demonstrated that she was not only assessing how he was physically and medically but to genuinely get to know him in order to match him as closely as possible to a carer.

Throughout the time she spent with Dad she was so empathic, patient and brilliant at drawing out information from him with such ease and showed a deep understanding of the difficulty that he was having coming to terms with losing his independence. She gave both Dad and I confidence in the standard of care we could expect from Agincare and was one of the main reasons we chose your company. You were able to provide a carer so swiftly meaning that the ambition of my father to get out of hospital was met less than a week from interview with Lisa. Emson, in the words of my father is "a gem". I know that being a carer is his job but he brings to it such a gentleness, respect, encouragement and genuine "care" for my Dad at all times. I know that he is there for Dad and this means so much to both of us.

Neither Dad or I want me to be the "carer". I want to always be his daughter and he my father, Emson enables that relationship to continue. It sounds rather selfish, but it enables me to continue with my life knowing that Dad is cared for and safe. One hears so much about the care of the elderly (mostly bad) but this is one person who is very positive about the care received to date.

Please feel free to share this feedback with the people involved, the customer care people on the phone/backroom people who also made the whole thing from the time I called to the day Emson arrived a smooth and stress free experience.

Once home our support worker was able to build a good working relationship with SP. It took some time for her to build SP’s confidence in carrying out tasks around the home, but with the support of the PRRT team and gentle prompting and encouragement from our care worker SP began to come on in leaps and bounds. It was a great achievement when SP took a shower for the first time since being home. The pride in herself and the pride the care worker felt was brilliant to see and well justified. SP’s skills and confidence continued to grow. The support worker was able to spend greater lengths of time away from SP to encourage her independence and prevent over attachment or reliance on the support worker. It was a great achievement when SP spent the first night without support. It has been fantastic to be able to offer a service that could meet SP’s needs so effectively. As SP’s dedicated support we could work with her at a pace and level that suited her needs without having conflicting...

SP had spent a long time in hospital. She had originally been admitted due to a fall where she fractured her neck of femur. SP went from the ward to the rehabilitation unit where unfortunately she fell and fractured both her wrists. This then required a further stay on the ward and then more time on the rehabilitation unit.

Understandably SP was nervous of returning home, was still a falls risk and had become unable to self-manage her care or daily living tasks. SP hated being on her own and was nervous of remaining at home without support. There were also some concerns around fluctuating capacity. It was agreed that the best thing for SP would be to return home with a 24hr reablement support worker to assess her abilities at home and work on increasing her confidence and abilities to determine what level of ongoing support would be needed. Or indeed whether remaining at home was a viable option.

Working with the PRRT team our support worker was immediately able to coordinate the necessary health care professionals to work with KS to start to address these issues. KS engaged well with our support worker and other health care professionals and his confidence and abilities grew. With the assistance of our support worker KS regained full daily living task skills. His mobility improved and he was confident to manage this around the house. We agreed to extend the support we were offering KS from 14 days to 21 days in order to continue to work with him around the medication issues. At the end of the 3 weeks KS was still working with the GP and adult social care in order to manage his medication misuse. KS also decided to make a move into sheltered accommodation so he could continue to live independently, but still have a level of support available. Undoubtedly without the support of the reablement support worker on discharge it would not have been identified so quickly...

KS was admitted to hospital following a fall and subsequent hip pain. KS had a pre-existing condition that caused him to require a frame to walk with. He had a history of self-neglect and previous alcohol misuse issues. KS lived in shared accommodation and there was a chance he was going to be evicted due to issues around his memory and causing potential risks to the other tenants such as leaving the cooker gas on.

On discharge from the hospital it was identified that KS required support to regain his daily living skill tasks, increase confidence in his mobility and to assess his cognitive abilities within the home environment.  KS returned home with a reablement support worker assisting him.  Once home with KS our support worker quickly identified that there were issues around medication misuse. KS was showing signs of being overly reliant on pain relief medication and it became evident that this was causing a large amount of his confusion and falls risk. 

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