#WeAreNSCP WELCOME TO OUR NEW MAGAZINE INSIDE SHOWCASING HOW WE WORK TO PROVIDE COMMUNITY HEALTHCARE IN NORTH SOMERSET NEW

Transcription

1 ISSUE 1 SPRING 2018 NEW #WeAreNSCP THE NSCP PRINT AND ONLINE MAGAZINE WELCOME TO OUR NEW MAGAZINE SHOWCASING HOW WE WORK TO PROVIDE COMMUNITY HEALTHCARE IN NORTH SOMERSET INSIDE FRAILTY SERVICE MINOR INJURY UNIT RAPID RESPONSE DISCHARGE 2 ASSESS COMMUNITY NURSING

2 WE ARE NSCP We are a social enterprise dedicated to North Somerset. We have 750 staff and are accountable to our staff shareholders. We provide community health services to support people to improve their health and wellbeing with care and compassion. OUR VISION Healthy communities where people are cared for closer to home and supported to maintain their independence. OUR AIMS Aim One Aim Two Aim Three To deliver high quality care by focusing on the needs of individuals, promoting self-care and supporting people to remain independent. OUR VALUES To create a sustainable workforce which is appropriately trained and supported to meet the needs of people and communities we serve. To ensure the long-term sustainability of our services and Company Quality: We provide patients and those who care for others with safe and effective healthcare, at the right time and in the right place. We strive to use the latest practices and continuously improve our approach. Respect: We really care about people. We put the needs of patients and carers first, understanding their best interests and listening closely to the views of colleagues before we make decisions. Partnership: We can only provide a great service if we join forces with partners across the health, education, social services sectors and community groups, and we use the ideas of patients, carers and our employees to shape the future. Effectiveness: By providing quality care efficiently and effectively, we can secure our future success and do more good in the community by investing surplus income and sharing our expertise and resources. Integrity: Every action we take is in the interest of improving the health of our community. If we see something we think is wrong, we have the courage to speak up and act. 02 #WEARENSCP MAGAZINESPRING 2018

3 WELCOME WELCOME FROM OUR CHIEF EXECUTIVE JUDITH BROWN We are proud to be rated Good by the Care Quality Commission and are striving to become Outstanding. I hope you will find our new publication interesting and informative. I am delighted to welcome you to the first edition of #WeAreNSCP; our brand new stakeholder newsletter. This biannual publication will help keep you up to date with the latest developments at NSCP and provide an opportunity for us to share our many achievements and successes with you. It is an exciting time for NSCP. We are nearly two years into our current contract to provide community health services for the people of North Somerset and have made huge strides in moving to our commissioned service model. We have created a new divisional structure for our clinical services aligned to GP localities and recognising urgent care, children and young people s services and specialist services as requiring their own discrete structures. We have successfully introduced mobile working with around 450 staff now able to work remotely and access the patient records in both patient s homes and all primary care settings. This is a really significant change for us. Mobile working increases patient safety as clinicians can easily access GP records, it enhances quality, as clinicians do not have to duplicate their assessments of patients and improves efficiency as clinicians do not have to return to their base to complete patient records. We have been working extremely hard with our partners on many projects. This work includes establishing the integrated discharge service at Weston General Hospital, developing the Making Every Contact Count programme and further developing our volunteer services. As well as these important developments we have recently been awarded the contract to provide childhood flu vaccinations across Bristol, North Somerset and South Gloucestershire and are looking forward to delivering this service alongside our fellow community health service providers; Bristol Community Health and Sirona care and health. I have particularly enjoyed visiting GP practices across North Somerset in recent months to further develop relationships with practices and enhance partnership working for the benefit of our patients. We are proud to be rated Good by the Care Quality Commission and are striving to become Outstanding. I hope you will find our new publication interesting and informative. We value all feedback and would appreciate your thoughts, or questions about this or any of our services. Please contact us at nscp.commentsandcompliments@nhs.net or call #WEARENSCP MAGAZINE SPRING

4 NEWS ROUND-UP IN THIS ISSUE Welcome An Introduction from our Chief Executive, Judith Brown. 04 News Round Up All the latest news from across NSCP. Getting to know our services 07 Introducing our Frailty Service How the team works and a patient s positive experience. 08 The Minor Injury Unit How the unit works and valuable advice about how to use our service. 10 How does Rapid Response Work? A service guide and a day in the life of a rapid response nurse. 12 How does Discharge to Assess Work? How we assess your discharge from hospital. NORTH SOMERSET COMMUNITY HOSPITAL REOPENING OUR INPATIENT UNIT In December the Inpatient Unit at North Somerset Community Hospital (NSCH) reopened following the completion of essential building works. Upon opening, the hospital officially changed its name from Clevedon Community Hospital to North Somerset Community Hospital. Sara Harding, Director of Operations, NSCP, said: We are pleased the Inpatient Unit at the community hospital reopened ahead of the busy winter period. This has allowed the unit to play its part in supporting the wider health service in North Somerset and beyond during the busiest time of the year for the acute hospitals. This has been an important project for NSCP and I would like to thank everyone who has worked so hard to make it happen. provide better environments for patient care. During the building works NSCP has been supported by the hospital s League of Friends, North Somerset Clinical Commissioning Group, hospital staff and the community. The beds in unit will form part of NSCP s Discharge to Assess (D2A) pathway 2. Find out more about D2A on page Find out about Community Nursing What we do and how we work in the community. NHS Property Services owns the hospital site. James Wakeham, Principal Construction Manager for the South West, NHS Property Services, said: We re pleased the upgrade is complete and that patients have returned to the ward. The investment is part of our work to Muriel Vaughan, the first inpatient admitted upon reopening CONTACT THE COMMUNICATIONS TEAM This magazine has been brought to you by the NSCP Communications team. If you have any feedback about #WeAreNSCP then you can contact Edward Keating or Rebecca Porch on Alternatively you can NSCP.communications@nhs.net FIND OUT MORE To find out more about North Somerset Community Hospital, log on to 04 #WEARENSCP MAGAZINE SPRING 2018

5 NEWS ROUND-UP SCHOOL-AGED CHILDREN IMMUNISATION CONTRACT NSCP has been awarded the contract to provide flu immunisations to school-aged children across Bristol, North Somerset and South Gloucestershire. NSCP will be the lead provider supported by sub-contractors Bristol Community Health (BCH) and Sirona care and health. Since September 2015 the children s flu vaccine has been offered as a yearly nasal spray free to eligible children. From June 2018 NSCP, BCH and Sirona care and health will provide the vaccination at schools. WINNING THE CONTRACT IS TESTAMENT TO THE SKILLS AND COMMITMENT OF STAFF ACROSS THE ORGANISATIONS AND NSCP S SUCCESS WITH LAST YEAR S CHILD FLU VACCINE CAMPAIGN. NSCP already provide the children s flu vaccine in schools in North Somerset and last year achieved an uptake rate of 78% - the highest recorded in the South West. Sara Harding, Director of Operations, NSCP, said: I am delighted NSCP has been awarded the contract as lead provider for the children s flu vaccine across Bristol, North Somerset and South Gloucestershire. Flu Immunisation at Winford School We are very much looking forward to working in partnership with Bristol Community Health and Sirona care and health to deliver this service. Winning the contract is testament to the skills and commitment of staff across the organisations and NSCP s success with last year s child flu vaccine campaign. This achievement will enable NSCP to extend knowledge and expertise into the Bristol and South Gloucestershire areas. Fiona Owens, School Nurse Lead, NSCP, said: Flu can be a very unpleasant illness for children and can lead to potentially serious complications including bronchitis and pneumonia. Healthy children under the age of five are more likely to have to be admitted to hospital with flu than any other age group which is why it s so important children have the vaccine. The vaccine is given as a single spray squirted up each nostril. Not only is it needle-free, a big advantage for children, the nasal spray is quick, painless, and works even better than the injected flu vaccine. I am pleased NSCP will continue to provide this very important service to children in North Somerset and I look forward to sharing knowledge with our partners. NSCP STAFF ARE FLU FIGHTERS PROTECTING PATIENTS BY HAVING THE FLU VACCINATION Each year the NSCP Flu Fighters run a campaign to encourage all staff, whether they work in a clinical roles or not, to have the flu vaccination. The NSCP Flu Fighters meet to begin planning the annual campaign in summer and strive to ensure staff have all the information they need and are able to have the flu vaccination at a time and a place which suits them. As healthcare professionals, it s our duty of care to take steps to reduce risk to those we care for. Flu can be fatal, particularly for people with certain long-term conditions, the elderly and very young. This isn t the only reason the flu vaccine is so important to us, we need to ensure we can continue to provide our services efficiently during the busy winter period. Following the success of last year s staff flu vaccination campaign, Flu Champions were once again recruited across services with the aim of encouraging colleagues to have the jab and help with any flu-related questions or concerns. Our final uptake rate is 79% of Frontline Healthcare Workers (FHCW) vaccinated which exceeds last year s rate. Judith Brown, Chief Executive, NSCP, said: Flu is a highly transmissible infection and the flu vaccine is the best possible protection against flu. Frontline Healthcare Workers are more likely to be exposed to the influenza virus, particularly during winter months when some of their patients will be infected. NSCP staff have also been reminded you can pass the flu virus on to patients, friends and family without even knowing you have it. There are many misconceptions about the flu vaccine which the NSCP Flu Fighters and Flu Champions have worked hard to dispel. I would like to thank all staff who have had the flu vaccine. #WEARENSCP MAGAZINE SPRING

6 NEWS ROUND-UP LEND A HAND ONCE AGAIN NSCP IS CALLING ON COMMUNITIES ACROSS NORTH SOMERSET TO LEND A HAND THIS WINTER AND HELP OLDER VULNERABLE PEOPLE SEND IN YOUR SOCKS CAMPAIGN The aim of the Lend a Hand campaign is to encourage local people to check relatives and neighbours are warm, have supplies of food, drink and medication and know how to access healthcare services if they become unwell. Now in its third year, Lend a Hand runs alongside the NHS Stay Well This Winter campaign ( which offers detailed winter health advice as well as the Bristol, North Somerset and South Gloucestershire s Right Care, First Time campaign which encourages people to choose the most appropriate healthcare services for their needs. Mary Lewis, Director of Nursing, NSCP, said: Winter is a challenging time for older people and healthcare services, due to the impact cold weather can have on health. There are lots of simple steps which can be taken to stay well in cold weather, for example, having a flu jab, eating at least one hot meal a day and staying as active as possible. It is important to seek advice from a pharmacist at the first sign of a winter illness too. Lend a Hand sponsors: Olivia Coleman and David Tennant This winter I would like to urge everyone to take the time to look in on loved ones and older, vulnerable neighbours to check they are safe and warm in their homes. It s an easy way to make a positive contribution to your community and could make a huge difference. WINTER IS A CHALLENGING TIME FOR OLDER PEOPLE AND HEALTHCARE SERVICES DUE TO THE IMPACT COLD WEATHER CAN HAVE ON HEALTH. Doreen Smith, Chief Executive, Voluntary Action North Somerset (VANS), said: We re proud to support NSCP s annual initiative and would like to encourage everyone reading this to pledge to Lend a Hand this winter. Winter can be a difficult time of year for older people who are more susceptible to health problems in cold weather so checking on neighbours and relatives can help them stay healthy, safe and comfortable. Volunteering is at the forefront of positive social change and development and has many benefits, not only for those receiving support, but for volunteers too. If you re worried about an elderly relative or neighbour, contact North Somerset Council on or call the Age UK helpline on Please join us and Lend a Hand this winter If you use social media, please tell us what you do to help using #lendahandns SUPPORT FOR HOMELESS PEOPLE IN NORTH SOMERSET FROM OUR COMMUNITY OUTREACH SERVICE Our Community Outreach service provides valuable support to homeless people who have a background of substance and / or alcohol misuse. The team care for homeless people in Weston-super-Mare and help with general health advice, dietary advice, minor injury care, advice on safer sex, alcohol and drug use and support with registering at a GP practice and other local health services. People become homeless due to many different personal and social factors and sadly life expectancy for a homeless person is just 47 years. Winter is a difficult and dangerous time for homeless people and this year the Community Outreach service called on NSCP staff for help. During the winter months the team see an increase in the number of homeless people suffering with skin damage to their feet caused by the drop in temperature. To help prevent this the team asked staff to send new, or good condition, second hand socks which the team is giving to homeless service users to prevent cold weather foot problems such as chilblains. This small act of kindness is making a huge difference to homeless people in North Somerset. 06 #WEARENSCP MAGAZINE SPRING 2018

7 GETTING TO KNOW A OUR DAY IN SERVICES THE LIFE AN INTRODUCTION TO NSCP S FRAILTY SERVICE NSCP s Frailty Service supports older people who live with frailty in North Somerset. Frailty is used to describe a health state generally related to the ageing process. Around 10% of people aged 65 and over have frailty, rising to between 25 and 50% of those aged 85 or over. Older people living with frailty are vulnerable to sudden changes in physical or mental wellbeing caused by seemingly minor changes such as an infection or the introduction of a new medicine. The good news is the adverse effects of frailty can be prevented and /or reduced and in the last two years NSCP s Frailty Service has helped improve the quality of life for more than 1,000 people living with frailty in North Somerset. NSCP use a clinical tool called The Edmonton Frail Scale to recognise frailty; people s individual needs are then reviewed with the Comprehensive Geriatric Assessment, a holistic review of physical, mental and social needs and recommendations are made to enhance well-being. NSCP s Frailty Service can support people with: New diagnosis; most commonly Dementia, Parkinson s Disease, Postural Hypotension (low blood pressure), Disorders of balance and movement and others. Optimising long-term conditions such as diabetes, heart failure, anaemia, osteoporosis and many others Medication reviews Blood tests, cardiac tests and X-ray Onward referrals, for example to other NSCP services such as the Falls team, physiotherapy and occupational therapy, but also to external specialist services like the Memory Service and Hospital Consultants. PATIENT CASE STUDY THE FRAILY TEAM ENABLE QUALITY SERVICE FOLLOWING REFERAL The Frailty Service provides support in the following ways: Complex Frailty Clinics held in various locations in North Somerset Home visits offered to patients who have difficulty attending a clinic Multi-disciplinary meetings in which GPs and other healthcare professionals are supported by providing specialist advice Ad hoc advice to support clinicians to manage patients in the community without a specialist appointment Specialist advice for Parkinson s disease patients including support for newly diagnosed patients and medication reviews for housebound patients. The team comprises of a Consultant Geriatrician, Frailty Practitioner and Mental Health Nurses and work very closely with NSCP s Clinical Pharmacist and Community Matrons. NSCP s Frailty Service accepts referrals for people aged 75 and over, or younger, with several diseases, or disorders, who are registered with a North Somerset GP. Referrals are only accepted from health and social care professionals. The Frailty Service works in integration with primary care, the acute hospitals, social care and voluntary sector. FIND OUT MORE NSCP s Frailty Team have improved quality of life for over 1,000 people The referral form and Edmonton Frail Scale can be found at: HOW THE FRAILTY SERVICE HELPED BETTY Betty is 86 years old and lives in a care home in North Somerset. She was referred to the Frailty Service by Weston General Hospital following an admission after a fall, which resulted in her sustaining a head injury. In the six months prior to her admission, Betty had become more confused and was experiencing periods of agitation and many falls. Betty has vascular dementia, a decline in thinking skills caused by conditions which block or reduce blood flow to the brain and a diagnosis of atrial fibrillation, a heart condition. Betty was taking nine medications to manage her conditions. Things began to improve for Betty after she was seen by the Frailty Service. The team completed an assessment and Betty scored 14 out of 17 on the Edmonton Frail Scale which indicates severe frailty. As part of the assessment, Betty s blood pressure and heart function were investigated. She had a thorough examination of her abdominal area and central nervous system. Betty was found to have apraxia, meaning she found motor skill tasks such as walking difficult, which she developed due to the progression of her vascular dementia. Betty s nutrition and dietary intake were reviewed and appropriate advice was given to the care home staff. The mental Health Nurse completed an assessment of the mood and advised the staff on how to best support Betty. The Frailty Service identified Betty was at high risk of falling again. The team advised care home staff on techniques to reduce her risk of falling and prescribed bone protection medication to reduce her risk of fractures if she did fall. Advice was given around skin care and delirium, an acute confusional state. Medication was prescribed to reduce the agitation Betty experienced at night-time and a mental health nurse gave further advice on how to support people with dementia to the care home staff. In addition, other medications which were no longer appropriate were stopped and a care plan was created with guidance on inappropriate ambulance calls. A letter with all the recommendations was sent to Betty s family, her GP and the care home with advice on how to contact the team if further input was required. Six months following the intervention from the Frailty Service, the care home informed the team despite the occasional fall, Betty has not been admitted to hospital again. #WEARENSCP MAGAZINE SPRING

8 GETTING TO KNOW OUR SERVICES Our on site X-ray facility. Open 9am-12pm and 2pm-4pm - weekdays only, unavailable on bank holidays. New Image Key messages here to ensure correct use of the MIU WELCOME TO THE MINOR INJURY UNIT The Minor Injury Unit (MIU) is a purpose-built facility based in North Somerset Community Hospital offering treatment for a wide range of minor injuries. Treatment is delivered by our specialist emergency nurse practitioners who are fully trained in the care of both adults and children. Our specialist practitioners are able to treat patients with minor injuries such as: Wounds and grazes Cuts needing stitches Trips and falls Broken bones (we have an X-ray facility on site) Minor injuries resulting from minor road traffic accidents Minor burns Sports injuries Sprains, bruises and abrasions Head injuries (no loss of consciousness) Simple eye trauma, e.g. foreign bodies Removal of foreign bodies Advice FIND OUT MORE For information about MIU, please log on to: Anyone above the age of three years can visit the MIU. Our waiting times are usually much shorter than at your local A and E department. We aim to see people within two hours and children are dealt with as a priority. We encourage you to attend the MIU with the conditions listed on the left to avoid delays and to help ease the pressure on our local A and E departments. There is free parking available at North Somerset Community Hospital. Opening hours: 8am-9pm (last patient admitted 8.30pm) seven days a week - aside from Christmas Day, Boxing Day and New Year s Day when opening times are 10am-6pm. X-ray opening hours: 9am-12pm and 2pm-4pm - weekdays only, unavailable on bank holidays. For patients attending the Minor Injury Unit, X-rays are only prescribed when clinically necessary following full assessment by an Emergency Nurse Practitioner. 08 #WEARENSCP MAGAZINE SPRING 2018

9 GETTING TO KNOW A OUR DAY IN SERVICES THE LIFE PATIENT CASE STUDY CHARLIE S TRAMPOLINE TRIP LANDS HIM IN MIU BOUNCING BREAKS BONES Charlie is a five-year-old boy who had been having a great time on the trampoline in the garden with his older sister who is nine. Whilst having lots of bouncy fun Charlie fell over and his sister landed straight on top of him. Charlie s mum heard him scream and it was obvious to her from the outset he had really hurt himself as he was screaming his head off. They only live a few minutes from the Minor Injury Unit (MIU) so she picked him up and carried him there and presented at the desk. Staff could tell from his cries he was clearly in distress and he was taken straight through into the department so he could be given some pain relief. As he was brought through it was obvious to the Emergency Nurse Practitioner (ENP) he had sustained a significant injury to his lower leg. On this basis he was given very strong pain relief and this rapidly helped settle Charlie somewhat. When he was feeling slightly more comfortable the staff were able to take him round on the trolley for an X-ray where their suspicions were confirmed that he had in fact fractured both the tibia and fibula bones in his leg. Once confirmed by X-ray the ENP with the help of the Healthcare Assistant (HCA) set his leg set into a plaster cast and this greatly helped with the pain as his leg was now stabilised. The HCA let Charlie choose a teddy from our give away box to help cheer him up. Then, given the nature of the injury, the ENP phoned the Bristol Children s Hospital and discussed the injury with the Orthopaedic Registrar at the acute hospital who was able to view the X-rays the MIU had just taken. Following this discussion, it was decided that Charlie should be transferred immediately to the Bristol Children s Hospital as they would likely need to take him to the operating theatre and reset his leg. Due to the severity of the injury and the likely need for further analgesia on route it was decided an ambulance transfer would be the most appropriate option on this occasion so one was organised. At the suggestion of the staff Charlie s mum called her partner and he went to their home to prepare an overnight bag and then came to MIU and brought Charlie s Lion that he sleeps with every night. The parents were very happy with the MIU service and a week or so later Charlie s mum came in to see the MIU staff to let them know that Charlie had actually had an operation and had some pins in his leg to help stabilise it but was doing really well and loving his crutches. #WEARENSCP MAGAZINE SPRING

10 GETTING TO KNOW OUR SERVICES DISCOVER OUR RAPID RESPONSE SERVICE The Community Rapid Response team provides 24-hour intensive nursing assessment and support. This includes short-term care packages for patients with acute health needs, in their own home for up to 14 days. We also support patients being looked after by our district nurses and community matrons. We strive to be the service which will visit all patients where it is appropriate in order to reduce unnecessary hospital admissions. The service includes referrals from the ambulance service to assist and assess patients who have fallen. Our service is for adults who: Have urgent health needs Have experienced a rapid deterioration in health or function which does not need hospital care as a result Require rapid intervention and a timely intensive care package Require access to time-limited social care as a result of a health need Require immediate access to a short-term care home bed and a timely return to their own home, or a home of choice. FIND OUT MORE For information about the Rapid Response Service, please log on to: When a patient falls and Rapid Response attends, the following process is followed. Initial inspection for any obvious injuries National Early Warning Score (NEWS) score whilst still on the floor NEWS score when raised with lifting device Assessment for sepsis Physical Assessment and Clinical Reasoning (PACR) (medical model) assessment to find cause of fall, e.g. Urinary Tract Infections (UTI), lower respiratory tract infections (LRTI) etc Mobility assessment Falls Risk Assessment Tool (FRAT) score Waterlow/Malnutrition Universal Screening Tool (MUST) score Onward referrals needed, ie physiotherapy or occupational therapy, pharmacist, Falls team (involved with multiple falls prevention), telecare Next day faller review which includes NEWS/ Sepsis screen. Edmonton frailty score with onward referral to Frailty service if score over #WEARENSCP MAGAZINE SPRING 2018

11 GETTING TO KNOW A OUR DAY IN SERVICES THE LIFE PATIENT CASE STUDY CARE AT HOME RAPID INTERVENTION ENSURES ACCESS TO APPROPRIATE HEALTHCARE Mr Davies, 92, lives alone in North Somerset and is supported by his three daughters. He has arthritis and poor eyesight. Mr Davies was referred to our Community Rapid Response service by his GP last year. He had a swollen wrist and was suddenly finding it less easy to move around. Community Rapid Response nurses visited Mr Davies at home and undertook a full nursing assessment. They identified Mr Davies needed additional care and a commode whilst he had mobility issues. The team referred Mr Davies to our occupational therapy and physiotherapy services. The next night Community Rapid Response received a call from one of Mr Davies daughters, she was concerned as she had noticed blood in his urine. A blood sample was taken to check for anaemia, a condition where the blood does not contain enough red blood cells or haemoglobin. The blood test showed Mr Davies did have anaemia and Community Rapid Response contacted his GP to advise this. In the meantime, the Community Matron sought advice from our Consultant Geriatrician with the Frailty Service. He was concerned, based on his symptoms, Mr Davies could have bladder or kidney cancer and made an urgent referral for a specialist appointment. The Community Rapid Response team continued to monitor Mr Davies carefully while he waited for the appointment and visited him twice a day at home. It is thanks to the team s perseverance and the Frailty Service s support Mr Davies received the urgent care and support he needed. PROFILE A DAY IN THE LIFE OF A RAPID RESPONSE NURSE WE CATCH UP WITH NURSE SUE BEBBER TO EXPLAIN HER WORKING DAY My shift today starts at 7am and ends at 8.30pm (I choose to work long days). 7am Arrive at work along with a General Support Worker (GSW). I take handover from the night staff via a phone call. This morning the night team hand over two patients, one who had a fall overnight and one who may require homecare. 7.15am A patient calls to report a blocked catheter. It was clear a visit was required before the district nurses came on duty. There is another palliative patient, in pain. I decided the palliative patient took priority and visited to administer medicine and offer advice and support to his family. Then I visited the patient with catheter problems and changed the catheter as it was blocked. 8.45am Back at base. Every morning at this time we have a telephone conference call. This includes both North and South Rapid Response, clinical hub, physiotherapy and occupational therapy. We discuss staffing for the day, capacity of our team, IV team, homecare and the hospital. 9am I have handover with the rest of the team who have now come on shift. As team lead I allocate the visits in the diary of which there are six. Before I leave for my visits a referral comes via the clinical hub, a lady has fallen. A GSW and I attend. We help the lady from the floor using specialist equipment and carry out a full assessment. I then visit my allocated patients. This includes a lady with a chest infection the GP has requested we monitor for a few days. She was much improved, so was discharged. Next is a man with catheter problems who may have a Urinary Tract Infection (UTI). The patient was found slumped across the bed semi-conscious. Ambulance called and the patient taken to hospital. 3pm We discuss our visits this morning with those coming on shift: who has been discharged and who requires further input. 3.30pm I catch up with some admin and complete any outstanding EMIS entries (patient records). 4.45pm I visit a patient for a faller review, who was able to be discharged. I visit a lady who was referred from the ambulance service. She had fallen earlier today and was seen by them due to being on the floor for several hours. She declined hospital admission and had two skin flap wounds. I dressed the wounds. 8.30pm My shift ends. My job is extremely varied and no two days are the same. I never know what I will be asked to attend next, which is what I love most. The team I work with are very professional, experienced, caring and hard-working, which makes my job a pleasure. #WEARENSCP MAGAZINE SPRING

12 GETTING TO KNOW OUR SERVICES DISCHARGE TO ASSESS SUPPORT AFTER HOSPITAL Discharge to Assess (D2A) is a therapy-led rehabilitation service which aims to get patients home from hospital more quickly and safely. Our service operates between 8.30am-8pm. We provide intensive rehabilitation and up to three support visits a day, over a seven day period. Most usually this is best achieved in their own home, or in a community inpatient setting in the event there are safety concerns at home. Our aim is to support these patients whilst they continue to recover, always encourage independence and provide support to make any important decisions regarding ongoing care needs, away from the busy acute hospital where needs can be more accurately determined. Support at home Once they are at home, a therapist from our multi-disciplinary team will aim to visit within two hours. They will complete a holistic assessment to identify tasks the patient may require assistance with and set a programme to increase their independence. Following this assessment, the team will focus on promoting patient independence, so arrangements will be made to ensure the team visits to support them with completing the relevant tasks. Due to the nature of our service, we are unable to give specific time slots for our rehabilitation support workers to visit but a morning visit will be between the hours of 8.30am and noon, a lunchtime call between noon and 3.00pm and an evening visit will be between 4.00pm and 8.00pm. Community inpatient bed If a patient requires a community inpatient bed, it will either be at the newly reopened North Somerset Community Hospital (NSCH) or occasionally be in a nursing or a residential care home. The patient will be informed of where they will be staying prior to being discharged from the acute hospital. Once the patient has arrived at the rehabilitation bed the staff there will help them to settle in and a therapist from our multidisciplinary team will visit and assess their needs. The team will work closely together to increase the patient s independence and plan for their discharge back home. Initially the service is free, but, needs will continually be assessed and should the patient require ongoing assistance a referral will be made to social services for a package of care, at this point a financial assessment will be made and further information about this will be explained to the patient. This is a short-term service where the therapist will help the patient set specific rehabilitation goals to achieve whilst receiving our input. There is a strong focus on promoting independence and self-management within a safe and familiar environment for the patient. FIND OUT MORE For information about D2A please log on to: This is a short-term service where the therapist will help the patient set specific rehabilitation goals. 12 #WEARENSCP MAGAZINE SPRING 2018

13 GETTING TO KNOW A OUR DAY IN SERVICES THE LIFE PATIENT CASE STUDY HOW THE CORRECT CARE WAS FOUND Shirley was admitted to hospital with a gradual deterioration of mobility and a subsequent fractured hip following a fall which was treated with a hip replacement. She lives with her husband and had been independent with all her personal care prior to the hospital admission. She was referred to D2A pathway 1 once medically ready to leave hospital. The D2A Occupational Therapist (OT) carried out initial holistic assessment on the day Shirley came home from hospital. Each visit by the therapist included a discussion about setting and adjusting realistic goals to enable Shirley to work towards becoming as independent as possible. In addition to the therapy visits, Shirley was receiving a once a day morning visit from the rehabilitation support workers to help with her personal care, using an enabling approach to promote independence and was walking using a wheeled walking frame. Shirley managed well in the kitchen and was able to sequence the tasks effectively to make a hot drink and a cup of soup. The D2A OT advised Shirley on strategies for moving around in the kitchen to remain safe. As well as recovering from the fracture, Shirley had Oedema, a swelling in her legs caused when fluid leaks out of the body s capillaries, building up in the tissues around the leaking blood vessels. The therapists and rehabilitation support workers worked with her to enable her to be independent enough to attend NSCP s leg club where her dressings could be changed in a social setting. The therapists added equipment to enable greater independence with washing and as Shirley wanted to resume showering, so the D2A therapists assessed the downstairs shower facilities in her house with a plan to complete a shower assessment once her leg dressings are removed. With the help of the multi-disciplinary team Shirley practised her shower transfers three times a week and after five weeks of daily intervention from rehab support workers, was discharged from D2A as she was now able to get out of the front and back doors of her house using the walker and shower independently and was able to attend social activities such as the leg club with support from her husband. HOW DOES DISCHARGE TO ASSESS (D2A) WORK? Infographic How we help a patient to return home from hospital through two pathway procedures 1 2 If the patient has a reduction in their usual level of function, hospital staff decide whether they can safely continue their rehabilitation in their own home and discuss with the patient and family/carers and make a referral to D2A Hospital staff identify the point at which a patient is medically well enough to leave hospital PATHWAY 1 PATHWAY 2 3 PATHWAY 1 SUPPORTED AT HOME A therapists visits on day of discharge from hospital and undertakes a holistic assessment of the patient in their own environment. A rehab programme and care plan is implemented 3 PATHWAY 2 A COMMUNITY INPATIENT REHABILITATION BED A team of therapists and nurses undertake the holistic assessment and rehabilitation plan to prepare the patient to return to their own home as soon as possible Multi-disciplinary team visit the patient regularly progressing their rehabilitation and enabling the patients to become as independent as possible 4 MULTI-DISCIPLINARY TEAM Physiotherapists Occupational Therapists Rehabilitation Support Workers Therapy Assistant Practitioners Nurses Multi-disciplinary team visit the patient regularly progressing their rehabilitation and enabling the patients to become as independent as possible #WEARENSCP MAGAZINE SPRING

14 GETTING TO KNOW OUR SERVICES ALL ABOUT COMMUNITY NURSING What we do The District Nursing teams work very closely and in collaboration with primary health and social care teams, which include General Practitioners, Practice Nurses, Social Care staff and Allied Health Professionals alongside the voluntary sector. District Nursing teams are each led by an Integrated Care Team Manager, and comprise Team Coordinators / Managers, District Nurses, Community Sisters / Charge Nurses, Community Registered Nurses, and General Support Workers. Community Matrons are part of the District Nurse team, working closely with the Frailty Service to identify and support the management the more complex patients. The service works in collaboration with a range of Specialist Services such as End of Life, Tissue Viability, Falls Service, Bladder and Bowel and the Phlebotomy Service. Across North Somerset, the District Nursing teams provide in hours and out of hours nursing care, with services available 365 days per year. The late and night shifts are supported by the Rapid Response Team, as well as dedicated night staff, who are managed as part of the Urgent Care Service. The District Nursing service receives referrals via the Single Point of Access, from anyone who contacts them, including relatives, carers and friends. Likewise the Clinical Hub receives referrals from other professionals, such as GP s and Social Services. The aims of the service are: To provide a high quality nursing service to patients aged 18 years and over. The patient needs to be registered with a North Somerset GP and require nursing care to be delivered within their own home either on a temporarily basis or permanently. To provide a 24-hour service, seven days a week, with the support of the community Rapid Response team outside of normal working hours. To work with primary and acute care providers, social care providers and the voluntary sector. We aim to work in an integrated way with each of these partner organisations. To ensure the delivery of a patient-centred service, which, from a patient point of view is seamless, with no difference between providers from different organisations. This ensures there is no duplication of services across the various organisations involved in a patient s care. It also aims to reduce avoidable admissions to hospital and, where patients are in hospital, to ensure as early a discharge as possible. To work with a range of specialist community services to meet patient s needs; such as the End of Life Care Team, Tissue Viability, Bladder and Bowel and other Allied Health Professionals such as Physiotherapy, Occupational Therapy and Podiatry. To maximise patient independence where possible, to improve the patient s quality of life and to allow patients to remain safely in their own homes. To promote equal access to the service, irrespective of any physical, functional, sensory or cognitive difficulties. The Community Nurses use their professional opinion to determine if it is appropriate for care / treatment to be undertaken in the patient s home. All patients being seen by the service receive regular reviews of their care. The frequency of reviews differ from patient to patient, depending on individual needs. FIND OUT MORE For information about Community Nursing, please log on to: 14 #WEARENSCP MAGAZINE SPRING 2018

15 GETTING TO KNOW A OUR DAY IN SERVICES THE LIFE OUR TISSUE VIABILITY SERVICE IMPRESSIVE HEALING RATES PROMOTE PATIENT SELF CARE A STAFF DEMONSTRATION AT THE NSCP BOARD PATIENT CASE STUDY As part of our commitment to quality, each month our board receives updates about our patient services. Our tissue and viability team demonstrated the benefits of negative pressure wound therapy to the board as shown below. And the following patient case study explains how successful this innovation is proving to be. District nurses provided nursing care to a 22-year-old man who had a pilonidal sinus (a small hole or tunnel in the skin at the top of the buttocks) for two years. Prior to this he had been attending his GP Practice Nurse, but required specialist intervention. The district nurses were able to provide continuity of care and regular reassessment of the wound. He was referred to our Tissue Viability service and the initial consultation discovered the patient had friable granulation tissue (high bacteria load in the wound) which was treated with antimicrobial dressing (a wound dressing containing an antimicrobial agent to kill or prevent growth and multiplication of bacteria) to reduce bacterial in the wound. FIND OUT MORE Small negative pressure devices, which involve the application of a controlled vacuum to a wound, have been used to reduce the size of the wound. The wound was 2cm shorter in length within six weeks and has since gone on to heal. For information explaining our tissue viability service please log on to: The Queen s Nurses #WEARENSCP MAGAZINE SPRING

16 What our community is saying about NSCP I am extremely grateful to everyone who helped me and found all to be caring, pleasant and a credit to their profession. From a patient of our D2A service The nurses are always polite and gave me time as I have problems moving. From a patient of Weston Integrated Care Team My house adaptations have given me a new lease of life and I now have confidence in my own home. From a patient the Falls Team Having a chronic illness, metaphorically speaking, I couldn t live without the care and support that I have received. From a patient of our Community Neuro Service My care is very good, the nurses are amazing and very kind. From a patient of Weston Integrated Care Team I must inform you of the excellent care I received during my stay at North Somerset Community Hospital. The nurses were wonderful. From a patient of NSCH Excellent. Learnt a lot about my condition and why I have falls. From a patient of our Falls Team All the nurses and staff are amazing which has helped me so much in this awful time of my life. From a patient of our Intravenous (IV) Service The whole experience is enhanced by the ability to remain in my own house and not have to travel. From a patient of our Falls Team To hear about NSCP s achievements please follow and get involved using the hashtag #WeareNSCP North Somerset Community Partnership Castlewood PO Box 237, Tickenham Road, Clevedon, North Somerset BS21 6FW