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Assessment and Independence

The assessment and independence service’s primary purpose is to ensure that the right social care support is provided to local people. They assess what each person’s needs are and agree what can be done to maintain or improve their independence where possible. The services provided can range from long-term care and support in a person’s  home, or in a nursing or residential home, through to short-term reablement services aimed at helping people discharged from hospital or being unable to cope becoming independent again. 

What have we done over the past year?​

We asked people what they from the assessment and independence service.

Key areas pinpointed are detailed below: 

 

YOU SAID

We value being independent and living together and remaining in our home for as long as possible 

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WE DID

We want to support people to be independent and to live in their own homes for as long as possible. Staffing our teams appropriately is an ongoing challenge and therefore we have invested new ways of working. One of the most effective approaches is ‘single handed care.’ This is the use of equipment designed to reduce the need for more than one staff member to provide support.  Care that required two members of staff previously can now be provided by one person. This has strengthened the ability to provide care to a greater number of people, reducing hospital delays and enabling people to get the support they need at home.
 

In 2018/19 1,294 patients were seen by the emergency response team.  The team’s focus is to divert people from being admitted to hospital.  16% were given information and advice and signposted to other services, 45% went home with a package of care and 11% went home with no services. A real achievement.
 

A number of other measures have also been developed to support people live independent lives in places they feel most comfortable. These include; 

  • Continued development of integrated adult services via the Dudley Vanguard, (where services across health and adult social care work closely together) promoting greater independence and value keeping more people well.

  • Pushed our prioritisation of crisis intervention to support people whose circumstances have suddenly changed and have substantially increased investment in reablement and preventative services – giving people greater opportunity to enhance and in cases recover their skills for daily living

  • Maintained a focus on managing emergency responses where trained staff are available in hospital to provide an emergency response and in cases can help avoid admissions to hospital where this is achievable and appropriate

YOU SAID

If I need to go into hospital I need to be sure I will have your help to return home safely with the right support in-place so I can stay in my home

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WE DID

In order to help people return safely to their own homes we have continued to working closely with health partners. We are actively reducing delayed transfers from hospital into care by improving the discharge process and using new and innovative ways of assessing people after they have been declared medically fit.  In 2018/19 our discharge team supported 428 people and enabled them to safely leave hospital sooner into a ‘step down’ reablement unit where intensive support is still available.

 

Here people are able to recuperate, receive additional support and to be prepared to return to their own homes. The number of delayed discharges from hospital has improved from being one of the worst to one of the best in the country. Appropriate aftercare following discharge is vital and we are monitoring how many people remain out of hospital once discharged to ensure that the care provided is effective.

 

The assessment and independence team and access and prevention teams work closely to ensure that if a person needs any adaptions to their home this can be done quickly to support the person’s return to full independence. Additional care packages are also available to help support people once they have returned home and these are tailored to the individual’s specific needs.

YOU SAID

I want feel like I am in greater control of the care I receive.

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WE DID

We want people to have more control over the care that they receive. In order to achieve this the intention is to increase the number of people who receive a personal budget. People in receipt of a personal budget are able to decide how best to allocate their budget to suit the own needs.

 

In 2018/19 the number of people who received a personal budget to help manage their social care needs was 2,910. This figure is similar to previous years but the efforts are being made increase the numbers of people in control of their own personal budget and give them greater choice in choosing their own care. To strengthen support for those who wish to use their personal budget to employ a personal assistant we are continuing to look at ways of increasing the numbers of personal assistants who can provide such support locally.

News from 2018/19

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Over the course of the year the assessment and independence team have successfully worked with our NHS colleagues to keep numerous people out of hospital where an admission would have been inappropriate. When an admission to hospital is required the service then helps people who are ready to be discharged by ensuring somewhere safe and appropriate to leave hospital. Some case study examples are included below: For privacy names have been changed.
 

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Timely hospital discharges

Case study – Harriet
Harriet was admitted to hospital with a chest infection causing shortness of breath. She had already been seen by her GP who prescribed antibiotics but there was no improvement. Harriet had advanced dementia and was unable to verbally communicate her wishes but was able to follow instructions.
 
Her husband visited the hospital daily and assisted with feeding her. A ward assessment was completed and through the work of the discharge impact team based at the hospital Harriet was then able to return home quickly. She was assessed as needing four care and support calls each day which reduced after a short time to two calls. Harriet’s husband is now managing between calls and Harriet has settled into a routine.

 
 

Dudley Dementia Action Alliance

Developing dementia friendly communities can help people with dementia and their carers to live a good quality of life.

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A good quality of life is seen by people with dementia as being able to live as independently as they are able within their chosen local community and where contact with members of their local community (whether the corner shop owner, the bank, local restaurant or their carers’ workplace) is understanding and supportive of their needs.

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The Dudley Dementia Action Alliance aims to establish dementia friendly communities across Dudley Borough. The have been working on building on a strong commitment locally to improve the quality of life for people living with dementia and their carers. The group has identified a range of areas for action from art and culture through to transport. Through these actions Dudley Borough has been recognised by the Alzheimer Society as working to become dementia friendly. 
 

Dudley Dignity Charter

Dudley Centre for Inclusive Living and Disability in Action with the support of Dudley Council and Healthwatch Dudley launched a campaign to find out what dignity in care means to local people.


The two organisations have spent over a year gathering information from individuals and local groups about how we can improve the way people are treated.


The two voluntary groups have used this information to develop a Dignity Charter The charter is a list of top ten actions, which includes making sure people are included when making decisions, making sure people can understand and be part of a conversation and treating people fairly.  The Dignity Charter will be released shortly.

The Ideas Alliance

The Ideas Alliance is a social enterprise aimed at promoting the benefits of collaborative, strengths-based and community driven approaches.  The Ideas Alliance were asked by Dudley’s Health and Wellbeing Board to find out what Dudley people thought should be key priorities for the Health and Wellbeing Board and Council.  From talking to Dudley residents and a wide range of community groups one of the key messages was the need to address social isolation and loneliness.


“Many people told us of their sense of loneliness and lack of purpose being trapped indoors”

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The issue of loneliness and social isolation has been acknowledged by the Council and Adult Social Care as an area for action and our response is featured on the Assessment and Prevention pages
 

For more information about the findings of the project please go to: http://ideas-hub.org.uk/ideas-hub/for-the-love-of-dudley/

Future working for assessment and intervention

 

Assessment and Independence have identified four key priority areas to focus on in 2019/20:​

  1. To pilot the redesign of the reablement service and evaluate its success going forward

  2. Identify the resources required to ensure Improved Better Care Fund (iBCF) funded schemes are sustainable in the future

  3. Maintain very low delayed transfer of care levels by increased partnership working with hospital and health staff so that everyone is discharged appropriately, safely and quickly

  4. Successfully implement an approach where the focus is on what the client can achieve rather than what they can’t manage

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