Assessment and Independence

The assessment and independence service works to support local people to get the right social care support they need. This can be shorter term intensive ‘reablement’ services aimed at getting people who have been ill, or in hospital back to successful independent living, or more medium or long term care and support either at home, or in a residential setting.

What have we done over the past year?


We want to remain independent and together in our own home for as long as possible.

We are working hard to increase support available to people at home and support to  help people choose the right kind of  support and care they need.  We are committed to increasing the numbers of people supported by ‘early intervention’ and ‘prevention’ services to delay the need for longer term care and support wherever possible.


Alongside this work, the council’s urgent care team is working to reduce avoidable admissions into hospital by developing better community-based preventative services. 1261 episodes of urgent care support were provided in the community.  This work has successfully reduced the number of admissions to hospital.


The hospital discharge team has continued to work effectively with partners from across health and social care.  This team have supported 2,523 people to safely leave hospital as soon as they are ready.  Our measure of success in supporting people to leave hospital is how many are still at home after 91 days following discharge.  The proportion of people in 2017-18 has remained high where 84% of people were still at home after 91 days.


I want to feel in greater control of the care I receive.

A personal budget is an agreed amount of money that is allocated to a person, by the council following an assessment of the person’s  care and support needs. The money is to be spent on care and support services. These services are decided upon and controlled by the person themselves. They are totally in control.


n 2017-18 the number of people who received a personal budget to help manage their social care needs was 2910.  This figure is similar to previous years and demonstrates the commitment to giving people choice and control over their social care needs.  To strengthen support for those who wish to use their personal budget to employ a personal assistant the council is exploring ways of increasing the numbers of personal assistants who can provide such support locally.


We continue to prioritise crisis intervention to support people whose circumstances have suddenly changed and have substantially increased investment in reablement and preventative services. The aim of strengthening reablement  and preventative service is to give people greater opportunity to enhance and recover their daily living skills.


If I’ve got to go into hospital I want your help to return home safely and have the right support for me to stay at home.

The introduction of new working practices in September 2017 has seen a very significant reduction in delayed discharges from hospital.  Adult Social Care is on course to meet it’s target  with a considerable reduction to delays in people being discharged from hospital.

This has been achieved through a range of improvements enabling people to return home sooner including:


  • Improved emergency response where trained staff are available in hospital to provide an emergency response and in some cases can help  avoid admissions to hospital

  • Improved patient assessment processes that gather clear evidence of support needs to enable an accurate assessment of the long term care support required

  • Improved discharge flow through providing additional assessment and screening capacity (alongside increased reablement care hours in the community) have enabled the discharge team to increase hospital discharge

  • Improved ways of working using equipment designed to reduce the need for more than one staff member to provide support. ( called single handed care ). This means staff can provide care to more people, helping reduce delayed hospital discharges


people received a My Assessment and Support Plan Assessment (MASP)


reduction in hospital discharge delayed days  from August 2017

News from 2018

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.

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.

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”

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: