Recovery at home is all in day's work for Hayley

by Hayley Oakley, Home First social care assessor

I work for Home First in east Kent as a health and social care assessor. We are a joint health and social care wraparound service between KCHFT and Kent County Council, with an aim to get people back to independence after a hospital stay, in their own home.

My team is multi-disciplinary, made up of support workers, therapists, nursing and medical staff. We visit people on the day they are discharged from hospital and then after 72 hours at home.

Our first job is to get to know people. Understanding their situation and where they were before their hospital stay is important. We then work together setting goals, before putting together a package of care.

The package is individual to the person. It could be a regular support carer in the home, medical equipment, nutritional advice or an external referral to a charity, like Age UK.

For example, Joyce, who left hospital after a fall this year. We worked with her on what we call, ‘enablement goals’. One of these goals was to get more mobile, so she could dress herself.

We arranged bed levers, perching stools and grab rails, as well as physical therapy. We then worked with her, gradually reducing visits over a few months until she reached independence.

For every service user, I am responsible for processing their assessment through our system. The beauty of our new service is that people will get the support they need much faster, as there aren’t multiple referrals to separate organisations.

I also act as a middle-person, referring people on to other, longer term solutions. Margaret, for instance, had a hospital stay after an illness and was discharged home with support from Home First.

Our team decided she would need longer care, which meant we carried out a care needs assessment for social care. She might not have gained independence with Home First, but we got her the right help and kept her out of hospital.

Day-to-day I also have the responsibility of swooping in to help people with anything they need. Those involved in a person’s care have two meetings every day where issues are raised. I take down details and speak to partner services to arrange assistance.

Recently, one service user’s husband had food poisoning, meaning she didn’t have her usual support. I called for urgent care to see him and our support workers stepped in for interim care as he recovered.

Each step means we catch people at every hurdle and get them back on the right path to recovery. Since we started in December, 62 of the 114 people we have helped are now independent.

Because we are effective, we build trust with families. Many stay in touch with us long after their loved ones are back on their feet.

Being part of a service that works, is revitalising and it makes every single day worthwhile.