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Before you leave hospital

The Hospital Social Care Team is based within the hospital. Ward staff may make us aware that you might need our support to leave hospital safely. We will be working with you whilst you are in hospital to provide a service to help with your discharge from hospital.

Being in hospital can be a daunting and frightening experience which can leave patients and their families unsure about what is happening. Whilst you are in hospital, the Hospital Social Care Team are able to support with a range of personal, emotional and practical matters.

To achieve this, we will be talking with you and those important to you to identify what matters to you and what support you feel you may need on discharge. The aim is to help you leave hospital as safely as possible when you are ready to be discharged.

In order to assess what support you need, we will listen to your views and those of other professionals and any persons important to you. We want you and the people that matter to you to work with us in a timely manner to ensure that you do not remain in hospital any longer than is necessary.


A hospital occupational therapist will consider whether the Reablement Service is a service that may be able to help your recovery at home. If they feel that it could, with your agreement, they will complete a referral. A practitioner from the Reablement Service will visit you on the ward, discuss your circumstances with you, your family or representatives, and the hospital staff caring for you and decide whether the Reablement Service is right for you.

The Reablement Service helps individuals who have lost some of their independence due to illness or disability and seeks to support them to do as much for themselves as possible. The service will enable individuals to try to achieve this by providing support at home for a short period, on daily activities where you need help with to improve your ability to do tasks such as:

  • washing and dressing
  • food preparation
  • getting in and out of bed
  • going out
  • managing your medication.

The service may involve a range of different professionals and practitioners which include reablement assistants, reablement officers, supervisors, occupational therapy assistants and occupational therapists who help individuals to build their confidence, which sometimes involves learning how to do daily activities differently. The service will also explore if any aids, adaptations or technology that could help.

If reablement has worked well, you may find you can manage on your own or only need a little support. If you continue to still need longer-term support, a social care practitioner will complete a social care assessment to explore ongoing support.

If the hospital occupational therapist decides that reablement is not suitable for you, they will notify the Hospital Social Care Team and a social worker or social care practitioner will visit you on the ward or at home to carry out a Social Care Assessment.

The assessment will involve having a conversation with you about what things you can do for yourself, your interests and ambitions and looking at those daily activities that you may be having difficulties with. These may include: 

  • how you manage to get dressed
  • food preparation
  • social activities
  • running of your home
  • other activities that matter to you.

Your assessment may also identify that you do not meet the criteria for social care support or that you need support to find alternative accommodation. We will explore all of the support options available to you.

Services we may identify

  • Advice and support to maximise independence
  • Advice and support for carers/family members
  • Advocacy support
  • Appointee referral if required
  • Domiciliary Care (personal care)
  • Day Care/Social Activities
  • Advice about meal provision at home
  • Advice on how to manage daily household tasks
  • Referral to Age UK/Community Services
  • Residential and Nursing Home information
  • Referrals for financial assessments

Community Recovery Service

The Community Recovery Service offers intermediate care support for patients leaving hospital in their own home who have a new or increased care need, to enable you to return home confidently from hospital following your treatment or an accident / injury or illness.

It is a free, short-term support service, for up to 6 weeks and is part of the Discharge to Assess Pathway 1 offer in Warwickshire.

The length of the service you receive will be dependent on your needs. Many patients finish using this service before 6 weeks as some people recover more quickly. After the period of recovery and assessment, if you need ongoing care and support at home, you may have to pay a contribution towards this service.

The service will support you with a blend of home care and / or therapy input to support your recovery and help you to manage independently or reduce your care needs.

The short-term service will comprise initially of up to 2 care workers from an independent home care provider, visiting you at home daily. The support you receive may increase or decrease during the period of time that you are with the Community Recovery Service, depending on your individual support requirements.

The team consists of a variety of healthcare and social care practitioners with support from home care agencies. As a multi-disciplinary team, we work together to assist you to get back to your previous level of independence.

Do I have to pay for my care?

To identify what contribution you have to pay towards your care support, you will receive a financial assessment from the Financial Assessment and Benefits Advice Team (FABA) who will contact you directly to arrange this.

The assessment usually takes place within your own home or care setting, online or over the telephone. As part of the financial assessment, we may also give you advice on welfare benefits that you may be entitled to. The financial assessment will identify the amount you are able to contribute towards the cost of your service.

Your information rights

To see how we use your personal data and what your information rights are, please read our overall customer privacy notice.

This includes the contact details you’ll need if you have a complaint about your information rights.

For general enquiries, contact Warwickshire County Council customer services on 01926 410410.

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