Leaving hospital: experiences of those needing reablement support at home or intermediate care

As part of our focus on social care, Healthwatch Calderdale and Healthwatch Kirklees looked at people's experience of intermediate care and reablement services following discharge from hospitals in Kirklees and Calderdale.  Pathways to intermediate care and reablement have recently changed and commissioners were interested in testing out how well things are working for people.

From 19 February - 19 April 2024 they spoke directly to people accessing intermediate care or reablement services.  They visited all intermediate care settings in Kirklees and Calderdale to speak to people receiving care there.  They were given access to phone numbers for people receiving reablement (or their carers) so they could speak to those people at home.

We also asked about the discharge process in hospitals.

Discharge planning in hospital 

• Not feeling involved in discharge planning. 
• Being discharged to a place that didn’t meet their needs. 
• Not feeling ready to leave hospital. 
• Feeling of a chaotic, mismanaged, poorly communicated discharge, resulting in errors and oversight.
• Lack of information about the service being discharged. 
• Not being given written information about who to contact if they needed further advice or support.

Patients largely praised the care and treatment they received in hospitals but noted the strain on staff due to the busy environment, understanding, and excessive demands. 

Intermediate care settings

• Plenty of praise for the care and support being offered in intermediate care settings. Staff interactions with patients were friendly and respectful. 
• The quality of physiotherapy was highlighted as positive.
• There were concerns about the number of staff in all settings, with patients feeling the staff were over-stretched and that this impacted the quality of care. 
• Patients wanted clearer information on how long their stay was likely to be.

Reablement at home 

The majority of people receiving reablement felt the care they received has helped them to be independent.  There was praise for the quality of care, skill, and kindness of staff but there were numerous suggestions for how the service could be improved, including:

• Providing reablement for longer, or providing a more flexible package of care. 
• Providing reablement in a timely way, not relying on family to bridge the gap until the service is available. 

Overall

There is inequality of access to reablement and intermediate care beds for ethnically diverse people. Healthwatch are undertaking an additional piece of engagement to understand this better.

Recommendations were provided to Hospital Trusts, Intermediate Care Settings and Reablement Services.  Action plans have been developed by partners to meet the recommendations.