We inspected Portsmouth Rehabilitation and Reablement Team (ILS) (known to the people who work there and use it as ‘PRRT’) on 18, 19 and 20 January 2017. The first day of the inspection was unannounced which meant the service did not know we were coming.PRRT is an integrated health and social care service. The registered provider is Portsmouth City Council, although the service comprises a partnership between Portsmouth City Council and Solent NHS Trust. PRRT provides short term support for people who may need care, equipment or rehabilitation. The team includes nurses, social workers, physiotherapists, occupational therapists and rehabilitation assistants. The majority of care is provided to people in their own homes and focuses on supporting people to remain at home for as long as possible and preventing their admission to hospital.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People who used the service said they felt safe. Staff had received safeguarding training and could describe the forms of abuse people might be vulnerable to and how to report it appropriately. Recruitment procedures at the service were robust.
Risks to people had been assessed and managed. People were supported to take positive risks when the benefits outweighed potential adverse outcomes.
Staff who supported people to take their medicines had received training. Records showed medicines had been administered as prescribed.
There had been issues at the service with high caseloads; staff told us they had felt under pressure as a result. People told us they received the support they needed and never felt rushed by staff. The registered manager and service manager were in the process of re-evaluating the capacity of the service and recruiting more staff.
Records showed staff had access to training to support them in their roles. They also received regular supervision and an annual appraisal. Staff we spoke with said they felt supported by management to do their jobs.
People experiencing problems with their mental capacity were assessed in line with the Mental Capacity Act 2005 by social workers in PRRT. Other staff described how they gave people living with dementia choices to help them make day-to-day decisions.
The service supported people to meet their nutritional needs; we saw this often focused on building people’s independence to cook and prepare drinks for themselves.
The service worked in partnership with other acute and community health and social care providers to help people meet their wider health needs.
People and their relatives told us PRRT staff were kind and caring. They also described staff as friendly and said they looked forward to their visits.
Records showed, and people told us, they set their own rehabilitation goals. Care plans focused on supporting people to regain and maximise their independence.
The service protected people’s personal information and respected their confidentiality.
People’s care plans were person-centred. They were supported by a multidisciplinary team of healthcare professionals within PRRT; this included the provision of specialist equipment or exercise regimes depending on people’s assessed needs.
People’s progress with their rehabilitation goals was assessed on a daily basis by PRRT at handover meetings and weekly at multidisciplinary team meetings.
Efforts were made by PRRT to arrange ongoing care packages for those people who needed them and to ensure a smooth transition to new home care providers.
Complaints were investigated and responded to appropriately. Compliments were used by the registered manager to motivate staff in the team.
Feedback from PRRT staff about the registered manager and other managers at the service was positive. People and their relatives thought the service was well managed.
A system of safety and quality monitoring was in place at the service. Various aspects of the service were discussed at weekly and monthly meetings within the team, and with the service’s commissioners and stakeholder organisations on a monthly or bimonthly basis.
People were asked to feed back about their care experience with PRRT on surveys they were asked to complete when they were discharged. We saw almost all respondents were very complimentary.
Staff were asked to share ideas and suggestions to improve the service. These were discussed at monthly staff meetings.
Staff told us they thought the different teams of health and social care professionals that made up PRRT worked together to support people. They could explain the vision and values of the service and all told us they enjoyed their jobs.