Quality Standards for:

Transcription

1 Quality s for: Transfer from Acute Hospital Care Intermediate Care Version 1.5 March 2016

2 August 2014 West Midlands Quality Review Service These Quality s may be reproduced and used freely by NHS and social care organisations in the West Midlands for the purpose of improving health services for residents of the West Midlands and those who use West Midlands services. No part of the Quality s may be reproduced by other organisations or individuals or for other purposes without the permission of the West Midlands Quality Review Service. Organisations and individuals wishing to reproduce any part of the Quality s should the West Midlands Quality Review Service at: swb-tr.swbh-gm-wmqrs@nhs.net. Whilst the West Midlands Quality Review Service has taken reasonable steps to ensure that these Quality s are fit for the purpose of reviewing the quality of services in the West Midlands, this is not warranted and the West Midlands Quality Review Service will not have any liability to the service provider, service commissioner or any other person in the event that the Quality s are not fit for this purpose. The provision of services in accordance with these s does not guarantee that the service provider will comply with its legal obligations to any third party, including the proper discharge of any duty of care, in providing these services. Review by: September 2018 at the latest Version No. Date V N/A Change from previous version V Review date extended to September 2016 V Review date extended to September 2018 V Paragraph added about organisation s clinical governance arrangements UKAS accreditation logo added V Sn-301 Note about information on website removed V UKAS logo removed - previously added in error as this set of s were developed prior to accreditation being obtained. WMQRS Discharge & Int Care QS V

3 CONTENTS INTRODUCTION.4 QUALITY STANDARDS Primary Care Acute Trust All Wards Information and Support for Patients and Carers Staffing Support Services Facilities and Equipment Guidelines and Protocols Service Organisation and Liaison with Other Services Governance Intermediate Care Service Information and Support for Patients and Carers Staffing Support Services Facilities and Equipment Guidelines and Protocols Service Organisation and Liaison with Other Services Governance Commissioning Appendix 1 Reference Sources Appendix 2 Cross-References to Care Quality Commission and NHS Litigation Authority s Appendix 3 Glossary of Terms and Abbreviations Appendix 4 Presentation of Evidence for Peer Review s Appendix 5 Expected Patient Pathway Timescales WMQRS Discharge & Int Care QS V

4 INTRODUCTION BACKGROUND These Quality s were developed as part of the West Midlands Quality Review Service s 2013/14 work with CCGs and Trusts in Shropshire, Telford & Wrekin, Birmingham Cross-City, Worcestershire, North Staffordshire, Sandwell and West Birmingham. Comments were also invited from other NHS and social care organisations in the West Midlands and comments received were taken into account in finalising the s. These Quality s aim to improve the quality of services for the transfer from acute hospital care and to help to answer the question: For each service, how will I know that national guidance and what has been shown to be best practice have been implemented? The Quality s are suitable for use in selfassessment, monitoring by commissioners and providers, and peer review visits. They describe what services should be aiming to provide, and all services should be moving towards meeting all applicable Quality s within the next two to five years. In general, we hope that through the use of WMQRS Quality s: a. Patients and carers will know more about the services they can expect. b. Commissioners will be supported in assessing and meeting the needs of their population, improving health and reducing health inequalities, and will have better service specifications. c. Service providers and commissioners will work together to improve service quality. d. Service providers and commissioners will have external assurance of the quality of local services. e. Reviewers will learn from taking part in review visits. f. Good practice will be shared. g. Service providers and commissioners will have better information to give to the Care Quality Commission and Monitor. Specific improvements expected from the use of these Quality s for Transfer from Acute Hospital Care and Intermediate Care are: Outcomes Improvements: a. An increase in the proportion of patients discharged who are home for lunch b. Reduced transfers of care c. Reduced lengths of stay in acute hospitals d. Fewer level 3 and 4 capacity escalations e. Improved patient and GP satisfaction with the discharge process f. Fewer patients readmitted because the quality of the discharge process was poor (although we recognise that this may be difficult to measure) Process Improvements: a. A clearer understanding within each health economy of community bed types, extent of medical input, criteria for admission, expected interventions, and the potential to flex capacity and admission criteria safely. Quality s are cross-referenced to their reference sources (Appendix 1) and to Care Quality Commission and NHSLA s (Appendix 2). Appendix 3 gives a glossary of terms and abbreviations and Appendix 4 summarises the way in which evidence can be presented for review visits. Appendix 5 summarises the expected timescales for the patient pathway, as described in the Quality s. WMQRS Discharge & Int Care QS V

5 SCOPE OF THE QUALITY STANDARDS These Quality s cover: 1 Primary care 2 Transfer from acute hospital care 3 Intermediate care a. For admission avoidance as well as after acute hospital care b. In community hospitals, care homes or patients own homes Intermediate care is defined as additional health and/or social care support for people in order to avoid admission to hospital or following a hospital admission: a. with the aim of re-ablement and return to normal place of residence but recognising that return to normal place of residence: i. may need the introduction of or a change in the package of care ii. will not always be possible iii. may not be clear at the time of transfer from acute hospital care b. to provide additional care while a new normal place of residence is arranged More detail of the scope of the Quality s: Included a. Services which divert possible admissions to an alternative care pathway b. Transfer of care following emergency and elective admission to acute hospitals c. Contribution of community hospitals and other services (for example, re-ablement team, rapid response and others) to the transfer of care pathway d. Transfer of care from tertiary services e. Links with out of hours services f. Care of adults Not specifically covered: g. Care of children h. Transfer of care from mental health services and services for people with learning disability i. Transfer of care from acute hospitals to the care of mental health services and services for people with learning disability j. Pre- and post-delivery maternity transfers of care k. Specialty-specific aspects of transfer of care including those that may apply to transfers of care from specialist hospitals l. Transfer of care of private patients Throughout the Quality s the term therapeutic intervention is used to mean a therapeutic, rehabilitation and/or re-ablement intervention offered by the service. The Transfer from Acute Hospital Care Intermediate Care Quality s should sit within organisations overall clinical governance arrangements. The WMQRS Clinical Governance Quality s describe the clinical governance arrangements which should be in place. Compliance in NHS provider organisations will usually be assured through NHS Litigation Authority s. Non-NHS organisations may wish to use the WMQRS Clinical Governance Quality s to assure themselves of the robustness of their overall clinical governance arrangements. PATIENT PATHWAYS The patient pathways on which the Quality s are based are shown below. NB. In general, extra steps in any patient pathway add risk and adversely affect the patient experience. WMQRS Discharge & Int Care QS V

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9 LINKS WITH OTHER QUALITY STANDARDS These Quality s link with other WMQRS Quality s and, in particular, with: Quality s for Urgent Care: These s cover primary care, ambulance services, Emergency Department and acute medical and surgical admissions, including the first 24 hours of any hospital admission. Access to intermediate care is also covered by these s. Quality s for the Care of People with Long-Term Conditions: These s cover the ongoing care of people with long-term conditions, including care by community long-term conditions teams and specialist condition-specific teams Quality s for the Care of Vulnerable Adults in Acute Hospitals: These s for the care of adults who are particularly vulnerable also cover several general aspects of acute hospital care. They have not been repeated here and these s for Transfer from Acute Hospital Care and Intermediate Care should be seen as supplementary to the s for the Care of Vulnerable Adults in Acute Hospitals Palliative and end of life care WMQRS has not yet developed Quality s for palliative and end of life care. Relevant measures are available for patients with cancer and can be found at: STRUCTURE OF THE QUALITY STANDARDS Each is structured as follows: Reference Number (Ref) This column contains the reference number for the Quality, which is unique to these standards and is used for all cross-referencing. Each reference number is composed of two letters and three digits (see below for more detail). The reference column also includes a guide to how the Quality will be reviewed: Background information ing facilities Meeting patients, carers and staff Case note review or clinical observation umentation The shaded area indicates the approach that will be used for reviewing compliance with the Quality. Appendix 4 summarises the evidence needed for review visits. Quality (QS) Notes This describes the quality that the services are expected to have. The notes give more detail about either the interpretation or the applicability of the. WMQRS Discharge & Int Care QS V

10 Pathway and Service Letters: s for Transfer from Acute Hospital Care use the pathway letter S. The s are in the following sections: Pathway SA - Transfer from Acute Hospital Care Primary Care SM- Transfer from Acute Hospital Care Acute Trust: All wards Service SN - Transfer from Acute Hospital Care Intermediate Care Service SZ - Transfer from Acute Hospital Care Commissioning Topic Sections: Each section covers the following topics: -100 Information and Support for Patients and Carers -200 Staffing -300 Support Services -400 Facilities and Equipment -500 Guidelines and Protocols -600 Service Organisation and Liaison with Other Services -700 Governance Policies, Protocols, Guidelines and Procedures: The Quality s use the words policy, protocol, guidelines and procedure based on the following definitions: Policy: A course or general plan adopted by an organisation, which sets out the overall aims and objectives in a particular area. Protocol: Guidelines: Procedure: A document laying down in precise detail the tests or steps that must be performed. Principles which are set down to help determine a course of action. They assist the practitioner to decide on a course of action but do not need to be automatically applied. Clinical guidelines do not replace professional judgement and discretion. A method of conducting business or performing a task, which is made up of a series of actions or steps to be taken. For simplicity, some Quality s use the term guidelines and protocols, which should be taken as referring to policies, protocols, guidelines and procedures. All clinical guidelines should be based on national guidance, including NICE guidance where available. Local guidelines and protocols should specify the way in which national guidance will be implemented locally and should show consideration of local circumstances. Guidelines and protocols should be organised in the way that is most helpful to the local service; for example, one guideline may cover several Quality s or several guidelines may relate to one Quality. Appendix 3 gives a glossary of terms and abbreviations used in the Quality s. WMQRS Discharge & Int Care QS V

11 COMMENTS ON THE QUALITY STANDARDS The Quality s will be revised as new national guidance becomes available and as a result of experience of their use in peer review. Comments on the Quality s are welcomed and will be taken into account when the Quality s are updated. Comments should be sent to swb-tr.swbh-gm-wmqrs@nhs.net. More information about WMQRS and its Quality s and reviews is available at or by calling WMQRS Discharge & Int Care QS V

12 QUALITY STANDARDS PRIMARY CARE NB. s for access to intermediate care services are covered in the WMQRS Quality s for Urgent Care and so are not repeated here. Ref SA-101 Patients at High Risk of Admission SA-601 Patients at high risk of admission to an acute hospital should have a Patient Passport or equivalent patient-held record that covers: a. Diagnoses b. Allergies c. Medication d. Care package (or equivalent) e. Name and contact details of GP f. Name and contact details of main carer/s g. Advice for the patient and their carers on likely problems and what to do in an emergency h. Advice to emergency services on likely problems and recommendations for their management i. Advice for acute hospital services on the most appropriate ward (if admission is required) Notes: 1 Emergency services includes GP out of hours, ambulance, Emergency Department and acute medical and Surgical admissions services. The Patient Passport or equivalent should be easily available, ideally electronically, to these services. 2 Patient Passports may be specific to one service, or a generic format may be agreed by the Local Health and Social Care Review and Learning Group (QS SZ-798). Summary Medical Record A summary of the patient s medical record including diagnoses, allergies, medication and agencies involved in their care should be sent with each patient referred to intermediate care or to an acute hospital for assessment or admission. Note: If it is not feasible to send the Summary Medical Record with the patient then it should be sent to the hospital as soon as possible on the next working day. WMQRS Discharge & Int Care QS V

13 ACUTE TRUST ALL WARDS These Quality s apply to all acute hospital wards for adults except Acute Medical and Surgical Admissions Units and Day Surgery Units and are additional to Acute Trust-wide s for other pathways. Ref INFORMATION AND SUPPORT FOR PATIENTS AND CARERS SM-101 Planned Admissions All patients awaiting a planned admission to hospital should be offered written information about arrangements for leaving the hospital and returning to their usual place of residence. SM-102 SM-103 SM-104 Information about Leaving Hospital Each ward should clearly display information for patients, carers and staff about arrangements for transfer of care on leaving the hospital, covering at least: a. The process of transfer of care b. Additional support available in the patient s usual place of residence c. Intermediate care options, criteria for accessing these and time limits on their provision (if applicable) d. How to access a discussion with medical and/or nursing staff about the patient s condition and plans for care on leaving hospital Note: Separate information about different transfer of care pathways may be presented separately. Discussion with Families Members of the multi-disciplinary team should be easily available to families for discussions about the patient s condition and plans for care on leaving hospital. Information on how to arrange a discussion should be clearly displayed in all ward areas. Notes: 1 Availability to families may include booked appointments or booked telephone calls, but should include the opportunity for discussion outside normal working hours. 2 The ward multi-disciplinary team includes medical staff. Patients at High Risk of Re-Admission Patients at high risk of re-admission should have their Patient Passport or equivalent patient-held record (QS SA-101) updated during the course of their admission. Note: If patients at high risk of re-admission do not have a Patient Passport or equivalent then they should be given one. WMQRS Discharge & Int Care QS V

14 Ref SM-196 Transfer of Care Plan SM-198 SM-199 Patients and, when appropriate, their carers should be involved in discussing and agreeing the plan for their care after leaving the hospital and should be given a written summary of their Transfer of Care Plan, which should include: a. Expected date of discharge b. Essential pre-discharge assessments c. Care after leaving the acute hospital, including self-care d. Medication required on leaving the acute hospital e. Who is taking medical responsibility for care after leaving the acute hospital f. Further investigations, treatment, rehabilitation and re-ablement to be carried out after leaving hospital, and who will arrange these, including separately identifying any of these which the GP is expected to arrange g. Possible complications and what to do if these occur, including in an emergency h. Transport i. Equipment supply or loan j. Dressings and continence aids k. Who to contact with queries or for advice l. Date by which their care should be reviewed, who is expected to undertake this review and how to access a review more quickly if required This Transfer of Care Plan should be copied to the patient s GP and to all services involved in providing after-hospital care. Carers Needs Carers should be offered advice and written information on: a. How to access an assessment of their own needs b. Benefits available, including carers allowance (if applicable), and how to access benefits advice c. Services available to provide support Notes: 1 This QS is about sign-posting carers to appropriate services. Detailed information is not expected. For example, a small card would be sufficient for compliance. 2 Support for carers may include carers groups, carers breaks, emergency response, support for children in the family and cognitive and behavioural therapy, usually accessed through primary carebased psychological therapy services. Support may be provided by voluntary and charitable organisations. Involving Patients and Carers The service should have: a. Mechanisms for receiving regular feedback from patients and carers about transfer of care from the acute hospital b. Examples of changes made as a result of feedback and involvement of patients and carers Note: The arrangements for receiving feedback from patients and carers may involve surveys, including the national patient survey, focus groups and/or other arrangements. They may involve Trust-wide arrangements so long as issues relating to the specific service can be identified. WMQRS Discharge & Int Care QS V

15 Ref STAFFING SM-201 SM-202 SM-203 Multi-Disciplinary Teams A multi-disciplinary team to coordinate discharge planning should be available on each ward including: a. Staff with occupational therapy and physiotherapy competences with time allocated daily (7/7) for discharge planning, essential pre-discharge assessments and active pre-discharge rehabilitation b. Senior decision-maker review of patients fitness for discharge at least daily (7/7) c. Nurse with competences in event-led discharge from 9am to 8pm daily (7/7) d. Someone identified to coordinate discharge planning and preparation for discharge from 9am to 8pm daily (7/7) e. Access to social services staff available to undertake social care assessment within 24 hours of request f. Access to pharmacy services and medication To Take Out available within four hours of request Notes: 1 Members of the multi-disciplinary team should have time allocated for their work on the ward. This time should be sufficient to ensure that discharge planning and essential pre-discharge assessments can be undertaken within 24 hours of request. 2 A senior decision-maker is a doctor of grade ST or SAS 3 or above or a nurse consultant. 3 Event-led discharge includes, for example, discharge when results of investigations are available or when certain clinical parameters are met. Event-led discharge should be within agreed guidelines (QS SM-597). Trusted Assessors A member of staff trusted and with competences to assess for local intermediate care services, including intermediate care in community hospitals, in care homes or at home, should be available to each ward daily (7/7) and able to respond on the same day to requests received by 12 noon. Note: Trusted Assessors will normally be part of the ward multi-disciplinary team (QS SM-201). Availability of staff from an intermediate care service is sufficient for compliance so long as they are able to respond within the timescales expected. Training in Transfer of Care from the Acute Hospital All staff, including junior medical staff, should have training in the hospital transfer of care pathway (QS SM-597), local intermediate care services (QS SM-602) and local enabling agreements (QS SZ-602). Note: This should, ideally, form part of induction for junior doctors and locum medical staff and form part of mandatory training for all clinical staff involved in the transfer of care from acute hospitals. WMQRS Discharge & Int Care QS V

16 Ref SUPPORT SERVICES SM-301 SM-302 Support Services Access to the following support services should be available daily (7/7): a. Appropriate staff to undertake a home assessment within 24 hours of request b. Patient transport able to respond within four hours of request c. Simple equipment available within four hours of request d. Supply of sufficient dressings and continence aids for 72 hours available within four hours of request e. All equipment, including beds and hoists, available within 24 hours of request f. Simple adaptations available within 24 hours of request g. Voluntary sector settling home support able to respond by the end of the next working day and continue for up to five days h. Simple assistive technology available within 24 hours of request i. Medicines reconciliation (7/7) Notes: 1 Examples of simple equipment are raised toilet seats, chairs, frames and other walking aids. 2 The supply of dressings and continence aids should be sufficient until the next working day. Around Bank Holidays this may be longer than 72 hours. These items may be supplied by the ward or by district nurses. 3 Examples of simple adaptations are fitting of grab handles or key safes. 4 Voluntary sector settling home support may include shopping and other simple errands. 5 Examples of simple assistive technology include pill dispensers and pendant alarms. Short-Term Care at Home Additional health and social care support should be available within four hours of request, comprising up to four visits per day for at least 72 hours after return home. Notes: 1 Short-term care at home may be available for longer than 72 hours. Ideally, short-term care should include night-visiting. 2 Short-term care should be available until at least the next working day. Around Bank Holidays this may be longer than 72 hours. FACILITIES AND EQUIPMENT SM-499 IT System Trusted assessors and ward-based staff responsible for coordinating discharge planning (QS SM-201) should have electronic access to: a. Health and social care records of patients from the main areas served by the hospital b. Patient Passports (if electronic) WMQRS Discharge & Int Care QS V

17 Ref GUIDELINES AND PROTOCOLS SM-595 Ward and Consultant Handover The latest version of their Transfer of Care Plan should be handed over to the new ward or consultant whenever patients are transferred to another ward within the acute hospital or to the care of another consultant and the Transfer of Care Checklist (QS SM-601) updated. WMQRS Discharge & Int Care QS V

18 Ref SM-596 Transfer of Care Guidelines Transfer of care guidelines for both simple and complex discharge pathways should be in use covering at least: a. Ensuring each patient has an expected date of discharge, ideally within 12 hours of admission b. Event-led discharge c. Discussion with patients and carers about the Transfer of Care Plan d. Multi-disciplinary review for complex discharges or where discharge destination is unclear, ideally within 24 hours of admission e. Single assessment process f. Transport options including patient transport service, relatives, taxis or care home transport g. Development, agreement and giving the patient, GP and, where appropriate, carers a copy of the of the Transfer of Care Plan: i. Expected date of discharge ii. Essential pre-discharge assessments iii. Care after leaving the acute hospital, including self-care iv. Medication required on leaving the acute hospital v. Who is taking medical responsibility for care after leaving the acute hospital vi. Further investigations, treatment, rehabilitation and re-ablement to be carried out after leaving hospital, and who will arrange these, including separately identifying any of these which the GP is expected to arrange vii. Possible complications and what to do if these occur, including in an emergency viii. Transport ix. Equipment supply or loan x. Dressings and continence aids xi. Who to contact with queries or for advice xii. Date by which their care should be reviewed, who is expected to undertake this review and how to access a review more quickly if required h. How to access funding decisions on specialist care not normally available in the local area i. Latest time when patients can normally be discharged home or to care homes j. Handover of the Transfer of Care Plan to services providing after-hospital care, including intermediate care services k. Informing the GP, the person taking medical responsibility for the patient and any other relevant services that the patient has left hospital, ideally within four hours of transfer of care l. Contingency plan when capacity in intermediate care services is not available Notes: 1 Notification of transfer of care to the patient s GP and other services involved in their care should, ideally, be electronic. Other relevant services include district nurses, community matrons, community hospitals, other intermediate care providers and care agencies. 2 Transfer of Care Plans should include progress on finding long-term placements (where applicable) and details of any assessments undertaken. Intermediate care services should not normally have to repeat assessments or steps on the patient pathway. 3 The ward should normally be able to transfer a patient back to the care home from which they were admitted up to 8pm. 4 Event-led discharge includes, for example, discharge when results of investigations are available or when certain clinical parameters are met. Event-led discharge should be within agreed guidelines. WMQRS Discharge & Int Care QS V

19 Ref SM-597 More Complex Transfers of Care Guidelines should be in use covering: a. Transfer of care to other local authority or Clinical Commissioning Group areas covering at least social care assessments, intermediate care services available, patient transport and equipment supply or loan b. Transfer to a care home for long-term care c. NHS continuing care assessments and place-finding d. Liaison with palliative and end of life care services e. Patients and/or carers who do not agree a Transfer of Care Plan or who unreasonably delay their transfer of care SERVICE ORGANISATION AND LIAISON WITH OTHER SERVICES SM-601 Ward-Level Arrangements The following arrangements should be implemented on each ward: a. On admission: i. Requesting a Summary Medical Record from the patient s GP if this is not sent with the patient (QS SA-601) ii. Identifying agencies involved in the patient s care and, if necessary, informing them of the admission b. Availability for discussion with families (QS SM-103) c. A Patient at a Glance or equivalent system so that all staff can see the patient s stage on the transfer of care pathway and actions required d. A Transfer of Care checklist (or equivalent) in each patient s notes showing their stage on the transfer of care pathway and actions required e. Updating the Patient Passport (QS SA-101) for people at high risk of re-admission or issuing one if not available f. Rapid access to investigations and consultant clinics for patients following discharge (7/7) g. Local enabling agreements (QS SZ-602) Notes: 1 Patient at a Glance systems should ideally be electronic. 2 The Transfer of Care checklist should cover all aspects of the Transfer of Care Plan (QS SM-196) and may be used for handover to new wards or consultants (QS SM-595) WMQRS Discharge & Int Care QS V

20 Ref SM-602 Intermediate Care A protocol on access to local intermediate care services should be in use on each ward covering at least: a. Criteria for acceptance by each local intermediate care service and time limit for provision of the service (if applicable) b. Type of care, rehabilitation and re-ablement provided and, in particular, whether the service is able to support: i. 24/7 on-site care (community hospital or care home) ii. Overnight care (night-visiting or night sitting) iii. Intravenous therapy iv. PEG feeds v. Care for dementia or significant cognitive impairment vi. VAC therapy and other complex wound care c. Trusted Assessor (QS SM-202) or other arrangements for agreement of patient suitability d. Arrangements for handover of the patient s Transfer of Care Plan Note: Funding decisions should not normally be required for admissions to intermediate care services of patients meeting agreed criteria (QS SZ-601). If funding decisions are required then the protocol should include contact details for the on call commissioning manager. GOVERNANCE SM-701 SM-702 SM-797 Data Collection and Monitoring Each ward should have access to data on its own performance and comparative information for other wards covering: a. Proportion of patients achieving their expected date of discharge b. Proportion of patients home for lunch c. Key quality and performance indicators agreed with commissioners Note: Data on patient experience are covered in QS SM-199. Audit Each ward should have a rolling programme of audit of: a. Achievement of expected timescales for the patient pathway b. Patients re-admitted within 28 days who did not have a Patient Passport or equivalent patientheld record c. Proportion of further investigations or follow up appointments arranged within five days of transfer from acute hospital Notes: Appendix 5 gives a summary of expected timescales on transfer of care from acute hospitals. Health and Social Care Review and Learning Each ward should have a mechanism for influencing, and receiving feedback from, the local Health and Social Care Review and Learning Group on transfer of care from acute hospitals and intermediate care (QS SZ-798). WMQRS Discharge & Int Care QS V

21 Ref SM-798 Multi-disciplinary Review and Learning Each ward should have multi-disciplinary arrangements for the reviewing of, and implementation of learning from, positive feedback, complaints, outcomes, incidents and near misses relating to transfer of care from the acute hospital. SM-799 ument Control All policies, procedures and guidelines should comply with Trust (or equivalent) document control procedures. Note: Specific documentary evidence of compliance is not required. Compliance with this QS will be determined from the other documentary information provided. Copies of Trust document control policies are not required. WMQRS Discharge & Int Care QS V

22 INTERMEDIATE CARE SERVICE These Quality s apply to intermediate care provided in community hospitals, care homes and patients own homes. Ref INFORMATION AND SUPPORT FOR PATIENTS AND CARERS SN-101 Service Information Each service should offer patients and their carers written information covering: a. Organisation of the service b. Care and therapeutic interventions offered by the service c. If beds: routines, visiting times and how to get refreshments d. Staff and facilities available e. How to contact the service for help and advice, including out of hours f. Who to contact with concerns about the service g. After intermediate care, including information about the length of time for which the service will be provided and the options for, and process of transfer to, longer-term care (if required) h. Sources of further advice and information Notes: 1 Information should be written in clear, plain English and should be available in formats and languages appropriate to the needs of the patients, including developmentally appropriate information for people with learning disabilities. 2 Information may be in paper or electronic/e-learning formats. Guidance on how to access information is sufficient for compliance so long as it points to easily available information of appropriate quality. If the information is provided only in individual patient letters then examples will need to be seen by reviewers. WMQRS Discharge & Int Care QS V

23 Ref SN-103 Care Plan SN-104 Each patient and, where appropriate, their carer and appropriate members of the multi-disciplinary team should discuss and agree their Care Plan and should have easy access to a written record covering at least: a. Agreed goals, including life-style goals b. Self-management c. Medication d. Planned care and therapeutic interventions e. Early warning signs of problems, including acute exacerbations, and what to do if these occur f. Expected date of discharge from the service g. Name of care coordinator h. Name of doctor taking medical responsibility for their care i. Who to contact with queries or for advice j. Planned review date and how to access a review more quickly, if necessary Notes: 1 The Care Plan should normally be agreed within 24 hours of transfer to intermediate care, although this time may sometimes be longer, especially if an appropriate Plan had been agreed before transfer to intermediate care. 2 Care Plans should be easily accessible to patients and their carers. This requirement would be met if a copy was given to a patient or kept near their bed or chair but not if the Care Plan was kept in a trolley or staff office. Review of Care Plan A formal review of the patient s Care Plan should take place as planned and, at least, weekly. This review should involve the patient, their carer, where appropriate, and appropriate members of the multi-disciplinary team. The outcome of the review should be recorded in the Care Plan. SN-105 SN-106 Contact for Queries and Advice Each patient and, where appropriate, their carer should have a contact point within the service for queries and advice. If advice and support is not immediately available then the timescales for a response should be clear, and advice on what to do in an emergency should be given. Response times should be no longer than the end of the next day. Note: A response by the end of the next day means a response that is given by the end of the next day by, or following discussion with, a health or social care professional. It does not mean that a particular health or social care professional involved in the individual s care will respond by the end of the next day. Care Coordinator Each patient should have a nominated individual responsible for planning and coordinating their care, including planning their longer-term care. WMQRS Discharge & Int Care QS V

24 Ref SN-107 Communication Aids Communication aids should be available to enable patients with communication difficulties to participate in decisions about their care. SN-108 SN-196 Patients at High Risk of Re-Admission Patients at high risk of re-admission should have their Patient Passport or equivalent patient-held record (QS SA-101) updated during the course of their intermediate care. Note: If patients at high risk of re-admission do not have a Patient Passport or equivalent then they should be given one. After Intermediate Care Plan Patients and, when appropriate, their carers should be involved in discussing and agreeing the plan for their care after leaving the intermediate care service, and should be given a written summary of their After Intermediate Care Plan, which should include: a. Expected date of discharge from the intermediate care service b. Care after leaving intermediate care, including self-care c. Medication d. Who is taking medical responsibility for care after leaving intermediate care e. Further investigations, treatment, rehabilitation and re-ablement to be carried out after leaving intermediate care, and who will arrange these, including separately identifying any of these which the GP is expected to arrange f. Possible complications and what to do if these occur, including in an emergency g. Transport (if required) h. Equipment supply or loan i. Dressings and continence aids j. Who to contact with queries or for advice k. Date by which their care should be reviewed, who is expected to undertake this review and how to access a review more quickly if required This After Intermediate Care Plan should be copied to the patient s GP and to all services involved in providing ongoing care. WMQRS Discharge & Int Care QS V

25 Ref SN-197 General Support for Patients and Carers SN-198 SN-199 Patients and carers should have easy access to the following services, and information about these services should be easily available: a. Interpreter services, including British Sign Language b. Independent advocacy services c. Complaints procedures d. Social workers e. Benefits advice f. Spiritual support g. HealthWatch or equivalent organisation h. Relevant voluntary organisations providing support and advice Notes: 1 As QS SN-101 note 1. 2 This QS is about sign-posting to relevant services. The actual services available may be different in different areas. Carers Needs Carers should be offered information on: a. How to access an assessment of their own needs b. Benefits available, including carers allowance (if applicable), and how to access advice on these c. Services available to provide support Notes: 1 This QS is about sign-posting carers to appropriate services. Detailed information is not expected. For example, a small card would be sufficient for compliance. 2 Support for carers may include carers groups, carers breaks, emergency response, support for children in the family and cognitive and behavioural therapy, usually accessed through primary carebased psychological therapy services. Support may be provided by voluntary and charitable organisations. Involving Patients and Carers The service should have: a. Mechanisms for receiving regular feedback from patients and carers about the treatment and care they receive b. Examples of changes made as a result of the feedback and involvement of patients and carers Note: The arrangements for receiving feedback from patients and carers may involve surveys, including the national patient survey, focus groups and/or other arrangements. They may involve Trust-wide (or equivalent) arrangements so long as issues relating to the specific service can be identified. WMQRS Discharge & Int Care QS V

26 Ref STAFFING SN-201 SN-202 Lead Clinician and Lead Manager A nominated lead clinician and a lead manager should be responsible for the effective delivery of the service, including staffing, training, guidelines and protocols, service organisation, governance and liaison with other services. The lead clinician should be a registered healthcare professional with appropriate specialist competences in this role and should undertake regular clinical work within the service. Notes: 1 Integrated health and social care services may be led by a registered social care professional. 2 The lead clinician and lead manager may be the same person. Staffing Levels and Skill Mix Sufficient health and care staff with appropriate competences should be available for: a. The number of patients usually cared for by the service and the usual case mix of patients b. The service s role in the patient pathway and expected timescales c. The assessments, care and therapeutic interventions offered by the service Staffing should include: i. At least two registered healthcare professionals at all times the service is operational ii. A registered nurse available 24/7 in bedded units and daily (7/7) in other services iii. Appropriate therapists for the needs of the patients daily (7/7) iv. Access to social services staff available to undertake social care assessments within 24 hours of request v. Medical staff (QS SN-205) Cover for absences should be available so that the patient pathway is not unreasonably delayed, and patient outcomes and experience are not adversely affected, when individual members of staff are away. Notes: 1 A clear methodology should, ideally, be used to determine appropriate staffing levels and skill mix. Staff should have time allocated for their role in the service, but roles may be part-time and staff may be shared with other services. 2 Any specialist nurses should have completed an appropriate post-registration (LBR) education programme. 3 Healthcare support workers should normally have, or be working towards, relevant NVQ level 2 or 3 qualifications. Skills for Health competence frameworks may be helpful in defining appropriate competences: 4 Reviewers will be concerned about the availability of staff with appropriate competences rather than management arrangements. WMQRS Discharge & Int Care QS V

27 Ref SN-203 Service Competences and Training Plan SN-204 The competences expected for each role in the service should be identified. A training and development plan for achieving and maintaining competences should be in place. If provided by the service, the competence framework should cover: a. Intravenous therapy b. PEG feeds c. Care for patients with dementia or significant cognitive impairment d. VAC therapy and other complex wound care Notes: 1This QS is about the needs of the service and cannot be met solely by individual staff appraisals and personal development reviews (PDRs). Appraisals and PDRs are sufficient for the maintenance of competence. Details of individual appraisals and PDRs are not required. Reviewers may, however, request information about specific aspects of relevance to the service, particularly where a therapeutic intervention or activity is undertaken rarely and/or where competence may not be maintained by the individual s usual clinical practice. 2 For compliance with this QS the service should provide: a. A matrix of the roles within the service, competences expected and approach to maintaining competences b. A training and development plan showing how competences are being achieved and maintained. Examples of competence frameworks and training and development plans are available on the WMQRS website: 3 Training may be delivered through a variety of mechanisms, including e-learning, Trust-wide training and departmental training. Competences All Health and Social Care Professionals All health and social care professionals working in the service should have competences appropriate to their role in: a. Resuscitation b. Safeguarding vulnerable adults c. Recognising and meeting the needs of vulnerable adults d. Dealing with challenging behaviour, violence and aggression e. Mental Capacity Act and Deprivation of Liberty Safeguards f. Privacy and dignity g. Infection control h. Information governance, information sharing and awareness of any local information sharing agreements i. Local enabling agreements (QS SZ-602) WMQRS Discharge & Int Care QS V

28 Ref SN-205 Medical Staff SN-299 The service should have the following medical staffing: a. A nominated lead doctor with responsibility for coordinating medical input to the service b. A doctor available for emergencies 24/7 c. A doctor or other registered health professional with authorisation to prescribe who can attend within two hours of request, for conditions where hospital admission may be avoided d. Medical review of patients: i. Community hospitals: Daily (7/7) ii. Other intermediate care services: As appropriate for the usual case mix of patients and at least weekly. Notes: 1 Conditions for which hospital admission may be avoided include urinary tract and chest infections, blocked PEG feeds and blocked catheters. 2 Medical review may be through a board round or telephone discussion, especially where intermediate care is provided in patients own homes. Administrative, Clerical and Data Collection Support Administrative, clerical and data collection support should be available. Note: The amount of administrative, clerical and data collection support is not defined. Clinical staff should not, however, be spending unreasonable amounts of time that could be used for clinical work on administrative tasks. WMQRS Discharge & Int Care QS V

29 Ref SUPPORT SERVICES SN-301 Clinical Support Services Timely access to an appropriate range of clinical support services should be available, including: a. Imaging b. Pathology, including microbiology c. Pharmacy, including medication supply and medicines management advice d. Appropriate staff to undertake a home assessment within 24 hours of request e. Infection control (7/7 and on call 24/7) f. Tissue viability (7/7) g. Falls prevention (next working day) h. Continence service (7/7) i. Mental health team (crisis response within four hours) j. Counselling Notes: 1 Timely is not defined strictly but the service should ensure that patient pathways are not unreasonably delayed and that the service s timescales for assessments, care and therapeutic interventions are not unreasonably delayed. Specific indications for referral to, and timescales for response by, support services may be agreed. Support services include imaging, pathology, pharmacy and other services relevant to the particular patient pathway. Ancillary services such as porters, security and cleaning should be included where these are specifically relevant to the service provided or the case mix of patients. 2 For compliance with this QS, the service should provide a list of essential support services, indications for urgent and routine referral and agreed response times (urgent and routine). An audit of compliance with referral indications and response times is desirable. WMQRS Discharge & Int Care QS V

30 Ref SN-302 Support Services for Patients Returning Home Access to the following support services for patients returning home should be available daily (7/7): a. Appropriate staff to undertake a home assessment within 24 hours of request b. Medication To Take Out available within four hours of request c. Patient transport able to respond within four hours of request d. Simple equipment available within four hours of request e. Supply of sufficient dressings and continence aids for 72 hours available within four hours of request f. All equipment, including beds and hoists, available within 24 hours of request g. Simple adaptations available within 24 hours of request h. Additional health and social care support within four hours of request, comprising up to four visits per day for up to 72 hours after return home i. Voluntary sector settling home support able to respond by the end of the next working day and continue for up to five days j. Simple assistive technology available within 24 hours of request Notes: 1 Examples of simple equipment are raised toilet seats, chairs, frames and other walking aids. 2 The supply of dressings and continence aids should be sufficient until the next working day. Around Bank Holidays this may be longer than 72 hours. These items may be supplied by the ward or by district nurses. 3 Examples of simple adaptations are fitting of grab handles or key safes. 4 Voluntary sector settling home support may include shopping and other simple errands. 5 Examples of simple assistive technology include pill dispensers and pendant alarms. FACILITIES AND EQUIPMENT SN-401 Facilities and Equipment Facilities and equipment available should be appropriate for the assessments, care and therapeutic interventions offered by the service for the usual number and case mix of patients. SN-499 IT System IT systems for storage, retrieval and transmission of patient information should be in use for patient administration, clinical records, outcome information and other data to support service improvement, audit and revalidation. Note: IT and records systems should be integrated to avoid duplicate entries of patient data. WMQRS Discharge & Int Care QS V

31 Ref GUIDELINES AND PROTOCOLS SN-501 SN-502 Initial Assessment Guidelines Guidelines on initial assessment should be in use that ensure that an initial assessment is undertaken within 30 minutes of transfer to the intermediate care service, or within four hours if intermediate care is provided in the home, covering at least: a. Assessment of pressure ulcers, nutrition, hydration and cognition b. Initial review of the Transfer of Care Plan to ensure its appropriateness for the intermediate care service Note: Guidelines should be based on national guidance, including NICE guidance, and on the commissioned local pathway, and should be localised to show how national guidance will be implemented in the local situation. Use of national guidance without consideration of local implementation is not sufficient for compliance with this QS. Clinical Guidelines Guidelines on management of the usual case mix of patients referred to the service should be in use covering at least: a. Pain b. Depression c. Skin integrity d. Falls and mobility e. Continence f. Delirium and dementia g. Nutrition and hydration h. Sensory loss i. Medicines management j. Catheter care k. Spasticity management l. Care of patients with diabetes, COPD, heart failure and other long-term conditions m. Activities of daily living n. Health promotion, including smoking cessation, healthy eating, weight management, exercise, alcohol use, sexual and reproductive health, and mental and emotional health and well-being Note: As QS SN-501. WMQRS Discharge & Int Care QS V