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Portsmouth Better Care Voluntary & Community Sector Reablement projects 2015-16

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Reablement is a personalised and responsive process, delivering a range of services and interventions, which enables people to maximise their potential and quality of life and live as independently as possible for as long as possible.

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Page 1: Better care - reablement brochure

Portsmouth Better Care Voluntary & Community Sector Reablement projects

2015-16

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Introduction

Reablement is a personalised and responsive process, delivering a range of services and interventions, which enables people to maximise their potential and quality of life and live as independently as possible for as long as possible.

Reablement forms a key part of Better Care in Portsmouth, the partnership programme joining together health and social care. It supports the commitment to reduce emergency admissions to hospital, provide health and social care in the community, and reduce the extent of social isolation amongst older people. Better Care has a preventative ethos and will look at where interventions can take place earlier to prevent a person’s health deteriorating to help them stay well and independent as long as possible – and reablement services are vital in achieving this

In this directory you will find details of the reablement schemes in Portsmouth funded by Better Care during 2015-16.

The projects are a mix of some that have already been running in the community improving the lives of service users and pilot projects that will test new ideas and ways of working.

Please use the contact information in this directory to make referrals to the services.

For more information about the reablement grant programme please contact the Integrated Commissioning Unit on 023 9268 8374 or email [email protected]

For more information about Better Care visit www.portsmouth.gov.uk and search better care.

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Portsmouth Support at Home Service

The Portsmouth Support at Home Service provides free, low-level practical and emotional support to help people remain safe and independent in their own homes after a crisis. The British Red Cross helps patients resettle in their home after being discharged from hospital and supports them to regain their independence. They also help people avoid stays in hospital.

The service is available on a short-term basis to Portsmouth residents living in postcodes PO1 to PO6.

A member of the Red Cross will assess the individual’s needs as soon as possible following the referral. The service offered is based on need, and the length of the support can vary from 72 hours to four weeks.

Generally, volunteers or staff will visit the patient once a week for about an hour or make contact by telephone. Trusted Assessor-trained staff help ensure that home is safe after hospital discharge, that it’s at a comfortable temperature and that there is sufficient food.

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All volunteers and staff take part in a comprehensive training programme and undergo personal interviews and DBS checks. They have good interpersonal skills and an understanding of the differing physical and emotional needs of our service users.

The Red Cross helps individuals regain their independence with a service that is person-centred and tailored to each individual’s needs and goals. Some examples of what they offer include:

• help resettling at home safely after hospital discharge

• confidence building and reablement

• help achieving goals to live independently

• accompanying on trips (e.g. shopping, community activities)

• support by phone and linking to other agencies for additional support

• essential shopping

• bereavement support

• loaning of wheelchairs and other mobility aids

By partnering with Age UK Portsmouth and Learning Links, they enable their clients to access additional services, including cleaning, laundry, and pension collection, as well as health and social care advocacy.

Referrals

The service is offered daily from 10am–6pm. Referrals can be accepted from hospital discharge teams, health and social care professionals, community hospitals, GPs, and other relevant community agencies.

Please call 07860 412799 or fax 023 9275 3262.

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Solent MindOlder Persons Mental Health Reablement Outreach Team and dementia based work at Queen Alexandra Hospital

Solent Mind’s ‘Older Persons Mental Health (OPMH) Reablement Outreach’ team supports people aged 65 and over who have a mental health condition in Portsmouth. We enable older people to be independent and remain in their own homes for longer, increase resilience and reduce the need for paid for services and emergency call outs. Our work prevents mental deterioration and improves quality of life.

After a referral has been made, we provide one to one short term interventions lasting between 6 and 8 weeks. A person centred action plan will be drawn up with the client for the period of support being given.

Referrals

Referrals can be made by anyone – clients can self-refer, or their loved ones, carers, or other professionals can refer on their behalf. Contact the service on 07436 166354 or email [email protected]. We will respond to all referrals and enquiries within five working days.

Solent Mind will also be continuing to support with dementia awareness and dementia care initiatives at Queen Alexandra Hospital including person centred care documentation and promotion of voluntary sector services available to dementia patients.

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Rowlands PharmacyPharmacy Review Service (following discharge from hospital)

Rowlands Pharmacy is working in collaboration with the pharmacy team at Queen Alexandra Hospital to support newly discharged patients who have been identified as being at risk of acute or unplanned re-admission due to issues with their medicines. Our aim is to reduce the level of these re-admissions.

Following a referral from the hospital, and with the client’s permission, a service pharmacist will visit the client in their own home within the first week post discharge to talk with them about their medicines and help them to get the maximum benefit from those medicines.

With client agreement, the pharmacist can remove any unused or discontinued medicines, synchronise quantities to facilitate future repeat supplies, and share information with the client’s GP and community pharmacy to assist them in providing appropriate, individualised services.

We are able to signpost to other relevant services and organisations that could be of help, and can communicate with carers and family members according to the client’s wishes. A medicines record card will be left with each client, and two further home visits provided over the following twelve weeks.

For more information about this service please contact Alex Lloyd on 07442 536377 or email [email protected]

Referrals

From the pharmacy department at Queen Alexandra Hospital only.

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Stroke AssociationLife After Stroke Service

Stroke Association is the leading charity in the UK changing the world for people affected by stroke.The Life After Stroke service is one of a number of services provided by the Stroke Association and provides support to stroke survivors and their family and carers.

The service aids people on their individual road to recovery by, for example, helping them re-engage with past interests and activities and/or assisting people as they tackle the new challenges of a life after stroke.

The service offers the following dependent on an individual’s need:

• One to one support

• Friendship networks

• Opportunity to practice communication

• Improving confidence

• Improving access to support and activity groups

• Help with returning to work

• Access to local leisure and social activities

• Support for carers.

Referrals

Referrals can be made by general practitioners, other health professionals, social workers, voluntary sector organisations, and from other services within the Stroke Association. Self-referrals are accepted.

For more information please contact Carly Davey, Life After Stroke Coordinator on 07712 326997 or [email protected]

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The British Red CrossProviding free short term equipment loans

The British Red Cross provides provide vulnerable people with a short-term loans of medical equipment, such as wheelchairs, mobility and living aids (including bath and walking aids) for periods of up to three months. The staff and volunteers help each person to use the equipment safely and to access other health and social care services.

Very often, an individual arrives at the depot after a recent injury or surgery that caused additional stress to them or their carer and the Red Cross team helps them by providing emotional support.

British Red Cross provides a limited delivery and collection of equipment to individuals who have no means to access the Portsmouth depot and who don’t have anyone who can pick up the equipment for them.

Referrals

Referrals can be made by GPs, hospital staff, occupational therapists, community nurses, disability associations, and reablement partners.

Call 023 9281 9194, fax 023 9275 3262, or visit the office at 338 Commercial Road, Portsmouth, PO1 4BT.

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The Rowans HospiceCommunity Based Palliative Care

The Rowans Hospice aims to achieve optimal quality of life for patients and families affected by cancer or other life-limiting illnesses within the hospice, in the community and at home.

In this project a specialist social worker works alongside a range of other professionals to support those who individuals living in the community, who may be in their last year of life, and their families. The service offers dedicated care management and person centered support, to enable individuals to retain their independence for as long as possible and enhance quality of life.

The social worker can help by offering practical and emotional support and /or information and advice. Support may be in the form of an assessment for care, liaising with Portsmouth City Council’s adult social care team, carer support, financial / benefits advice, housing matters and signposting to others services.

Early introduction to hospice services can also be considered if appropriate.

Referrals

Referrals welcome from General Practitioners, Community Matrons, Social Workers, Clinical Nurse Specialists and other appropriate professionals.

For information or to refer contact Sharon Hollins at the Rowans Hospice on 023 9225 0001, 07881 092472 or email [email protected].

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Two SaintsSupported Intensive Recovery Service

The Supported Intensive Recovery Service offers advocacy and support for clients leaving hospital with an immediate accommodation need and local connection to Portsmouth City.

Support is short-term, up to three months, during which time staff provide support to enable clients to access safe, suitable accommodation alongside relevant community support to aid their recuperation and recovery following a hospital stay.

Service aims

• To improve the health of homeless people, particularly in relation to alcohol.

• To reduce the harm caused by alcohol use.

• To reduce the number of hospital admissions caused by alcohol misuse

• To support homeless people to access accommodation following discharge from hospital

• To provide intensive support with housing and all DWP benefits

• To work in partnership with external services such as The Hub, The AIT/A&E Alcohol Intervention Team, Emergency Department and Alcohol Specialist Nurse Service at Queen Alexandra Hospital, Central Point Day Centre, Local Authority Housing Departments, The Salvation Army and other support services to reduce re-admissions to hospital

Eligibility

Over 18 years old

Single homeless or at risk of homelessness

Have health and alcohol issues or dual diagnosis

Referrals

Referrals can also be made from services prior to client admission to hospital. Contact kevin.bristow@ twosaints.org.uk or 07734 558597

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The YOU TrustPeace of Mind Advice Centre at St James Hospital

Advice Portsmouth (part of YOU Trust) provides an advice service at St James’ Hospital called Peace of Mind. It provides general advice and specialist legal advice in housing, benefits, debt and employment law. A regular Family Law Clinic is provided by Blavo & Co Solicitors.

The service is available to clients at St James’ on Wednesdays and Fridays. Advisers work with patients and staff to facilitate early discharge from wards or prevent admissions, prevent homelessness, maximise welfare benefits and support patients in their recovery.

The expertise of advisers and mental health professionals coming together at Peace of Mind has proved of huge benefit to people suffering mental ill health, doing much to aid and hasten their recovery.

Referrals

Referrals can be made for inpatients by St James’ Hospital staff directly to Peace of Mind advisers on clinic days.

Outpatients may also be referred by St James’ Hospital staff or may refer themselves via Advice Portsmouth. St James’ Hospital staff may refer outpatients not in crisis, direct to Advice Portsmouth. Referrals can be made at St James’ Hospital, phone 023 9279 4345 or email [email protected]

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Action for Blind PeopleFinding Your Feet courses for people newly diagnosed with sight loss

Action for Blind People provides practical and emotional advice and support to people who are blind or partially sighted and their friends and family.

Whether clients have just been diagnosed or have a long-term eye condition Action for Blind People offer a range of services to help with living with sight loss. These services include help with assistive technology, employment, independent living, welfare rights, holidays and leisure, and signposting.

This project is about confidence building. The service are running a programme of two day courses that provide the opportunity to discuss the challenges sight loss presents with people who have been through it and, where possible, elements of the courses are run by people who are blind or partially sighted themselves.

The courses are tailored to each group of attendees and include:

• Getting out and making the most of your leisure time

• Emotional and physical wellbeing

• Using technology

• Looking after your eyes and skills for making the most of your vision

• Peer support

Referrals

Referrals can be made by individuals, family, friends or professionals and via email to [email protected] or telephone to 01722 345440.

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Headway Portsmouth & SE HantsCognitive Reablement Service following brain injury

Headway Portsmouth and South East Hampshire works with people in the community who have experienced Brain Injury, their families and carers. This project works with service users to bring cognitive benefit for memory, communication, organisation, executive function and relationships through cognitive re-enablement courses and confidence building courses, one to one assessment and signposting and support.

Headway also run social inclusion sessions supported by volunteers and peer mentors where people can begin to take their place in community activities and make friends.

Referrals

Referrals can be made by General Practitioners, Social Workers, Clinical Nurse Specialists, Neuro Psychologists, Occupational Therapists, Physiotherapists and other appropriate professionals. Self-referral accepted with appropriate backing from GP.

For more information or to make a referral contact Deborah Robinson at Headway Portsmouth and SE Hants at The Mountbatten Centre, Twyford Avenue Portsmouth PO2 2QA on 023 9266 4972 or email [email protected].

Website www.headwayportsmouth.co.uk

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Portsmouth Disability ForumService user groups for people with sensory loss

The reablement grant to Portsmouth Disability Forum (PDF) enhances two of their service user groups:

• Cheerful Charlie’s Group for 10 individuals who have dual sensory loss (vision and hearing) aged from 80 to 95.

• Loud and Clear Group for 25 individuals who have various hearing impairments aged from 35 to mid 80’s.

Both groups meet monthly for advice, friendship and fun at the Frank Sorrell Centre. The grant provides a member of staff to facilitate the groups enhancing them and providing effective stimulation and co-ordination of a range of activities to provide longer, more enjoyable sessions.

It has also been used to purchase equipment for cultural events, reminiscence and learning for example craft materials music discs, dvds and games.

Group members make a small contribution towards their refreshments but there is little capacity for them to fundraise for themselves because of their age/ disabilities.

To find out more

Contact Portsmouth Disability Forum on 023 9281 5266 or email [email protected]

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SCA CareCognitive Stimulation Therapy programme for people with early stage dementia

SCA Memory Group brings together people with memory problems to take part in a 14 week programme of activities based on the principles of cognitive stimulation therapy (CST). Activities include recall tasks such as; word pairing games; using money; recognition of famous faces; and physical games such as kurling and carpet bowls. The tasks focus on the processing of information rather than recall of factual information. CST is the only non-medical treatment programme that the Department of Health guidelines recommend for the cognitive symptoms of dementia.

SCA has found that participants have benefitted through maintenance of memory function, increased confidence and new friendships. Whilst the group meet, carers are invited to share a coffee together.

Information, support and advice are made available and there is also a programme of speakers from relevant local organisations. The group meets every Monday from 10am in Southsea.

Referrals

Referrals are open and include self-referrals. You do not need a formal diagnosis to participate. A short assessment by the group co-ordinator is required to ensure suitability.

For more information or to make a referral please contact Elena on 023 8028 6345 or email [email protected]

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Helping Hooves UK delivers unique wellbeing experiences offered as accessible equine and countryside activities. In this project they are offering a series of weekly interventions that help people to identify and choose physical and emotional behaviours that assist their own recovery and maintain future health and well-being.

Participants are supported to explore and consider alternative solutions to their recovery, including building circles of support not necessarily dependent on health services, how to recognise their own stress build-up/trigger points relating to their recovery, and to adopt tools to manage stress and negativity i.e. positive self-talk.

Throughout the seven week programme people will experience the gentle horses in a safe and relaxing environment. Across the programmes people discover previously un-identified skills and a lasting desire to overcome physical and emotional barriers; enabling them to push their boundaries a little and bring about positive outcomes.

Referrals

To receive a full information pack about the reablement project and helping hooves full services email [email protected] or call 07842 709296.

Helping HoovesEquine activities programme

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Portsmouth Clinical Commissioning Group has also funded a range of voluntary and community sector interventions to improve health outcomes in the people of Portsmouth. Each project has clear health outcomes for service users, to find out more about these please contact each project directly.

The projects have received one year’s funding, and are all running throughout 2015 (with some running into 2016).

SustransActive Steps

The Active Steps project supports people through a free health-focused programme that encourages physical activity through 10 weeks of walking and/or cycling support. Participants are able to access group and one-to-one activities as well as information, advice and equipment that enable them to walk and/or cycle more often for short everyday trips.

For more information contact Phil Godfrey (Project Officer) on 07717 888659 or email [email protected]

Pompey in the CommunityLife ‘n’ Chimes

The Life’n’Chimes project helps people who suffer from dementia or who are at risk of developing dementia and their carers. Based at Fratton Park the project runs on a four week cycle incorporating guests speakers, objects and mementos helping the group to reminisce, New Age Kurling and a local visit.

If you think you or someone you know would benefit from taking part in this fun, relaxed project come along to the drop in sessions.

For further information contact [email protected] or call 023 9277 6824

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BrendoncareCosham Kurling Club

Cosham kurling club is open to men and women, offering local people the chance to take part in the new and exciting game of indoor kurling, which provides gentle exercise for people in a fun and supportive environment. The club also offers additional activities such as skittles, ping pong and advice on health-related issues and benefits.

The club meets every Wednesday from 1.30-3pm at Highbury Area Community Association, Cosham. The club is open to all and more information is available by phoning The Brendoncare Foundation on 01962 852133 or email [email protected]

There is also information online at www.brendoncare.org.uk

Wessex Cancer TrustPortsmouth Cancer Support Centre

Wessex Cancer Trust Support Centre in Cosham offers practical help and emotional support to anyone affected by a diagnosis of cancer, including their families, friends and carers, any cancer, any stage, any age.

Services are offered at no cost to the client and care is delivered through a patient tailored combination of psychological support through counselling, complementary therapies and informational materials and advice. Physical activity and empowering parents to self-manage looking forward are eased back into independence and everyday life on a “Reablement” Programme for those in remission. Everyone is very welcome.

For further information, please contact Karen Semmens on 023 9232 4235.

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Breathe Easy Portsmouth SouthBreath of Life

Breathe Easy Portsmouth South are working with Solent NHS Trust to extend the provision of Pulmonary Rehabilitation Programmes by providing more exercise maintenance classes. These classes are highly valued by patients and enable them to maintain the physical gains made through the initial rehabilitation programme. They are currently held in Paulsgrove and Copnor.

The service open to all people with a lung disease, and can be accessed via GP and nurse referrals into the Pulmonary Rehab Team.

For more information please contact Eric Compton on 023 9232 7840, mobile 07986 820828 or email [email protected]

British Lung FoundationCOPD Patient Education Programme

The British Lung Foundation are delivering a series of patient education workshops for people living with chronic obstructive pulmonary disease (COPD) to help them to manage their condition better, through friendly and interactive group workshops that will provide advice on managing breathlessness, understanding COPD, medication and information about how to access local respiratory services. Patients can attend two half day workshops, which will be running in Portsmouth from the beginning of July until early 2016.

To find out more and how your patients can access these workshops please contact Rachel Spriggens on 020 7688 6018 or [email protected]

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Aspex Visual Arts TrustGenerate

The Generate project is a series of art workshops for people with dementia. The sessions, led by artists Melanie Rose and Laura Fazackerley will be focusing on drawing and painting.

We will also be providing space for a carer support group at the same time. Sessions will run every Friday from 10am-12pm, starting on 10 July at Aspex gallery.

If you live in the Portsmouth area and would like to come along please contact Kellyn on 07940 424198 or Vicky on 02392 778080.

Age UK PortsmouthThe Get Outdoors! Club

The club enables people to continue their love of outdoors and introduce others to the benefits of a range of outdoor and gardening activities. Monthly activities include growing herbs and herb tasting, arts and crafts activities using natural materials, easy to do at home aromatherapy, harvest festival activities and a swap shop for sharing plants and cuttings, top tips for growers and healthy living ideas.

A variety of excursions are planned throughout the year including visits to Southsea Common, an annual country picnic and trips to local community gardens. Members are encouraged to help each other throughout the gardening year and come together to share their own gardens and lend each other a hand.

To get involved contact Age UK Portsmouth on 023 9286 2121 or drop into the Bradbury Centre, 16-18 Kingston Road.

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Portsmouth Rehabilitation and Reablement Team

The Portsmouth Rehabilitation and Reablement Team (PRRT) is provided as part of a community based pathway that supports the transition from illness to recovery in adults and older people by delivering assessment, stabilisation and treatment, as well as rehabilitation and reassessment for a period of up to 6 weeks through an integrated health and social care model.

The service aims to:

• provide timely, comprehensive, person centred assessment.

• provide a safe alternative to acute admission where a medical assessment has been carried out, a diagnosis has been established and a treatment plan that can be delivered in a primary care setting is in place.

• facilitate timely discharge following acute care for people who are clinically stable.

• meet the early needs of people who need rehabilitation.

• ensure that a personal support plan is in place for all those people accepted into the service that enables longer term health and well being needs to be addressed.

• achieve the best health and well being outcomes for patients with a recovery or reablement need for which the resources of the service are appropriate.

• To minimise the need for long term intervention from statutory services.

The team comprises Nurses, Social Workers, Occupational Therapists, Physiotherapists, Rehabilitation Assistants Rehabilitation and Reablement Assistants Administration Team and has the support from a Community Geriatrician.

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Referrals

The service is available to adults who are registered with a Portsmouth City GP.

• Where the referral is the result of deterioration in physical health needs the person must be clinically stable. For community referrals the clients GP will be notified with a request for medical summary and medication list. In the case of all referrals, PRRT will work alongside primary care and the Community Geriatrician to ensure that the health needs of patients are met.

• For transfers of care out of hospital assurance will be sought that the person is clinically stable and discharge ready.

The person must be agreeable to the support or intervention being provided, and in the case of rehabilitation and reablement programmes, be willing to participate in a goal based programme of reablement. Where capacity is impaired then intervention is provided in the ‘best interests’ of the individual in accordance with the Mental Capacity Act.

All referrals should be made through Single Point of Access between the hours of 08.00 hours and 20.00 hours. Referrals received out of those hours are to be notified to the team the next working day.

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Find out more, get involvedIf you would like to find out more visit: www.portsmouth.gov.uk and search: Better Care. If you would like to be involved or sign up to our newsletter email: [email protected]