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Admission, Transfer and Discharge Policy (Community Hospital Inpatient) V4.0 -1- October 2018

COMMUNITY HOSPITAL INPATIENT

ADMISSION, TRANSFER AND DISCHARGE POLICY

Version: 4.0

Date issued: October 2018 (Working Draft)

Review date: October 2021

Applies to: All community hospital staff including registered nurses, allied health professionals, medical professionals Information only for all referrers to community hospitals plus partner organisations

This document is available in other formats, including easy read summary versions and other languages upon request. Should you require this please contact the Trust Equality and

Diversity Lead on 01278 432000


DOCUMENT CONTROL

Reference HMJun13/ATDP

Version 4.0

Status Working Draft pending Ratification

Author Discharge Pathway Managers

Amendments Revised policy to reflect the current position of Community Hospitals within the Somerset Health and Social Care system. Revised post NHSLA Risk Management Standards following comments relating the Handover during Transfer.

Approving body Quality Assurance Group (virtual approval)

Date: August 2018

Equality Impact Assessment

Impact Part 1 Date: November 2018

Ratification Body Senior Management Team Date: TBC

Date of issue October 2018 (Working draft pending ratification)

Review date October 2021

Contact for review Service Director, Community Services

Lead Director Service Director, Community Services

CONTRIBUTION LIST Key individuals involved in developing the document

Contributor - Designation or Group

Chief Pharmacist/Head of Medicines Management

Community Heads of Adult Services

Director of Community Services

Discharge Pathway Managers – East and West

Senior Community Hospital Matron, Bridgwater Community Hospital

Claims and Litigation Manager

Equality and Diversity Lead

Interim Lead for Infection Prevention and Control

Senior Nurse Clinical Practice

Community Hospital Best Practice Group Clinical Policy Review Group Clinical Governance Group


CONTENTS

Section Summary of Section

Page

Doc Document Control 2

Cont Contents 3

1 Introduction 4

2 Purpose and Rationale 4

3 Policy Statement 6

4 Definitions 6

5 Duties and Responsibilities 7

6 Admissions 8

7 Transfers to Community Hospitals 10

8 Transfers to All Other Care Settings 12

9 Infection Prevention and Control 13

10 Discharge 14

11 Patients with Complex Discharge Needs and Reluctant Discharges

15

12 Training and Competency Requirements 16

13 Monitoring compliance and Effectiveness 16

14 References, Acknowledgements and Associated Documents

17

15 Appendices 19

Appendix A Referral to Community Hospital Criteria and Specialist Provision Admission Criteria for all Community Hospitals

20

Appendix B Patient Transfer Form

Home First SOP

23

Appendix C Transfer Checklist 33

Appendix D Inter-healthcare Infection Control Transfer Form 34

Appendix E Planning to go Home Leaflet 35

Appendix F Discharge Plan - Simple Discharge Checklist 37

Appendix G Complex Discharge Planning Form 40

Appendix H Self-Discharge Policy v0.2 Self-Discharge Form

41

Appendix I Guidelines for Patient Transfers from Acute Hospitals to Community Hospital Beds (including for Out of Hours)

45

Appendix J Complex needs assessment for plus sized persons requiring transfer to a community hospital

61


1 INTRODUCTION

1.1 All patients for transfer to a Somerset Partnership Community Hospital should be deemed medically fit. Each patient for transfer will be reviewed by a Somerset Partnership senior nurse on an individual basis. The referring senior nurse will also discuss with the receiving community hospital how the individual care of the patient can be met.

1.2 Somerset Partnership NHS Foundation Trust beds are a valuable resource and it is essential that they are used efficiently to be able to provide good patient care.

1.3 The admission, transfer and discharge policy aims to ensure a smooth journey for all patients throughout their stay across the health care economy. Good communication and integrated working with those involved in the transfer, admission and discharge process is essential to ensure effective use of time and resources.

1.4 Inefficient use of beds can lead to patient and carer distress, increases in

waiting lists, higher re-admission rates as well as increased workloads for staff and colleagues in the community.

2 PURPOSE AND RATIONALE

2.1 All admissions, transfers and discharges involving Somerset Partnership

NHS Foundation Trust community hospital inpatient beds will follow an agreed pathway that takes into account the needs of patients and carers.

2.2 Home First Pathway 2 beds now exist at Bridgwater and West Mendip Community Hospitals

Pathway 2 Short-term Rehabilitation in an interim placement

- Patient identified as medically fit but requires further

rehabilitation/enablement and is unsafe to be left between visits

- Patient requires further support but no longer required to be delivered in an inpatient setting

- Patient expected to return home - Interim facility with all staff demonstrating an

enablement approach with additional therapy support - Average length of stay 10 – 14 days

2.3 Appropriate timely admission and discharge planning is fundamental to

the provision of health care and this policy sets out the principles that underpin this policy and the pathway that should be followed.


2.4 It is the Trust’s policy to ensure that community health staff are informed, updated and equipped to carry out assessment and management of admission, transfer and discharge in the course of their work.

2.5 Professional Development Forums (PDF’s) will be held weekly at each

community hospital. For the two community hospitals that hold the Pathway 2 beds the forums will be held twice a week. These forums will require attendance from senior members of the multidisciplinary teams from the ward and the community.

2.6 The PDF will discuss each patient and create a discharge plan with a

timeline of actions that does not incur an unnecessary delay to the individual. The purpose and aim of the PDF will be for the patient not to experience a protracted length of stay which can have detrimental consequences for frail and older patients.

2.7 The daily board rounds will be the operational platform for the weekly

PDF actions to be followed up within an appropriate given time frame. The purpose of the given time line is for the effective, safe and well executed discharge plan that is tailored for the individual.

3 POLICY STATEMENT

3.1 Somerset Partnership NHS Foundation Trust is committed to ensuring safe

and effective practice when admitting, transferring or discharging patients from its community inpatient wards.

3.2 The Trust will ensure that all staff, including clinicians, senior managers,

general practitioners and all other relevant agencies, e.g. Acute Trusts, are fully conversant with the admission and transfer criteria and any escalation plans in accordance with capacity planning e.g. the Winter Plan Escalation Framework.

3.3 All patients will have a management/care plan in place within 24 hours of

admission. 3.4 The Trust will work with all health and social care providers to review and

update this policy to reflect the changes to discharge arrangements especially in times of capacity pressures.

3.5 The Trust will monitor and review the implementation of the policy locally

and undertake audits as required to review the appropriateness of admission to a community hospital.

3.6 The Trust is committed to ensuring all staff are appropriately qualified and

competent to deliver safe and effective clinical care over 24-hours, seven days a week for patients as agreed in the admission criteria categories.

3.7 The decision to accept an admission to a community hospital bed will be

made by the senior nurse on duty.


3.8 All admissions to Somerset Partnership NHS Foundation Trust will be

managed by appropriate clinical teams including the medical service provider. The organisation will ensure that, as far as is reasonably practicable, equality is achieved for all service users in accordance with the Equality Act 2010.

4 DEFINITIONS

4.1 Out of Hours – the time between 6.30pm and 8.00am, weekends and

public holidays.

4.2 Simple Discharge Plan – the plan for use for all patients being discharged.

4.3 Complex Discharge Plan – the additional plan for use for patients with

complex needs being discharged with a package of care and/or multi-agency involvement.

4.4 EPMA– Electronic Prescription and Medicine Administration

4.5 MAR – Medication Administration Record (see Medicines Policy Section

4 for definition). The MAR may be a paper chart (MAR Chart) or the Medication Administration Screen where EPMA is in operation.

4.6 ICT – Infection Control Team.

4.7 PEG/RIG Tubes – Percutaneous endoscopic gastrostomy tubes and

Radiologically inserted gastrostomy tubes.

4.8 NG – Nasogastric Feeding.

4.9 MRSA – Methicillin-Resistant Staphylococcus Aureus.

4.10 ESBL – Extended-Spectrum Beta-Lactamases.

4.11 PODS – Patient’s Own Drugs, Medicines dispensed and labelled for an individual identified patient.

4.12 TTAs/TTOs – To Take Away/To Take Out. Named patient medicines to

be supplied to the patient (on discharge) to allow a bridging of medicines need until a re-supply of medicines can be made in the new care setting.

4.13 Somerset Treatment Escalation Plan & Resuscitation Decision Form

(STEP) – This is a document designed to facilitate communication between healthcare professionals outlining an individual treatment plan, focusing on which treatments may or may not be the most helpful for a patient should they deteriorate. A variety of treatments can be considered such as antibiotic therapy or mechanical ventilation and the plan must include a resuscitation decision.


4.14 Resuscitation Decision – Also called ‘Allow Natural Death’ (AND).

This indicates that in the event of cardiopulmonary arrest, neither basic nor advanced resuscitation will be instigated. Where an AND has been completed in a setting outside of the community hospital, it will be reviewed between the receiving clinician and the patient within 24hrs

4.15 UY – Understanding You.

4.16 DATIX - the Trust’s electronic risk management database used for

recording the following data: PALS; Complaints; Untoward Events; Corporate and Local Risks; Medical Devices Register and CAS Alerts.

4.17 Medically Stable – A clinical decision has been made that the patient is

ready to transfer or discharge.

5 DUTIES AND RESPONSIBILITIES

5.1 The Trust Board has overall responsibility for procedural documents and delegate’s responsibility as appropriate.

5.2 The Lead Director with responsibility for Admission, Transfer and Discharge within the Community Health Directorate is the Chief Operating Officer Community and Mental Health services

5.3 The Identified Leads (Authors) are the Discharge Pathway Managers

for East and West respectively, responsible for producing written drafts of the document and for consulting with others and amending as appropriate.

5.4 The Divisional Governance Group is responsible for monitoring the

effectiveness of this policy:

Ensuring there are adequate controls to provide safe admission, transfer and discharge practice in line with national guidelines

Advising on training requirements for individual staff groups 5.5 The Community Hospital Best Practice Group is responsible for

monitoring performance in relation to Admission, Transfer and Discharge and will monitor compliance with the requirements outlined within this policy.

5.6 Service Managers/Heads of Service: responsibility for implementing

this policy is devolved to Heads of Service and Service Managers.

5.7 Matrons/Sisters/Charge Nurses/Service Managers are responsible for ensuring that they have a planned programme of training for staff in their team in accordance with the Trust wide Staff Mandatory Training Matrix.


5.8 All Community Health Staff including temporary staff are individually responsible for complying with this policy. This includes (a) attending training and updating risk assessment skills as directed by this policy, (b) reporting concerns to their line manager, (c) regularly updating risk related sections within the Patient’s Healthcare Records and also completing DATIX Untoward Event report forms in line with the Trust’s Untoward Event Reporting Policy accessible on the Trust Intranet.

6 ADMISSIONS Admission criteria for all community hospitals

6.1 All patients admitted to the community hospital will be aged 18 years or over and will require one of the following:

The provision of intensive nursing care and treatment when required to avoid admission/transfers to an acute hospital. This would include conditions which can be safely managed in the community hospitals eg urinary tract infections, chest infections, blood transfusion.

The provision of multidisciplinary assessment and ongoing clinical care where this cannot be delivered in the community.

The provision of admission for observation/treatment from the minor injury unit, the patient’s general practitioner, out of hour’s doctor, or other healthcare professional.

The provision of end of life care where the community hospital is the patient’s preferred place of death.

Admission Process

6.2 The admission process is detailed as follows:

All admissions to Somerset Partnership community hospital beds will be arranged through Somerset Primary Link and the Discharge Pathway Managers.

Referrals will be accepted from Acute Hospitals, GPs, the Out of Hours medical service, Emergency Care Practitioners (ECPs) and Minor Injury Units (MIUs).

Patients requiring specialist care (including those receiving treatment with complex or specialist medicines) i.e. NG Feeding will be admitted to community hospitals where the staff have the required competency to deliver the specialist care required – see Referral to Community Hospitals Criteria and Specialist Provision Admission Criteria for all Community Hospitals (Appendix A).


Patients requiring in patient specialist stroke rehabilitation will be admitted to a specialist stroke rehabilitation unit.

Patients will be identified for Home First Pathways during the daily Practice Development Forums (PDFs) which occur in the acute hospitals. This forum will identify patients who will require onward care and therapeutic support once they are medically optimised. This should be determined as soon as possible after admission and updated at the daily meetings to ensure that any further care is planned in advance of the expected date of discharge.

The PDF will discuss and agree the most appropriate pathway with the patient and their family, carers or representatives. It is anticipated that the majority of patients will return to their usual home environment (including residential homes) under Pathways 0 (nil input) and 1.

Pathway 2 beds are sited in West Mendip Community Hospital (Abbey Wing) and Bridgwater Community Hospital. Whilst within pathway 2, patients will be expected to have a therapy need which is greater than a nursing need or non-acute medical need.

Staff from all referring agencies will have to be responsible for ensuring that the Trust’s admission criteria are met in order for the patient to be admitted to Trust services.

The senior nurse on duty will work closely with primary link and will accept the patient providing the referral criteria are met, staff have the appropriate competencies to care for the patient and a suitable bed is available. Where necessary, the senior nurse will discuss the admission with the community hospital medical team or ANP and a formal handover will be taken and fully documented.

The requirements of single sex accommodation will be robustly adhered to.

If the senior nurse on duty in the community hospital has any concerns regarding the admission of a particular patient, they must discuss their concerns with the referrer and if necessary escalate these concerns to the community hospital Matron, Discharge Pathway Manager, Head of Community Services or On Call Manager.

In accordance with the Winter Plan Escalation Framework, at times of escalation the criteria for admission can be overruled with the agreement of the community hospital Matron and a member of the Community Health Services Directorate Senior Management Team and the relevant Discharge Pathway Manager. Patient Safety will, however, remain paramount.


On admission from the community, referral and handover information provided by the referrer will be recorded by Somerset Primary Link and will be passed to the relevant community hospital.

7 TRANSFERS TO COMMUNITY HOSPITALS

7.1 Patients are transferred to the community hospitals from acute providers.

Transfers of patients between hospitals must be undertaken with the consent and understanding of the patient. If the patient lacks capacity, a relevant family member or health care professional would be involved.

All transfers to Somerset Partnership community hospital beds will be arranged through Somerset Primary Link and the Discharge Pathway Managers.

Transfers should only take place between 8.00am and 6.00pm. Under exceptional circumstances at times of escalation this timescale may be extended to 9.00pm, dependent upon the patient’s circumstances and the status of escalation.

The patient’s clinical information and management plan (including details of current medicines) must be available prior to transfer via the electronic waiting list, or telephone and must be reinforced by a verbal handover.

The senior nurse on duty will complete a Patient Transfer Request form (Appendix B) for each patient for whom transfer is requested. The nurse will consider the workload, dependency of existing patients and staffing resources in the community hospital to ensure the admission request can be safely managed. Any concerns will be discussed with the referrer and if necessary escalated to the community hospital matron, the locality manager or the on call manager.

Patients with any form of cognitive impairment will require a clear/robust management plan in place prior to transfer to enable the ward staff receiving the patient to manage their mental health needs.

7.2 Patients who have specific care issues (including complex or specialist

medicines) or who are at risk of harm as detailed below must be discussed with the senior nurse on duty before the transfer can be accepted. These issues and risks must be recorded as part of the handover documentation. These patients include:

confused patients who can wander


patients with MRSA/ESBL/Clostridium Difficile positive infections (see Section 8 Infection Prevention and Control below)

patients requiring special size or strength equipment or bed

patients with a tracheostomy

patients with cognitive impairment, dementia

patients with a learning disability

any patient where specialised nursing or higher than usual levels of nursing is required.

7.3 When patients are transferred from a local acute hospital to a community

hospital the clinician in charge of the patient’s medical care must have agreed prior to the transfer that the patient is medically stable, and that a clinical management plan is available. The clinical management plan will have been reviewed within 24 hours prior to transfer and will include the following information:

Detailed summary of the patient’s medical condition

History of treatment and investigations undertaken

Clinical management plan including the current legible and up to date Medication Administration Record and details of the Medication Reconciliation on discharge from the referring hospital (which will include details of and reasons (i.e. indication, allergy, etc) for any medicines started or stopped whilst in the care of the referring hospital.

Record of any information shared with patients and family about the patient’s condition and prognosis

Full summary of any complex needs for any individual with a learning disability

An up to date Treatment Escalation Plan (TEP) 7.4 All medicines required for the patient’s continuing needs must be

transferred with the patient. Sufficient medicines must be supplied for a minimum period of 7 days’ treatment after transfer, unless a shorter period is more clinically appropriate (i.e. completion of course of antibiotics within the 7 days).

7.5 Patients will be transferred from an Acute Trust to a community hospital with the following documentation:


The patient’s record, which should contain an up to date management plan authorised by the discharging clinician within 24 hours of the planned discharge date. This must include a full summary of the patient’s medical condition, history of treatment and investigations, a record of all information shared with the patient and family, and the ongoing clinical management plan.

A full, comprehensive and legible Medication Administration Record (MAR) which has been reconciled in the 24 hours prior to the planned discharge date from the Acute Trust by the clinician responsible for the patient’s care.

Confirmation of all outstanding clinical investigations and outpatient appointments including transport arrangements.

A copy of the Inter Healthcare Infection Control Transfer Form (Appendix D).

7.6 Following transfer the doctor or ANP assuming medical responsibility for

the patient’s care should review any existing Treatment Escalation Plan (TEP). If there isn’t a TEP in place, this should be discussed with the patient as soon as is practicably possible. Please see the Somerset TEP Policy for more information.

8 TRANSFERS TO ALL OTHER CARE SETTINGS 8.1 The patient’s clinical information and management plan must be

available prior to transfer. 8.2 The senior nurse on duty will complete the Transfer Checklist (Appendix

C) which takes into account the following :

Patient’s condition summarised/reason for transfer

Resuscitation Decision and STEP handed over

All medicines required for continuing treatment in the new care setting and ensuring they are transferred with the patient (see 7.4 above)

A summary of medicines prescribed at point of discharge including clearly identifying medicines discontinued or initiated (if to be continued after transfer) since admission with reason for discontinuation or initiation.

Oxygen requirements

Infection Status handed over

Equipment/Aids

Mobility Status

Destination confirmed

Informed GP

Informed Relatives

Patient’s notes or clinical summary


The patient’s latest NEWS score

8.3 Patients who have specific care issues or who are at risk of harm must be discussed with the Senior nurse on duty before the transfer can be agreed.

8.4 Consideration needs to be given dependent on the patient’s needs whether an escort is required to transfer the patient to the care setting. This assessment is based on an individual risk assessment.

9 INFECTION PREVENTION AND CONTROL 9.1 When transferring patients/clients to another care setting it is vital to

inform the receiving ward or unit if the patient has a laboratory confirmed infection. This can be achieved using the Inter healthcare Infection Control Transfer Form (Appendix D) as advocated within the Department of Health’s document Essential Steps to Safe Clean Care 2007.

9.2 If a patient/client being transferred is suspected or confirmed as being

infectious the senior nurse on duty must contact Somerset Partnership NHS Foundation Trust Infection Prevention and Control Team (Tel: 01278 432132) within normal working hours prior to the transfer being carried out and BEFORE transport is arranged.

9.3 If advice is required Out of Hours, the On Call Manager should be contacted, who can take advice via the On Call Consultant Microbiologist based at Musgrove Park Hospital.

9.4 The Inter Healthcare Infection Control Transfer Form (Appendix D) must

be completed by the transferring facility and supplied to the receiving healthcare establishment. It is important to complete the form in full whether a patient/client presents an infection risk or not.

9.5 This form should be used for all inter-healthcare facility admissions,

transfers and discharges, including:

all patients/clients admitted to hospital from a shared-living environment (eg a care home)

all ward-to-ward inter-hospital transfers, community hospital to community hospital transfers or discharges and all discharges where healthcare may be involved

9.6 In the event of escalation, due to a lack of bed capacity across the

Somerset Healthcare system, Somerset Partnership NHS Foundation Trust managed community hospitals may be requested to directly admit patients diagnosed with gastro-intestinal symptoms. These patients would only be admitted if medically appropriate and if sufficient isolation facilities are available. Advice must be sought from the infection

Tel:01278

Tel:01278


prevention and control team prior to the acceptance of such patients. Out of hours, the on Call Manager must be contacted.

10 DISCHARGE 10.1 Timely discharge plays a key role in patients return to the community

setting and should be planned from the earliest stage possible with full involvement of the patient and their carer. The process outlined below is applicable to each discharge, regardless of when discharge takes place (including Out of Hours).

10.2 Somerset Partnership NHS Foundation Trust follow the principles of the Safer Patient Flow Bundle of Care

10.3 Somerset Partnership NHS Foundation Trust will plan all discharges in accordance with the Somerset Health and Social Care Community Principles of Discharge.

10.4 Key points for achieving timely discharge include:

A predicted date of discharge should be identified within 24 hours of admission by the multi-disciplinary team using the principles of PDFs and Board Rounds, and the patient and family/carer informed

Patients should be provided with the ‘Planning to go Home’ Leaflet (Appendix E)

The predicted date of discharge will be pro-actively managed against the discharge plan on a daily basis and formally reviewed at each ward round and multi-disciplinary meeting ensuring that all changes are communicated to the patient

Appropriate written discharge care plans including follow up arrangements will be provided to patients on discharge

Inpatient discharges should be planned to occur before 12 noon, on any day of the week, including weekends in order to safeguard vulnerable patients against the associated risks of late/out of hours discharges

The discharging nurse will refer to the Simple Discharge Checklist (Appendix F) and the Complex Discharge Planning Form (Appendix H) if required, to ensure completion of the various components of discharge, eg TTA’s, transport, referral to appropriate specialist professionals, provision of information and documentation to the Patient, GP and other key professionals

Ward discharge summaries to be forwarded to GP/relevant health agencies and copy given to the patient at the time of discharge. A


record of this will be recorded in the Simple Discharge Checklist (Appendix F)

A full summary of the admission will be provided to the patients GP within 24 hours of patient’s discharge, with a copy given to the patient. A record of this will be recorded in the Simple Discharge Checklist (Appendix F).

11 PATIENTS WITH COMPLEX DISCHARGE NEEDS AND ‘RELUCTANT

DISCHARGES’ 11.1 All patients requiring a Nursing or Residential Home placement will

receive a letter from the ward sister/nurse in charge outlining the hospital’s expectations regarding discharge, regardless of funding arrangements.

11.2 Every attempt must be made to ensure that patients are discharged in

line with their predicted discharge date. Proactive and regular communication with the patient and their family must be promoted where it is judged that a timely discharge is at risk of not happening.

11.3 The multi-disciplinary team will identify potential reluctant discharges and

discuss these with the ward sister/charge nurse and community hospital matron in the first instance in line with the Somerset Reluctant Discharge Policy.

11.4 Where the patient or carer appears to be reluctant to discharge the nurse

in charge will refer to the Somerset Health and Social Care Community Principles of Discharge – Good Practice in Handling Difficult or Reluctant Discharges from Hospital Care and issue the appropriate letter. (Appendix G)

12 TRAINING REQUIREMENTS 12.1 The ward sister/charge nurse is responsible for training staff in the

management of patient admission / transfer and discharge. This should be part of local induction training and the relevant competency framework.

12.2 Service managers and team leaders are responsible for training referring

staff in the criteria and process for admission.

13 MONITORING COMPLIANCE AND EFFECTIVENESS 13.1 The following measures will be used to review the impact of the

Admission, Transfer and Discharge Policy and will be formally reported to the Community Hospital Best Practice Group and the Senior Management Team on a monthly basis:

patient readmission rates


delayed discharge rate

average length of stay

13.2 In addition the following metrics will be monitored as part of the community hospital performance scorecard which will be monitored by the Community Hospital Best Practice Group and Senior Management Team on a monthly basis:

Numbers of admissions discharges and transfers

Performance against the following standards:

Direct admission from Primary Care – patient admitted within four hours of referral

Acute Hospital transfers – patients transferred within 48 hours of being assessed as “medically optimised for transfer”

13.3 The following will be used to monitor the quality of admissions, transfers

and discharges:

documentation audits – undertaken annually as part of the organisational annual audit plan

patient satisfaction survey – undertaken for all discharges and reported to the Divisional Governance Group on a bi-monthly basis

patient safety incidents reports (including inappropriate admissions) – reviewed at the Divisional Governance Group meeting on a monthly basis

complaints - reviewed at the Divisional Governance on a monthly basis and themes shared

13.4 The responsibility for developing action plans as a result of the above

monitoring and the sharing of lessons learnt will sit with the Community Hospital Best Practice Group which is chaired by the Project Director, Community Services Integration

14 REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED

DOCUMENTS

14.1 References

Department of Health’s document Essential Steps to Safe Clean Care 2007

Department of Health (2004) Achieving Timely ‘Simple’ Discharge from Hospital. Department of Health, London.


Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. Department of Health, London.

Equality Act 2010 (HMSO)

Human Rights Act 1998 (HMSO)

Parliamentary and Health Service Ombudsman (2008-2009) Six Lives: the provision of public services to people with learning disabilities. HC203

The Protocol for the Management of Community Hospital Multi Disciplinary Meetings and Implementation of the Single Assessment Process 2004

Somerset Health and Social Care Community Winter Plan 2010/11

14.2 Cross reference to other procedural documents The following procedure documents relate to this policy:

Being Open and Duty of Candour Policy

Clinical Supervision Policy

Consent and Capacity to Consent to Examination and Treatment Policy

Confidentiality and Data Protection Policy

Controlled Drugs Policy

Somerset Treatment Escalation Plan (Step) & Resuscitation Decision Policy

Deprivation of Liberty Safeguards (DOLS) Policy

Escorting Patients Between Care Settings

Handover Policy for Inpatient Wards

Learning Development and Mandatory Training Policy

Mandatory Training Matrix (Training Needs Analysis)

Medicines Policy

Privacy, Dignity and Respect Policy

Professional Interpreting and Translation Service Policy

Records Keeping and Records Management Policy

Somerset Treatment Escalation Plan Policy

Somerset Reluctant Discharge Policy

Risk Management Policy and Procedure

Risk Management Strategy

Safeguarding and Protection of Children Policy

Safeguarding Adults at Risk Policy

Serious Incidents Requiring Investigation (SIRI) Policy

Untoward Event Reporting Policy and Guidance


All current policies and procedures are accessible in the policy section of the public website (on the home page, click on ‘Policies and Procedures’). Trust Guidance is accessible to staff on the Trust Intranet.

15 APPENDICES

Appendix A Referral to Community Hospitals Criteria and Specialist Provision Admission Criteria for all Community Hospitals

Appendix B Patient Transfer Form Home First SOP

Appendix C Transfer Checklist

Appendix D Inter-healthcare Infection Control Transfer Form

Appendix E Planning to go Home Leaflet

Appendix F Discharge Plan - Simple Discharge Checklist (Adults)

Appendix G

Complex Discharge Planning Form

Appendix H Self-Discharge Policy Self-Discharge Form

Appendix I Guidelines for Patient Transfers from Acute Hospitals to Community Hospital Beds (including for Out of Hours)


APPENDIX A

REFERRAL TO COMMUNITY HOSPITALS CRITERIA AND SPECIALIST PROVISION ADMISSION CRITERIA FOR ALL COMMUNITY HOSPITALS

All Patients admitted to the Community Hospital will be aged 18 years require one of the following:

The provision of safe local observation and a suitable environment for patients who are medically stable but require further rehabilitation prior to returning safely to their home or future placement.

The provision of intensive nursing care and treatment when required to avoid admission/transfers to an acute hospital. This would include conditions which can be safely managed in the community hospitals eg urinary tract infections, chest infections, blood transfusion.

The provision of multidisciplinary assessment and ongoing clinical care where this cannot be delivered in the community.

The provision of admission for observation/treatment from the minor injury unit, the patient’s general practitioner, out of hours doctor, or other healthcare professional

The provision of end of life care where the community hospital is the patient’s preferred place of death.

All Community Hospitals will accept the following

Confused patients who may need DOLS – to be assessed on an individual basis

Patients needing IV antibiotics – to be assessed on an individual basis

Patients fed via PEG/RIG tubes

Patients receiving IV fluids

Patients needing sub-cut therapy

Patients needing vac therapy (in discussion with tissue viability team

Patients needing oxygen

Patients requiring active rehabilitation

Patients with dysphagia

Patients needing palliative/EOL care

Patients requiring specialist rehab equipment (e.g. encore hoist, pulpit frame, stand aid hoist)

Amputees

Patients at risk of falling

Patients who need regular blood monitoring (eg INR)

Complex needs patients will be individually risk assessed and offered an appropriate bed as per individual care requirements. Admissions will be accepted between the hours of 08.00am and 6.00pm. Prior Acceptance Discussion/Assessment The following complex needs patients must be discussed and assessed as per information guide with the senior nurse on duty before an admission can be accepted:

Confused patients who can wander

Patients with MRSA positive infection


Complex needs patients requiring special size / strength equipment and or specialist hire beds and associated equipment (please refer to appendix J)

Patients with a diagnosis of dementia

Medicines needs including specific complex or specialist medicines

Supply of at least 7 days of all medicines required for the patient’s needs

Agreement to continue to supply all ‘specialist commissioning’ medicines for the duration of the patients SPFT inpatient stay and their TTA requirements after discharge from SPFT

Agreement that if in the event of the discharging Trust ward failing to supply all the medicines required in the discharging ward’s possession that those medicine will be urgently transferred to the receiving SPFT ward at the discharging Trust’s expense.

The ability to accept the patient will depend on the specific needs of the patient, the patient environment, the available staff competencies and the case mix within the hospital at any one time. Contact SPFT Medicines Management Team (01823 368265) for advice and/or guidance and support if required.


Specialist provision available at specific community hospitals

Criteria Y = Yes, can accept

these patients N = No, unable to

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N N N N N N N N N

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3 Patients for stroke rehabilitation

N N N N N N

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APPENDIX B SOMERSET PARTNERSHIP NHS TRUST

PATIENT TRANSFER FORM FOR PATIENTS TRANSFERRING TO COMMUNITY HOSPITALS

1. Form to be completed by Community Hospital staff/In-Reach Nurses for all

patients prior to patient transferring in from another hospital/ establishment. Please telephone the transferring hospital to obtain this information.

2. Please ensure an electronic or scanned copy of this form is entered into the

patient notes following admission.

3. Entries refer to current date only, and any monitoring records need to be kept separately.

Patient Name: Patient DOB:

Referring Nurse: Receiving Nurse (DB)

Referring Establishment:

Date:

Discussions Discussed? Comments

Yes No

Mobility Pre-admission

Present mobility

Falls Risk?

Continence Bowels

Bristol Stool Chart

Bladder

Catheter

Infection Control MRGNO

MRSA

C.Diff etc

History of loose stools in previous 72 hours

Wounds and Care Plan Pressure area risk score

VAC Therapy

Nutrition and Fluids MUST score

SALT


Discussions Discussed? Comments

Yes No

Mental State

Dementia Capacity Issues

CPN

Special Requirements Medications, bloods, warfarin, insulin, VTE prevention, PICC or Hickman line etc

Rehab Current mobility Weight bearing status ADL Equipment requirements Any specific treatment needs

Patient Discharge Goal

Name of Staff Member completing form: ……………………………………… Print Name: ……………………………………… Designation: ……………………………………… Contact Number: ………………………………………


APPENDIX B

Standard Operational Policy

For Home First

This is a Draft / Developmental / Working Document and will be up-dated as the project evolves


Standard Operational Policy: Home First

Accepted by: Ratified by:

Active date: September 2017

Ratification date: 15/08/18

Review date: August 2018

Applies to: Home First Discharge Process.

Exclusions: Patients <18 years Stroke and maternity.

Purpose: This policy outlines how the Home First Reablement Service will function.

VERSION CONTROL - This document can only be considered current when viewed via the Policies and Guidance database via the Trust intranet. If this document is printed or saved to another location, you are advised to check that the version you use remains current and valid, with reference to the active date.


CONTENTS

Introduction, Purpose, Scope and Home First Process 3

Home First Functions 5

Home First Pathways 6

Criteria, KPIs and Daily Procedure 8

Review Meetings and Movement between Pathways 9

Education and Training, Incident Reporting and Accountability. 10

Patient Flow 12

Standard Operational Policy for Pathway 1 Patients 13



Escalation Plan for Pathways 16-18

Risk Assessment Tool 18

Flow Diagram for Pathways 21


This SOP is to be used in line with the local Hospital Discharge Policy. It sets out the key features of a Discharge to Assess model and specific priority targets

The Standard Operating Procedure (SOP) is in line with the aims set out in the Care Act 2014 (replacing the Delayed Discharge Act 2003) to ensure that people do not remain in hospital when they no longer require care that can only be provided in an acute trust. It is our goal to safely and appropriately discharge patients with on their expected date of discharge, which should be the same day as they are medically stable.

Definition of Home First: Discharge to Assess Where people who are clinically optimised, both within a hospital setting and pre-admission, and do not require an acute hospital bed, but may still require care services are provided with short term, (funded) support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person.

Somerset default: Going home to their normal place of residence is the default position. This may be before (we are working towards this) or after admission to a hospital. (includes MPH YDH WGH RUH and Community Hospitals - Community Hospitals not yet in scope).

Wherever possible, people should be supported to return to their home for assessment, with alternative places for people who cannot go straight home.

Home First Key features of Discharge: Home First is the discharge process for Somerset. It is a systemwide response for discharge and ensures people who are medically stable and no longer require acute care, are assessed in the most appropriate setting to enable recovery and meaningful goal setting:

Going home to their normal place of residence is the default position.

Wherever possible, people should be supported to return to their home for assessment, with alternative places for people who cannot go straight home.

No new patient to leave hospital with funded care until PDF has agreed the most patient centred Home First pathway.

Home First is not a service, or separate process to any planned discharge, and it is not resourced as a separately staffed discharge provision. Rather, it is a way of working / ethos to ensure that any discharge for any person leaving hospital when they are medically stable needing any support or care services, is discharged to their home (where appropriate).

Home First Process

“Home First” supports the ethos of “Right Care, Right Time, Right Place” by getting it right for the patient first time.


“Home First” is a concept whereby patients are transferred from acute hospital at the point where they no longer require acute hospital care through one of three pathways:

Key service functions

The following 6 headings set out the key service functions for all discharges where intermediate support is required:

Conversation – anyone needing support will know about Shaping the expectations for the person (elective and emergency) ASC and NHS will share the ward responsibility for decision making and key worker roles. 48 hours of admittance to hospital will start planning about going home

Continuous Review – Data Monitoring and Flow Rate Management oversight of system intervention and discharge with targets for: Daily Discharge dashboard same reporting across the system, Daily PDF to manage hospital flow and delays within hospital and within core Home First resource. Twice weekly MDT with commissioned providers with prepared updates on progress from key workers. Case management reviews coordinated by Key Workers. Monthly management operational group for Home First. Change in Setting move from community to Res/Nur/ ECH (split by each) No change in Setting – in own home /in placement. Outcomes post discharge: needs increased, needs decreased, needs stayed the same, nil needs

MDT Board Round – Decision Making Forum Membership: Consultant, Nurse, Therapy and ASC. Robust decision making at board round with key information presented about patient history including: Date admitted, Presenting diagnosis, Planned discharge date, Previous admissions, Previous services and support, Named Key worker identified to support discharge and beyond, Patient /family conversations, Escalation plan sign-off , Safe discharge and risk assessment presented (which will evaluate anticipate resource) Long Term Outcomes

Reduced re-admissions

Increased person experience, wellbeing and independence

System-wide response: Increased communication between systems

Reduced demand on Long term care at home and placements

Discharge and Goal Setting – Core Home First Resource Core Home First Team to assess and hold: The core team will be members of the MDT board round and include: Nurse, OT, Physio, SW and ASCW, Band 4 practitioners. Clear goals agreed and wider resource release – Case management system


0 – 4 hours response at discharge: someone will meet me - from family to professional Home First oversight with daily MDT for all discharged on Home First. Integrated response – right time right place with wider partners

Interventions – Resource Release Therapy and Social Work response – redeployment of staff within the system: Therapy, ASCW and IRT to be available for timely intervention. Identify resource release: Involves and embraces timely (right time, right place) access to the wider support available to people at home including Health Coaches, Village Agents, voluntary/third sector partners, night service, Pharmacist, District Nursing, Complex Care, RAs and Therapists, IRT, Social Workers and ASCW, CPN and memory cognition services, equipment, dietician, GP, palliative care and commissioned providers to deliver care and support. Increase Pathway 1 resource to support admission avoidance and discharge access.

The Home First discharge to assess (D2A) pathways

Pathway 1 Home with additional support

- The patient has additional care needs that can be safely met at

home

- Patient identified as medically fit but further support required

- Patient deemed safe between visits at home

- 95% patients requiring further assessment or support take this

pathway

- Average length of therapeutic support at home 12 days

- 65% people leave this pathway without additional ongoing support

Pathway 2 Short-term Rehabilitation in an interim placement

- Patient identified as medically fit but requires further

rehabilitation/enablement and is unsafe to be left between visits

- Patient requires further support but no longer required to be

delivered in an inpatient setting

- Patient expected to return home

- Interim facility with all staff demonstrating an enablement

approach with additional therapy support


- Average length of stay 10 – 14 days

Pathway 3 Slow-stream rehabilitation in a placement

- The patient has more complex needs and is unable to return home

immediately and will benefit from a longer period of

rehabilitation/enablement

- The longer-term needs of the patient should be determined outside

of an acute inpatient environment

- Very few people are anticipated to require this pathway

- Average Length of stay 15 – 20 days

The Discharge staff will work alongside therapists and social work staff to support the wards by providing advice and guidance to identify routine discharges which wards themselves will be able to manage without referring patients to the Home First Pathways, while supporting the MDT (multidisciplinary Team) to identify patients that will be appropriate for the Home First Pathways.

The Risk Assessment tools will be used by the ward MDT staff to identify those patients that are appropriate for Home First. The MDT will facilitate the decision making process and help the ward staff facilitate transfers to relevant Pathways.

The Discharge staff will also support the ward MDT in identifying, referral & transfer of CHC fast track & homeless patients.

Essential criteria

Supporting people to go home should be the default position, with alternative

pathways for people who cannot go straight home.

Free at the point of delivery, regardless of ongoing funding arrangements.

To be safe if the person is going home, the assessment should be done

promptly (within 2 hours), with rapid (on the day) access to care and support if it

is required.

Support services should be time limited - up to 6 weeks, in the best systems the

average appears to be 2 weeks and can be longer than 6 weeks in exceptional

cases.

Non-selective, a service that tries to always say ‘yes’ - to include support for end of life care.


Additional guidance

Home First will ensure early identification of long term needs and appropriate

referral to ASC as part of the Pathway management.

Where there has been an existing POC, this may continue alongside Home

First where appropriate. There will be good communication between

providers to ensure timely discharge from Home First services and where

possible a reduction in the long term provision.

Home First is committed to a smooth and timely transition, however where this is not possible it will be escalated to the Pathway manager as soon as possible. Delays will be reported and discussed at PDF daily.

The IDT will continue to support discharge planning for those patients entering Pathways that require assistance and have been deemed self-funding. The ASC, Discharge Liaison Nurse and or discharge facilitator will provide this to the patient, family and staff if required.

Daily procedure A small Home First team is responsible for managing and coordinating the discharge flow. The discharge planners, therapists and ASC across the system are responsible for decisions, communications and medications pre-discharge and the professional assessment, goal setting, review and planning of longer term care and support arrangements. SCC in partnership with CCG and trusts, have commissioned a range of providers to support the process of assessment either in the persons home or the most appropriate setting. A keyworker (from ASC or Health) will be identified at MDT to support the discharge process, where the decision will be made about the appropriate route for assessment. The key workers role will be to assess at home or in an agreed setting outside of hospital, and develop clear goals to support recovery. The key worker will have access to appropriate resources and Home First will administer the support with the appropriate commissioned provider where funded support is required. (This will be for a time limited period to support specific goals and to enable the key worker to determine longer term arrangements) The ward MDT will identify patient appropriate for Home First Pathways when they are discussed at the ward board rounds. The referral form/risk assessment tool will be used to help MDT staff identify the right pathway for the patient, they will then complete the referral form for the pathway and refer in the agreed process for each pathway.


P1 = E-mail the referral to Home First ensuring this is followed by a call to the receiving therapy team. The provider will also be contacted with details of the discharge plans. P2 = Daily contact times will be agreed between the community hospital and Home First to discuss existing patients and agree new patients admissions that have been identified at the board rounds. P3 = Daily contact times will be agreed between the nursing home and Home First to discuss existing patients and agree any new admissions that have been identified at the board rounds. The decisions relating to appropriate pathways will be discussed and supported by the Pathway Manager/Appropriate representative and IDT to help the ward MDT in the identification of the most appropriate pathway. Home First will work in conjunction with the normal discharge processes for those patients either not appropriate for Home First or not yet within the project phase of the pilot period and therefore normal activity will be maintained and daily PDF forums will remain to ensure effective discharge processed continue. Stakeholders including: IDT- representatives from health, social care, and Somerset Partnership NHS Trust. This may also include therapy and or nursing staff from ward areas if required.

Patients discussed at the board round and

considered medically fit in 24 hours

MDT use Referral form/assessment tool to identify appropriate pathway

Referred to appropriate pathway for discharge on the date agreed as MFFD

Discharge communicated with patient and family and medication/transport and discharge summary arranged 24 hours before to discharge

Patient discharged on the agreed date MFFD. Patient met by community

reablement team and reablement plan set with new EDD.


Review meetings Regular review meeting will be held daily, and reviewed as the pilot progresses, they will be chaired by the Home First Pathway Manager and attended by the Somerset Partnership Pathway Manager (Therapy lead), SCC ASC, community therapy leads for Home First and Commissioned provider leads. (this may require a conference call where appropriate and for the initial start-up period of the service this may be required daily). Cases to be reviewed will be those patients who have been discharged into an appropriate pathway. A progress report will take place along with further actions required. (These meeting may be increased or reduced as the service requires). This will also be an opportunity for all stakeholders to agree a forward process, to highlight any capacity and demand issues that may affect flow, to discuss patients that are not progressing through the pathways and future options available and to share evidence of best practice. Practice Development Forums:

Key principles

Assessment upon day of admission with goals defined by the person themselves which will lead to a timely discharge back to the person’s home. Estimated date of discharge agreed at this point. Progress against goals monitored daily and shared at PDF to enhance discussions. Discharges to be timely and plans must take into account a person’s own assets and support network. Personalised approach with reduction in reliance upon funded care.

What is the purpose of a PDF?

To monitor progress of a person’s journey to discharge and ensure goals are met in a timely manner with professional discussion improving practice and service delivery and reducing any barriers to discharge. PDFs seek to develop professional practice by providing the opportunity for challenging but safe discussions to be held amongst multi-disciplinary teams for the benefit of patients. PDFs are the main decision making forum regarding care and support of each person.

Why do we need PDFs?

To ensure we deliver the best outcomes for people To reduce the length of time people spend in community hospitals, where we know they are at risk of physical and mental deterioration.

Who should attend a PDF?

The decision as to who the most appropriate people to attend a PDF should be made at a local level. However as a minimum it is expected that the following professionals should be represented.


Ward sister (and usually the chairperson)

Ward based nursing and therapies staff

Social care worker or locality lead (Pathway venues to have decision maker present at other venues decision to be validated within 24 hours)

An action note keeper Other attendees could include: medical staff, including GPs, district nurses, CPNs, health care assistants, village or community agents

How frequently should they meet?

This will vary from hospital to hospital, for example many acute hospitals have daily PDFs, some community hospitals have two every week but most only have one per week. You must decide within your team what works best for you and your patients If you have daily Board Rounds you may only need weekly PDFs. However PDFs should take no more than one hour for 10 patients. Transition and discharge arrangements

• The PDF will be presented with the challenges in getting home and a clear

support plan for short term core care or in very expedient circumstance P1.

• There will be a clear escalation plan for every patient

• Professionals representing the person will be asked to demonstrate the key

benefits for the transition off the pathway and the steps they will manage to

support this.

• Home visits will be made by P2 therapists and or ASC staff supporting the

pathway as appropriate to determine a safe transition home.

• Expectation to also explore no cost community options via community agents

and evidence that IRT or the Complex Care community team are unable to pick

up.

• A narrative will be required that includes details of the agreed goals, progress of

achievements and what additional support has been identified that demonstrates

the robust decision making for the step down rather than home with no care or

home with care.

• Pathway 2 will benchmark targets for transition and these will monitored and

reported. The Pathway 2 therapist to do the work-up for discharge planning.

• All referrals for placement (including self-funders) will be made on assessment

for long term care.

• In some circumstances where a person goes home with no other support follow-

up calls can be made following discharge for the first few days home.

• “Older reablement Service” will not be an option for people using pathways,

consideration of time limited core service would be the appropriate route.

• Where a person requires core care this is applied for in timely manner on P2.

Education and Training


All staff within the Home First programme will complete their mandatory training and regular updates as required by their individual partner organisation.

Generic working will raise issues of inter-professional competence and on-going training needs analysis will need to be regularly undertaken (on service mobilisation and at least annually) and steps taken to close any competency gaps with a particular discipline/group of staff.

Training needs will be identified by partners within the Home First Operational Group in order that the therapists and Reablement Service can meet the programme objectives. All support staff will complete additional training and be assessed as competent prior to undertaking delegated task; on-going training will be provided on a regular basis. Each member of the virtual Home First team has a responsibility to ensure all relevant assessment, therapeutic and reablement activity documentation is completed and up to date in accordance with organisational policy. Incident reporting All staff will use existing procedures in place to report incidents that have occurred for those staff or patients entering the Home First Pathways that relate to discharge concerns. For community Hospitals this will be the Datix system. For any high level concerns with the process of Home First the Pathway Managers should be contacted at the earliest opportunity. The Following incidents will be reported to Home First:

Poor Performance practitioner / practise level

Equipment incidents

Frailty incidents

Safeguarding alerts

Fails resulting in harm

Serious incidents

Pressure ulcer damage acquired on pathways

Staff capacity

Process: Any incident on pathway to be reported via specific provider process All incidents to report investigation actions (in organisation) All incidents reported on dashboard to be confirmed with clear actions by HF

manager. This will include:

Continuity planning

Mitigating risk

Patient/ provider escalation.

Lessons learnt from incidents to be shared at PDF and monthly governance /operations meetings.


Accountability The individuals within the Home First collaborative are ultimately accountable to their own organisations (known as partner organisations within this document), but also responsible to the Heads of Home First Pathway Managers in both Yeovil District Hospital and Taunton and Somerset NHS Foundation Trusts. There is an expectation that partners will work collaboratively to problem solve on day-to-day operational issues. Reporting – Data Monitoring and flow management Home First will report live info that can track progress of people through their recovery. All referrals to Home First will be uploaded to share point. The data sharing required for statutory returns will respond to any additional requirements to support statutory data sets. The data requirements for statutory reporting requires the need to upload all referrals to AIS system. This will be initiated from September 2018. Daily reporting of delays in systemwide agreed format. Weekly dashboard to contain the following detail: Number of Patients entering pathway Number of patients discharged on pathway Average bed days saved Hospital discharges 65+ Length of stay on pathway Pathway outcomes : continues POC, increased POC, reduced POC Readmitted 91 days Deaths on pathway Incidents Patient Flow See page 13. Seven day working Plans and timescales to be clarified.


Patient In hospital

In A&E

In Rapid Response

MDT or A&E Decision making and key worker identified – core

information

PDF to manage discharge flow

across the system

Not for HF: Stroke? Some LTC

restarts: Homecare and

placements

Home First pathway 24 hours response after MSFD

Key Worker to coordinate

Assessment and goal setting within 12 hours of discharge destination – any immediate

support needs met

Access to wider support services identified in Support Plan: deployed within 48 hours

2 x weekly PDF reporting by Key Workers Date set for discharge or moving on plan

Delays / unmet needs reported


The patient is discussed at the board round and deemed appropriate for discharge into

pathway 1 by the MDT after completion of the Risk Assessment tool. These will be patients that will be medically fit for Discharge within 24 hours.

(For the test and learn period and during the initial stages of roll out to the clinical

areas) : The Risk Assessment tool will be discussed and agreed with the Pathway Manager/appointed representative to help support the ward MDT staff with validation of acceptance into the appropriate pathway and actions agreed for discharge planning within 24 hours.

The patient is referred to Community Reablement teams and given a timely discharge

slot .

Transport services are arranged in accordance to the discharge slot. This can be done by the IDT or ward staff.

The patient and the family are informed of the discharge date and time. This should

match the information that the patient was given when setting a EDD. This can be done by the IDT or ward staff.

The patients medications and discharge letter are ordered 24 hours prior to the date of

discharge, and ready for discharge. This should be done by the appropriate ward staff with assistance of the IDT.

All other appropriate services are contacted if required, (as would normally be required

byt that patient) - such as DN teams 24 hours prior to discharge.

The patient is discharged on the date agreed as fit for discharge.

The patient will be met, in their own home at the agreed time by the reablement therapist and a reablement plan agreed. The therapist will inform the patient of the ongoing input and who will be providing this. The therapist will then set another EDD from the Pathway. The EDD will be communicated to the patient and family if nessassary. The reablement care required will be discussed by the community therapist to the provider teams and the EDD discussed. The information will then be fed back to the Pathway Manager on the day the EDD set. (this can be done via the admin support for Home First).

Daily review meeting will continue to monitor the progression of the discharge plan and

any further actions required. The community therapy team will liaise with the Pathway manager. If additional core care/placement required the IDT support.

The patient will complete required level of service and be discharged within the given

timeframes or continue with actions implemented or referred to a different pathway/voluntary sector.

At the time of Discharge from the pathway the patient will complete a patient

questionaire for feedback of the service during the test and learn period.

Standard Operational Policy for Pathway 1 Patients


The patient is discussed at the board round and deemed appropriate for discharge into pathway 2 by the MDT after completion of the Risk Assessment tool. These will be patients that will be medically fit for Discharge within 24 hours.


areas) : The Risk Assessment tool will be discussed the Pathway Manager/Appointed representative or IDT to help support the ward MDT staff with validation of acceptance into the appropriate pathway and actions agreed for discharge planning within 24 hours.

The patient is referred to Community Reablement inpatient teams and given a timely

discharge slot.



match the information that the patient was given when setting an EDD. This can be done by the IDT or ward staff.

The patients medications and discharge letter are ordered 24 hours prior to discharge

and are ready for discharge. This should be done by the appriopriate ward staff.

The patient is discharged.

The patient will transfer to the community inpatient setting and have reablement goals set by the therapy team. An EDD will be set and the reablement will progress during the patients stay. This period of reablment is subject to change according to the patients needs at the time, so patients may stay shorter or longer periods depending on their ability but the EDD should be reflective of approximatly 2 weeks.


any further actions required. The community therapy team will liaise with the Pathway manager.

Prior to discharge the patient may require additional consideration as to their longterm

care needs and a referral to IDT should be considered before the EDD so that if interventions are required this can be arrananged prior to the EDD.

The patient is discharged home and no longer needs reablement input. If onward care

provision is required the patient will be assisted by the IDT team or any voluntary services appropriate. In a small number of cases in may be nessassary to referr to a reablement provider to ensure that patient is safe at home.

At the time of Discharge from the pathway the patient will complete a patient




The patient is discussed at the board round and deemed appropriate for discharge into Pathway 3 by the MDT after completion of the Risk Assessment tool. These will be patients that will be medically fit for Discharge within 24 hours.


areas) : The Risk Assessment tool will be discussed and agreed with the Pathway Manager/appointed representative to help support the ward MDT staff with validation of acceptance into the appropriate pathway and actions agreed for discharge planning within 24 hours.

The patient is referred to Community Reablement inpatient teams and given a timely

discharge slot.



match the information that the patient was given when setting an EDD. This can be done by the IDT or ward staff.

The patients medications and discharge letter are ordered 24 hours prior to discharge

and ready for discharge. This should be done by the appriopriate ward staff.

The patient is discharged.

The patient will transfer to the community inpatient setting and have reablement goals set by the therapy team. An EDD will be set and the reablement will progress during the patients stay. This period of reablment is subject to change according to the patients needs at the time, so patients may stay shorter or longer periods depending on their ability but the EDD should be reflective of approximatly 6 weeks.


any further actions required. The community therapy team will liaise with the Pathway manager.

Prior to discharge the patient may require additional consideration as to their longterm

care needs and a referral to a social worker should be considered before the EDD so that if interventions are required this can be arrananged prior to the EDD. For patients in Pathway 3, because it is clear that the reablement will take longer then it should be a period of 3 weeks before social input is considered.

Further Discharge discussions should be continuing with the patient, family and

involving the reablement team as to what the realistic outcomes of the reablement programme are.

The discharge destination is agreed. The plan for all patients is to get home. If this is

not possible after reablement then the outreach IDT will support with discharge



planning to a long term environment agreed with the patient and/or family where appropriate.

The patient may require additional assessment need such as Understanding

You/CHC checklist. If this is required then a referral to the IDT at the acute trust is required.

At the time of discharge from the pathway the patient/family will complete a


Escalation Plan for Pathway 1 The wards will be asked to ensure the patients leave the ward by the agreed time slot and agreed date otherwise the patient may have to wait until the following day to be discharged. In the event the patient HAS left the ward after the time slot agreed, the coordinator must speak with the community Home First team a.s.a.p. to check if they are able to meet the patient at home or at the earliest possible time. If community rehab are unable to meet the patient at home and they have already left the ward, then all efforts must be made to try and liaise with the care providers and/or reablement team to priorities the needs immediately to enable the patient to remain at home. If possible refer the patient to the RHSS community reablement team so that the patient’s safety can be maintained until the home first team visit. The patient must be deemed to be safe to be left at home until the following morning when Rapid Response care will assess. The Coordinator/Pathway Manager must explore all areas of support available, such as other health teams on duty? DN, friends, family and care agencies including the volunteer sector. If support is unable to be sourced then the Home First Coordinator should explore inpatient support such as community hospital or interim placement. In the event these avenues are not successful and the patient is deemed unsafe to remain at home, then the patient must be returned to hospital and the ward to be informed. THIS MUST ONLY BE AS A LAST RESORT BECAUSE THE PATIENT IS UNSAFE TO REMAIN AT HOME. If cases occur when this has happened then the Home First Pathway Manager and the Discharging ward sister should hold a case review meeting to learn from and ensure future avoidance.

Escalation Plan for Pathway 2 and 3

The wards will be asked to ensure that the patients discharge happens at the agreed slots and date of discharge. If this has not happened then the ward staff


must contact the appropriate community reablement provider to ensure they still agree the discharge of the patient. If the community provider does not agree the discharge then the Pathway Manager/appropriate representative must be contacted to liaise with the community provider to resolve the discharge concerns to enable the patient to enter the pathway without returning to the hospital, UNLESS THIS IS CLINICALLY REQUIRED. For patients within Pathways 1, 2 & 3 if their clinical condition changes and they then require medical input the GP should be contacted as normal and more serious concerns may require further hospital interventions, however if the reablement needs change then the patient will be discussed at the daily review meetings and the pathway manager and the community therapy leads will identify new actions for onward management.

Minimum Requirements for Home First Tick All to Confirm

Patient is physically safe to be left alone BETWEEN visits

Patient is cognitively safe to be left alone BETWEEN visits

Continence can be managed throughout the day and night (independently or with arranged support)

Medication can be managed (independently or with arranged support)

Essential free standing equipment can be put in place by hospital

Patient Name: NHS Number:

Date: Ward:

Therapist Name: Signature:

Please tick either Yes or No YES NO

1. Has the patient consented and have the family been informed of the discharge plan?

2. Does the patient have any visual/hearing problems?

3. Does the patient have any cognitive impairment or mental health history/concerns?

4. Does the patient have medication and if YES, will they need support with taking it (include how many times per day they take it). Do they need to demonstrate concordance?

5. Any TTAs required for discharge?

6. Does the patient have any Nursing needs? If yes, SBAR to be completed and attached

7. What are the access arrangements? Does the patient have a key? Is there a key safe?

8. Does the patient need support (maximum 4 visits per day)? Please indicate how many visits per day you feel the person may require and what tasks they need

support with, including possible night support.

9. Is there any essential free standing equipment required that needs to be in place when the patient returns home? E.g. Commode

10. If lives alone, heating/essential supplies needed?

If Yes, please give any additional details here, please mark which question this refers to:

Risk Assessment Tool


Plan: Specify timescales patient needs to be seen:

Final Decision: Date:

Patent details

Staff Name: Contact Number:

Signature:

Eligibility Criteria: NB: The Service is free of charge to the patient Patient must: Be aged 18+ years of age, be a resident of Somerset & registered with a Somerset GP, require a Health and/or Social Care assessment within their home environment and meet the 'minimum requirements to for discharge Home First service’


Affix Patient Id Label Surname: Forename: Hospital / NHS Number: Date of Birth:

Patient Details Next of Kin

Address Name

Post code Relationship

Phone Phone

Carers Details (if applicable) LPOA

Name

Address

Phone

Registered GP & Practice

Referrer’s Details

Name Ward/Base

Designation Phone/Bleep

Date of referral Time of referral

Taken By

Social Situation and Current Social Care Support (any lone working/safeguarding concerns)

Presenting Complaint/ Reason for Referral/Suggested Goals (please include any cognitive issues)

Falls

Recurrent falls Single injurious fall

Single fall with balance or gait problems History of fragility fracture if over 50 years of age

Number of falls in the last 12 months Osteoporosis treatment

Relevant Medical History

Current Medication (include any known allergies)

Has medication been considered and excluded as a likely cause of falls or presenting complaint? If not what outstanding concerns remain

TSDFT 5060 0.6 03/17

Barcode

Home First Referral form

[email protected]


Home First SOP

Responsibilities of each partner organisation

Partner Responsibility within Home First programme

Somerset County Council

Funding

Contract Management

Strategic Leadership

Yeovil District Hospital

Leadership of Programme in South Somerset

Monitoring discharge pathways –

admission/discharge

Therapy Leadership in South Somerset

Taunton and Somerset

Trust

Leadership of Programme

Monitoring discharge pathways –

admission/discharge

Therapy Leadership in South Somerset

Somerset Partnership Trust

Community Hospital/Rehabilitation Facilities for D2A

Discharge Co-ordination within Community Hospitals

Community Nursing

Rehabilitation Partners Reablement Staffing for Home First Pathway 1

Efficient and effective rehabilitation of clients (KPI’s)

Symphony Healthcare

Complex Care Team (key workers) – admission

avoidance

GP and Health Coaches

CVS Community Agents

Micro Provision – self-directed support


APPENDIX C TRANSFER CHECK LIST

DATE

TIME

FROM HOSPITAL DESTINATION HOSPITAL

STAFF NAME

SIGNATURE

YES NO N/A COMMENTS

Patient’s condition summarised / reason for transfer

Resuscitation Decision and STEP handed over

Important medications handed over

Oxygen requirements

Infection Status handed over

Equipment/Aids

Mobility Status

Destination confirmed

Informed GP

Informed relatives

Patient’s Notes or Clinical Summary

Affix Patient Address Label

Here


APPENDIX D


If your preferred option is not immediately available, it will be necessary for you to move to a short-term placement. Information about this will be provided by your Social Worker. Other support to help with any concerns is available for patients and carers from:

Age Concern Tel: 01823 326212 Care Direct Tel: 0845 3459133 The day of your discharge A final check will take place to ensure that everything is in place for your discharge. You may be seen by a nurse instead of a doctor immediately before your discharge. On your day of discharge you will need to be ready to leave the ward by 11 am at the latest. If applicable, you will need to check that you have your SAP document and your discharge letter with you on the day of discharge. A supply of your current medication may be given to you or your family/carers. If you have any questions or concerns about your medication, please speak to the nurse in charge.

Useful Contacts (Staff to highlight those relevant to patient) Ward: ……………………………………………… Social Worker: Occupational Therapist: Physiotherapist: District Nurse:

PLANNING TO GO HOME (Adult patients)

Patient: Admission Date: Planned Discharge Date:

APPENDIX E


Our commitment to you We appreciate that a hospital stay can be a stressful and worrying time. We will offer support and advice to you and your family or carers throughout your hospital stay. We will discuss with you the continuing support you may need when you leave hospital. This will help to make the transition as easy as possible. If you have any queries regarding the information contained in this leaflet please raise them with any member of the team caring for you.

Planning for your discharge or transfer from hospital This hospital is the right place to be when you are in need of specific care and/or rehabilitation. However, when this has been completed it is important that you leave hospital as soon as possible so that another patient can be admitted to receive treatment We will start planning for your discharge as soon as you are admitted. This means that we will begin to:

assess what your needs are likely to be when you are ready to leave hospital

involve any relevant staff who can help in meeting those needs, e.g. Occupational Therapist, Physiotherapist, GP, Speech Therapist, Community Nurse, Social Worker, etc.

organise equipment or services that you may need when you leave hospital

Working together All staff will work with you and your family/carers to plan an effective discharge or transfer.

There may be concerns such as your future safety, your ability to move around, or to manage your personal care and domestic arrangements. If so, please have no hesitation in raising these with staff at the earliest opportunity.

As soon as we know when your treatment will be completed, you will be given an expected discharge or transfer date. It is important that you are aware of this so that necessary arrangements can be made. These may include:

transport home – patients are normally expected to arrange their own transport

suitable clothing and footwear, if you are not already using them in hospital

access to a key to your property

adequate basic food supplies at home

adequate heating in your home

delivery of any equipment needed to provide continuing care in your home

Further support If there are difficulties in returning to your

home, a number of options can be considered. A Social Worker is available to discuss these with you and your family/carers. Options might include:

an emergency call system

home care

adaptations in your own home

moving to sheltered housing

moving to extra care housing where there is 24 hour support and care

short stays in a residential or nursing home

longer term accommodation in a residential or nursing home

Admission, Transfer and Discharge Policy (Community Hospital Inpatient) V4.0 -- 51 -- October 2018

APPENDIX F SOMERSET PARTNERSHIP NHS FOUNDATION TRUST

COMMUNITY HOSPITAL SIMPLE DISCHARGE CHECKLIST

PLANNED DATE/ TIME OF DISCHARGE:

Initial Date: Change Date: Reason:

Change Date: Reason:

Planned Discharge Destination: Home Nursing Home Residential Home Other (please specify) Care Package Community Support Team

Comments Yes / No Date Signature

Multidisciplinary Team agreement for discharge

All equipment arrangements made Please state:

Social Work agreement to discharge date

Care package in place – Date and start time:

Patient aware of proposed discharge date

Relatives aware of proposed discharge date

Call required on discharge

Community Services informed OR Community Support Team arranged

Telephone contact with District Nurse Team

Person to receive patient arranged

House keys available

Heating on

Food available

Admission, Transfer and Discharge Policy (Community Hospital Inpatient) V4.0 -- 52 -- October 2018

Comments Yes / No Date Signature

Relatives able to transport patient home

Patient is able to transfer into a car?

Hospital transport booked (please circle)

Car / Ambulance / Sitting / Stretcher

Discharge Medication

Ordered Received

Consider Compliance Aid

GP Surgery informed

Out-patient appointment made / to follow by post

Referral to Specialist Psychiatric Liaison team / Memory Service, or GP for specialist diagnosis (dementia)


SIMPLE DISCHARGE CHECKLIST (Continued)

Day of Discharge

Tick Discharging Nurse (Print Name)

Inter-healthcare infection control transfer form to be completed on all relevant discharges

GP letter given to patient or sent to GP

District Nurse referral completed and given to patient if appropriate

All discharge medication given and explained to patient. Explain how and when to obtain resupply of medicines if required.

For all patients receiving anticoagulant therapy, fax INR and medication record to their GP on the day of discharge and update the patients yellow card. Ensure patient or carer understands daily dose to be taken and when and where next INR test is to be done.

For patients with monitored dose systems ‘blister packs’ – inform patient’s nominated community pharmacy that patient is to be discharged and of changes in medication since beginning of episode of care

Pad/dressing checked if appropriate

Pads/ dressings/catheters/stoma supplies given to patient if appropriate

Check that ALL cannulae have been removed

Property returned to patient including from the safe e.g dentures, glasses, hearing aid, etc

Relatives/ carers/ relevant destination informed

Yes/ No

In the event of death, checklist completed Yes/ No

In the event of a discharge or patient death, form completed and documented in records Yes / No Print Name:............................................................ Signature:............................................................... Date:.........................................................

Print Name: ............................................ Designation: ............................................... Signature: ............................................ Date / Time: ............................................ Contact Number: ............................................


APPENDIX G COMPLEX DISCHARGE PLANNING FORM

Patient at risk because (tick relevant box) Requires Specialist assessments Already received community services Requires complex package of care Family / Carers / Staff have concerns ↑Dementia ↑ Learning Disability Discharge Leaflet given on Admission: YES / NO Is SAP required: YES / NO

Referral to / request for

assessment to

Type of referral Verbal/written

Dated completed

Referrer Name and contact

details for assessor

Outcome of referral

Occupational Therapist

Physiotherapist

Social Worker

Specialist Learning Disability Service

Community Psychiatric Nurse

District Nurse

Community Matron or Case manager

Care Home Matron

Red Cross ‘Home from Hospital’

Other (eg Dietitian, Independent Mental Capacity Advocate

Use nursing continuation sheet for more detailed comments, ID labelled and attached to this form Difficult/Reluctant Discharge Policy (refer to policy)

Action By Whom Date Issued

Letter 1 issued

Letter 2 issued

Letter 3 issued

Addressograph


APPENDIX H

Self-Discharge 1.0 It is the Nurse in Charge responsibility to inform the ward doctor /ANP or out of hour’s medical service if a patient wishes to self-discharge against medical advice. Inform the on call Manager out of hours. 1.2 The Nurse in Charge should take all reasonable practical steps to persuade the patient to await the doctor’s arrival and discuss the reasons to remain. If there are any behavioural issues or risk of harm a priority call should be considered. 1.3 If self-discharge would leave the patient at risk it is the responsibility of the Clinician/Nurse in Charge to review the patient, reason for admission and the need to stay in hospital then consider using either the Mental Capacity Act or the Mental Health Act

If the MDT agrees a patient has mental capacity and no care needs, allow

discharge.

If the MDT agrees patient has mental capacity but also has care needs a,

notification 2 to Social Services should be completed if the patient consents.

If the MDT agrees patient lacks mental capacity a notification 2 should be sent

to Social services in the patient’s best interest.

1.4 Assess patient using the Mental Capacity Act - follow the Consent and Capacity to consent policy.

if the patient has capacity to make the decision to leave this has to be

respected by staff and recorded in the patient’s record;

if the patient lacks capacity to understand the implications of taking self-

discharge the clinician must make a best interest decision and record this in

the patient’s record;

consider the Deprivation of Liberty Safeguards Policy;

seek support from senior management/ nursing/safeguarding team as

required;

1.5 Assessed under Mental Health Act:

consider mental health referral or a Section 5:2 of the Mental Health Act;

consider the Deprivation of Liberty Safeguards Policy;

request support from senior management /nursing/safeguarding team;


1.6 If a patient has capacity and all reasonable attempts have been made to persuade the patient to remain in hospital have failed the patient should be asked to sign the self-discharge form which should be scanned into the patients record. If the patient is unwilling to sign the Nurse in Charge or doctor should record this in the patient’s record.


Self-Discharge Against Medical Advice and Refusal of Treatment

Hospital No ………………………

Consultant ………………………

Ward ………………………

Hospital ………………………

Patient ID Sticker or write

Patient name:………………….

Address:………………………..

………………………………….

CHI:…………………………….

Assessment of the Patient’s Ability to Self-Discharge / Refusal of Treatment (All criteria must be fulfilled for the patient to be deemed capable)

1. Does the patient UNDERSTAND the proposed medical treatment? Yes No (Its purpose, justification, benefits, risks and alternatives)

2. Does the patient understand the RISK ASSOCIATED with not receiving the treatment? (For example risks that is very specific to them at this time) Yes No

3. Is the patient able to retain the information for long enough to make an informed decision? Yes No

4. Is the patient able to make a free choice without coercion or duress? Yes No

5. Is the patient able to communicate their decision? (this may include the use of an interpreter) Yes No

NB – IF YOU ARE CONCERNED ABOUT THE INDIVIDUAL’S CAPACITY OR RISK POSED BY SELF DISCHARGE, DISCUSS WITH SENIOR STAFF AND CONSIDER REFERRAL TO LIAISON PSYCHIATRY FOR FORMAL ASSESSMENT


Assessment of the Patient’s Medical Risk

Indicate below the working diagnosis or presenting complaint

.............................................................................................................................................................

.............................................................................................................................................................

Proposed treatment

...............................................................................................................................................................

...............................................................................................................................................................

List below the risks of self-discharge and refusal of treatment explained to the patient and fully document in the case notes

...............................................................................................................................................................

............................................................................................................................................................... Outcome:

• Advised of symptoms to be aware of and when to seek medical attention Yes No

• Advised patient s/he can return at any time for reassessment Yes No

• Discharge against advice leaflet given Yes No

• Patient self-discharged without waiting for medical review Yes No

Follow-up arrangements and other agencies informed (e.g. Social Services, GP, Prison Health Care Staff, Police, Next of Kin) please detail below:

.....................................................................................................................................................................

.........................................................................................................................................................

Essential medication supplied to patient (should not exceed 48 hours supply)

.........................................................................................................................................................

.........................................................................................................................................................

I, the undersigned, am taking my own discharge against medical advice. The risks of self-discharge have been explained to me.

Patient’s Name...................................... Signature...................................... Date …………….

Doctor’s Name...................................... Signature...................................... Date …………… Witness’s Name.................................... Signature...................................... Date …………….

Tick if information has been provided by interpreter □ Name of interpreter ………………………….

PLEASE FILE IN PATIENTS MEDICAL RECORDS AND COMPLETE AN IR1 FORM


APPENDIX I

GUIDELINES FOR CLERKING PATIENTS TRANSFERRED FROM AN ACUTE HOSPITAL TO A COMMUNITY HOSPITAL BED

Following an episode of acute care, patients who have an ongoing need for clinical care (medical, nursing or rehabilitation) can be transferred to a Community Hospital if their health care needs cannot be met at home. Patients identified as suitable for Home First Pathway 2 rehabilitation can be transferred to community hospitals providing Home First Pathway 2 service. The Somerset Partnership NHS Foundation Trust county wide Community Hospital admission criteria requires patients to have been assessed as medically stable and fit for transfer prior to transfer to a Community Hospital . Acute Trust Discharge Documents It is expected that patients will be transferred from an Acute Trust to a Community Hospital with the following documents

The patient’s medical notes, which should contain an up to date management plan authorised by the discharging clinician within 24 hours of the planned discharge date. This must include a full summary of the patients medical condition, history of treatment and investigations, a record of all information shared with the patients and family, and the ongoing clinical management plan.

A full, comprehensive and legible Medication Administration Record (MAR) which has been reconciled within 24 hours of the planned discharge date by the Acute Trust clinician responsible for the patients care.

Confirmation of all outstanding clinical investigations and outpatient appointments including transport arrangements.

A copy of the Inter Healthcare Infection Control Transfer Form (Appendix D) Community Hospital Admission of Acute Trust Transfers All acute trust transfers to a Community Hospital will be admitted with prior agreement of the nurse in charge who will be responsible for ensuring that the medical practitioner is informed of the patient’s admission. Wherever possible, patients should be transferred between the hours of 08.00am and 6.00pm, and anticipated transfers after this time should always be in discussion with the nursing shift leader.


In-hours it is expected that all admissions (including Acute Trust transfers) will be clerked by the Community Hospital Medical Practitioner or ANP, unless they are a reablement patient only in line with the Somerset Partnership NHS Foundation Trust clerking checklist. During the periods 6.30pm and 8.00am Monday to Friday and 24 hours on Saturday, Sunday and Bank Holidays, medical cover is provided by the Out of Hours Medical Service. In most instances the clerking of Out of Hours Acute Trust transfers will be completed on the next working day ie by the Community Hospital Doctor or ANP. Exceptions to this will include the following:

If there is not an up to date and clear management plan in place on admission

If the MAR chart is not clear, legible or authorised as accurate before discharge from the Acute Trust

If the patient’s medical condition changes or deteriorates at any time following transfer from the Acute Trust, and the patient requires a clinical review or if the patient has been admitted into a reablement pathway..

If any of the above should happen, the nurse in charge of the Community Hospital ward will require an out of hours doctor to attend the ward to complete full clerking of the patient, to include completion of a Somerset Partnership NHS Foundation Trust MAR chart. In the case of incomplete documentation, such incidents will be reported back to the transferring organisation. Staff will complete a DATIX Untoward Events Report form (accessible on the Trust Intranet) which will be used to analyse trends and highlight areas of concern. NB Primary Care admissions to Community Hospitals during the Out of Hours period will always require clerking by the Out of Hours Medical Service. It is likely that this service will be acting as the referring agent and clerking packs are available for the Out of Hours Doctors to enable this function to be completed in the patient’s own home prior to admission.


Appendix J

COMPLEX NEEDS ASSESSMENT FOR PLUS SIZED PERSONS REQUIRING

TRANSFER TO A COMMUNITY HOSPITAL

It is recognised that there can be specific equipment and care requirements when nursing plus sized patients (patients above 160kg /Body Mass Index (BMI) in excess of 30+ / or due to weight distribution / immobility). Points to consider / discuss prior to acceptance to ensure safety and care needs of patient can be met within the environment available. This is to include preventative control measures in case of emergency situations such as resuscitation, falls and evacuation.

Transfer details

Referring Nurse: Referring Hospital / Establishment:

Receiving Nurse:

Receiving Hospital

Date:

Patient information

Patient Name: Patient DOB /

MRN :

Patient weight:

Patient weight distribution / shape:

Patient height:

Body mass Index (BMI:

Patient condition:

Patient mobility:

Key points from admission area (e.g. equipment already used / in place)

Please state:

Environmental review - A route survey should be undertaken to support access, routes of transfer and suitable clear space see consideration points below

Consideration points

Guidance notes Suitable? Comments

Access to building

Consider steps / Ramps

Door / corridor widths

Lift access and SWL

Yes/No


Room / ward access/bathroom

Door widths

Corridor widths

Use a bed that

adjusts to allow

access from

room / consider

trolley transfer if

patient bed

bound

Yes/No

Space requirement to support patient and equipment

Bed space (?

needs to be

increased)

Equipment size

/ shape and

allow use e.g.

hoist

Yes/No

The load bearing of the floor

Suitable for

patient weight

and equipment

(If unknown

contact estates

for further

guidance as

required)

Yes/No

Emergency evacuation routes

Door width

(including fire

exits)

Stairs

Corridors

(plus sized

trolley could be

used if bed too

wide / hover

jack for lateral

transfer

requirements

Yes/No

Emergency evacuation equipment / plan

Items available

suitable for

patients size

and transfer

requirements

Yes/No

Falls / resuscitation equipment and plan

flat lift kit

Hoist

Stretcher

attachment

(resus) hoist

Yes/No

Deceased / mortuary

onsite transfer

trolley / suitable

storage or

identified

funeral director

Yes/No


If environment suitable to support patient transfer the following should then completed to support equipment provision.

Equipment Review - From patient information establish safe working load (SWL) of immediate equipment available/ key clinical items to meet patient care requirements. List the equipment which supports patient weight and size and put hire if required


Guidance notes Suitable / hire /loan?

Comments – state why if no

Key clinical items

Consider wrist

bands, blood

pressure cuff

Yes/No Hire / Loan

Bed Supports patient

size for SWL /

width

Hire suitable –

consider type for

access to support

evacuation or

have a trolley

transfer for this

Yes/No Hire / Loan

Mattress

Supports patient

size for SWL /

width or hire

suitable

Yes/No Hire / Loan

Chair / wheelchair

Supports patient

height, width,

depth and SWL

or hire suitable

Yes/No Hire / Loan

Commode / shower chair

Supports patient

height, width,

depth and SWL

or hire suitable

Yes/No Hire / Loan

Toilet / bath

Suitable for

weight or use

commode /

shower facility

Yes/No

Zimmer frame / walking stick

Supports patient

height and SWL

Yes/No

Stand aid

Supports patient

weight/

dimensions

Yes/No

Hoist system /slings

Meets patient

size and care

needs and space

allows correct

use

Yes/No

Lateral transfer equipment

Safe process and

equipment

supports weight

limit

Suitable in the

event of

Yes/No


Equipment Review - From patient information establish safe working load (SWL) of immediate equipment available/ key clinical items to meet patient care requirements. List the equipment which supports patient weight and size and put hire if required


Guidance notes Suitable / hire /loan?

Comments – state why if no

evacuation

Weigh scales To assess for

equipment

requirement and

clinical care

needs

Yes/No

Patient accepted for transfer:

Yes/No

If no please provide rationale as to why

Staff name (print):

Designation:

Signature:

Contact no:

Hospital:

Date: