Service Directory. Bedfordshire and Luton Community and Mental Health Services.

Transcription

1 Service Directory Bedfordshire and Luton Community and Mental Health Services

2 Local Services, Local Solutions Main Trust Contacts South Essex Partnership University NHS Foundation Trust (SEPT) Head Office The Lodge The Chase Wickford Essex SS11 7XX Tel: Integrated Health Services Bedfordshire and Luton Community Health Services Bedfordshire Unit 2 Doolittle Mill Froghall Road Ampthill Bedfordshire MK45 2ND Tel: Fax: Mental Health Services Bedfordshire and Luton Charter House Alma Street Luton Bedfordshire LU1 2PJ Tel: Fax: Patient Experience Team If you have any concerns or need advice about accessing NHS services, you can speak in confidence to the Patient Experience Team on or you can pals.xxx@xxxx.xxx.uk About SEPT With an annual turnover of approximately 350m South Essex Partnership University NHS Foundation Trust (SEPT) is one of the most successful Foundation Trusts in the country providing integrated care including mental health, learning disability, social care and community health services from over 200 locations. We provide these services across Bedfordshire, Essex, Luton and Suffolk and employ approximately 7,000 people and serve a population of 2.5 million. We are a responsive, innovative and dynamic Foundation Trust delivering leading edge health services in a constantly changing environment. We work with a wide range of partner organisations to deliver care and support to people in their own homes and from a number of hospital and community based premises. We have many modern community based resource centres and community facilities to provide local services to local people where possible, operating from over 200 locations across Bedfordshire, Essex, Luton and Suffolk. SEPT provides a comprehensive range of services including: mental health services for adults and older people; Essex wide forensic services; low and medium secure services; specialist children s services; inpatient adolescent mental health services; learning disability services; drug and alcohol services; other specialist services. SEPT also provides community health services for those with physical health care needs including: urgent care; long term conditions; rehabilitation; health improvement; quality of life care; services for children, young people and families.

3 Overall Services Provided Mental Health Mental Health and Community Services Community Services Bedford Suffolk Bedfordshire Ampthill Saffron Walden Luton W Essex Harlow Essex Epping Brentwood Benfleet Basildon Southend London SW Essex SE Essex Grays Mental Health Mental Health and Community Health Services Community Health Service Contents In this Bedfordshire and Luton Integrated Service Directory we have colour coded the services: Community Health Services - Pink Mental Health Services - Orange Acquired Brain Injury 8 Active Bedfordshire 12 Adult Acute Inpatient Acute Inpatient Service Service 14 Community Adult Community Mental Mental Health Teams Health Teams 18 Assertive Outreach Teams 24 Community Beds Provision Service 30 Community Development Worker Team Team 34 Community Heart Failure Nurse Service 36 Community Matron Service 40 Community Nursing Service 44 Community Beds Provision Short Short Stay Stay Medical Medical Unit Unit (SSMU) (SSMU) 48 Continence Service 52 Criminal Justice Service HMP HMP Bedford and and Criminal Criminal Justice Justice Liaison Liason Team Team 56 Criminal Justice Service HMP HMP Bedford Primary Primary Healthcare Team Team 60 Crisis Resolution / Home / Treatment Teams Teams 62 Diverse Cultures Community Support Team Team 66 Drug & Alcohol Service - Luton - 70 Early Intervention in in Psychosis Service 74 Eating Adult Eating Disorder Disorder Service Service 78 Employment & Motivation for for People who of wish Working to work Age - EMPoWA - 82 Enhanced Care Service 86 Forensic Low Secure Inpatient Service 88 Macmillan Specialist Palliative Care Care 90 Mental Health Assessment Units Units (MHAU) 94

4 Cont. Nutrition and Dietetics 98 Older People Assessment Inpatient Service Service 104 Older People Community Mental Health Health Teams Teams Older People Continuing Health Care Inpatient Service Memory Assessment Service Service 116 Parkinson s Disease Disease Service Service 122 Patient Benefits Team Team 126 Podiatric Surgery Surgery 128 Podiatry Service Service 132 Psychology -- Direct Direct Access Access 138 Psychology -- Complex Needs Needs Service Service 140 Rapid Intervention Services Services 144 Rehabilitation and and Enablement Enablement 148 Rehabilitation In-patient In-patient 152 Resource Centres ACE ACE Enterprises Enterprises 156 Resource Centres Ashanti Ashanti Resource Resource Centre Centre 158 Resource Centres - Barford - Barford Avenue Avenue Resource Resource Centre Centre 162 Resource Centres The The Day Day Resource Resource Centre Centre (Bedford) (Bedford) 166 Resource Centres Roshni Roshni Resource Resource Centre Centre 170 Speech & Language Therapy Therapy Services For For People People With With Learning Learning Disabilities Disabilities (SPLD) (SPLD) Community Community 178 Services for for People People with with Learning Learning Disabilities Disabilities (SPLD) (SPLD) - Intensive - Intensive Support Support 182 Service for for People People with with Learning Learning Disabilities Disabilities (SPLD) (SPLD) - Low - Low Secure Secure Services Service 186 TB Nursing Service Service 190 Tissue Viability (Wound (Wound Care) Care) Service Service 194 Wheelchair Services Services 198 Children 0 19 Children s Service 202 Child and & Adolescent Mental Health Service -- Learning Disability 206 Child and Adolescent Mental Health Service Service 208 Children s Community Medical Service 212 Children s Community Nursing Team Team 216 Children s Continence Service 220 Children s Continuing Care Care Team Team 224 Children s Eye Service 228 Children s Intermediate Care Care Service 232 Children s Nursing Team at at the the Child Child Development Centre Centre 236 Children s Occupational Therapy 240 Children s Special Needs School Nursing Service Service 244 Children s Speech && Language Therapy 250 Early Intervention in in Psychosis Service Service 254 Looked After Children Service 258 If you have any questions about this directory, or would like to order additional copies - please xxxxxxxxxxxxxx@xxxx.xxx.uk

5 Acquired Brain Injury Overview of Service The Acquired Brain Injury (ABI) Service has been developed to enable access to specialist rehabilitation for people with complex needs following an acquired brain injury, whilst ensuring other health, psychological and social care needs are addressed. The service aims to provide rehabilitation to enable individuals to achieve their optimum recovery and potential following a severe acquired brain injury. The client group are those who have complex and intense needs which can not be met by other local rehabilitation services and require individualised packages to meet their changing needs. Where possible rehabilitation is provided close to home, however owing to the highly specialist nature of complex brain injury many placements are out of county. The ABI team strives to allow people to return home at the earliest opportunity, whilst ensuring their needs are still met. Where service is based Disability Resource Centre Poynters Road Dunstable Beds LU5 4TP Hours of operation Monday to Friday 08:30 16:30 How to contact service It is anticipated that any emergencies out of these hours will be managed by existing emergency services, such as Accident and Emergency, Duty Social Work team and Crisis Intervention teams etc. Helen Thomas Clinical Manager ABI Tel: xxxxx.xxxxxx@xxxx.xxx.uk How to refer into the service Referral criteria Referrals are accepted from: GPs; acute sector; health professionals; voluntary sector. Referrals are often received at the acute stage, however, owing to the complex nature of brain injury, referrals may be received further along the pathway. Therefore the service is provided to a wide range of acute hospitals in and out of the county, within the local community, including the community intermediate care beds and out of county specialist placements. Patient must be registered with a GP within Bedfordshire and be 18 years old. Patient must have suffered a significant acquired brain injury. We require verifiable evidence of severity: - loss of consciousness for greater than 30 minutes, disorientated during the first 24 hours, loss of concurrent memory and an initial Glasgow Coma Score GCS of less than 8. Patient has complex needs and requires specialised neurological rehabilitation that is beyond the scope of existing community services. This may be inpatient or community based. The case mix includes patients with an ABI as a result of: traumatic brain injury ( e.g. road tumour that is non-progressive traffic accident, falls, assault) stroke including haemorrhagic cerebral anoxia head injury that is nonprogressive carbon monoxide poisoning infection 9 Acquired Brain Injury

6 Additional information to support referral criteria Referrals are made using the Single Assessment Contact and Overview Assessment paperwork either by: Tel: or Safe Haven Fax: SEPT management responsible for service Clinical Manager: Helen Thomas Tel: Additional information may be requested to clarify access criteria. All referrals are discussed at the weekly clinical meeting, prioritised and allocated to the most appropriate team member to make an initial assessment. Associate Director: Hugh Johnston Tel: Exclusions from service Exclusions from the service include people who are acute medically unstable, have a currently unmanaged psychiatric disorder or who are engaging in the misuse of drugs or alcohol. Exclusion also includes congenital disorders, progressive conditions and learning disabilities (as defined by IQ or onset of ABI during childhood). Consultant Clincal Psychologist: Executive Director: Professor Gary Kupshik Tel: gary.kxxxxxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk What response times to expect The team will signpost to the most appropriate alternative service if the patient does not meet the criteria for the ABI service. An appointment for assessment is organised within two weeks of receipt of referral (or upon receipt of relevant medical history for community referrals). Prioritisation is given to acute patients who are medically stable and awaiting transfer to a more appropriate setting and patients in the community with unmanaged risk as a result of their acquired brain injury. Acquired Brain Injury 11

7 Active Bedfordshire Overview of Service The project aims to enable and empower adults aged 50 years and over to become more physically active through the development of community based programmes, specialist exercise classes and walking schemes run by trained volunteers and professionals. Another major aim of the scheme is to put in place interventions to reduce risk of falls in adults over 50 years old. Where service is based The project co-ordinator is based at: Unit 6, Doolittle Yard Froghall Road Ampthill MK45 2NX Hours of operation Monday to Friday to contact the co-ordinator How to contact service How to refer into the service Referral criteria Victoria Clout Tel: Referrals are accepted from: GPs; family, friend or self referral; voluntary sector groups; older peoples groups across Bedfordshire; medical profession referral; or by contacting the co-ordinator directly. The criteria is as follows: - over the age of 50 years old - need to live in Bedfordshire and be registered with a GP in the same location. Additional Information to support referral criteria Exclusions from service What response times to expect An information pack is sent to each referred patient and professional, any disease state or illness needs to be declared. Consent must be obtained from the patient Patients under 50 years old Response time to enquiries and referrals is within 48 hours of submission. SEPT Community Health Services Bedfordshire management responsible for service Project Manager: Associate Director: Victoria Clout Tel: victorxx.xxxxx@xxxx.xxx.uk David Robertson Tel: david.roberxxxx@xxxx.xxx.uk Director of Integrated Adult Helen Smart Services and Lead Nurse: Tel: helen.smart:sept.nhs.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 13 Active Bedfordshire

8 Acute Inpatient Service Overview of Service The Acute Inpatient Service provides 24 hour treatment and care in a safe and therapeutic setting, actively engaging and involving people who are experiencing an acute mental health episode which cannot be managed in a less restrictive setting, owing to the degree of risk, clinical need or patient choice. Many of those admitted will require detention under the Mental Health Act 1983 and the Amendment Act Where necessary, intense supervision and support will be provided. Patients receive individualised care and treatment based on the Care Programme Approach (CPA) which highlights crisis management and a place of safety, specialised risk assessments and risk management, intensive assessment, treatment and therapy, stabilisation of acute symptoms and relapse prevention. The service offers: assistance to acquire and enhance coping skills that promote and enable selfhelp and the self-management of mental health problems and difficulties; collaborative, structured approach towards assisting people to achieve their own recovery; diverse range of care interventions; individualised planning of treatment and care; specialist mental health and risk assessment; five Detox beds (three Keats, Bedford / two Coral, Luton). Staff in these wards work closely with the Crisis Resolution and Home Treatment Teams (CRHT) and the Community Mental Health Teams (CMHT). Where service is based Hours of operation Keats Ward (21 Beds + three Detox Beds) Weller Wing Bedford Hospital Kempston Road Bedford MK42 9DJ Tel: Coral Ward (28 Beds + two Detox Beds) Luton and Central Bedfordshire Mental Health Unit Off Calnwood Road Luton LU4 0FB Tel: Onyx Ward (22 Beds) Luton and Central Bedfordshire Mental Health Unit Off Calnwood Road Luton LU4 0FB Tel: hours, 365 days per year How to contact service Keats Ward, Bedford: Coral Ward, Luton: Onyx Ward, Luton: How to refer into the service & who can refer Referral criteria Referrals are accepted from: GPs acute sector (A&E) All admissions via Crisis Team (CRHT): Luton & South Beds: North & Mid Beds: requiring acute assessment Additional Information to support referral criteria The patient needs to have been seen within the last 24 hours by the Community Co-ordinator. The patient needs to be in an acute mental health state and at risk of harm to self or others. 15 Acute Inpatient Service

9 Exclusions from service Patients not experiencing an acute mental health episode. What response times to expect Assessment within four hours of referral; admission based on outcome of assessment. SEPT management responsible for service Bedford Clinical Group Manager Sylvie Downe (Acting) Keats: Tel: Luton Locality Clinical Group Manager (Acting) Shaun French Onyx / Coral: Tel: shaun.frxxxx@xxxx.xxx.uk Acute and Crisis Service Sharon Jackson Manager (Acting): Tel: sharxx.xxxxxxx@xxxx.xxx.uk Associate Director: Chris Bradley-Rushe Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Director Of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Adult Acute Inpatient Service 17

10 Community Mental Health Teams Overview of Service Community Mental Health Teams (CMHTs) are multi-disciplinary assessment teams for adults which provide mental health care and treatment for those individuals with more complex and enduring mental health needs, who can benefit from specialist interventions. The CMHTs also provide treatment and care for those with time-limited disorders who, it is felt, may benefit from specialist interventions. The teams provide services to people experiencing mental health difficulties in community settings, in order to promote positive mental health and independence. This ensures improved access to appropriate support services and resources, supporting timely discharge from hospital and reducing the need for hospital admission. The key aims of the CMHT are to: improve engagement with a range of community services including mainstream leisure and vocational services in order to promote positive relationships with patients and carers; promote stability within the lives of patients and their carers; promote social functioning and quality of life for patients by working to protect community tenure hence promoting the principles of recovery and social inclusion; offer meaningful engagement with patients and promote recovery; give advice on the management of mental health problems by other professionals in particular advice to primary care and a triage function through a single point of access to enable appropriate referral; provide treatment and care for those with time limited disorders who can benefit from specialist intervention; provide treatment and care for those with more complex and enduring needs; safeguard vulnerable adults and children from all forms of abuse and to preserve the rights and choices of individuals to take positive risks. Where service is based Bedford Bedford Assessment & Single Point of Access (ASPA) Weller Wing Ampthill Road Bedford Beds, MK42 9DJ Tel: Bedford Recovery Twinwoods Health Resource Centre Milton Road Clapham Beds, MK41 6AT Tel: Central Bedfordshire Ampthill CMHT Meadow Lodge Steppingly Hospital Ampthill Road Steppingly Beds, MK45 1AB Tel: Biggleswade CMHT Spring House Biggleswade Hospital Potton Road Biggleswade Beds, SG18 0EJ Tel: South Bedfordshire Dunstable CMHT Beacon House 5 Regent Street Dunstable Beds, LU6 1LP Tel: Leighton Buzzard CMHT Crombie House 36 Hockcliffe Street Leighton Buzzard Beds, LU7 1HJ Tel: Luton Locality Luton East CMHT Charter House Alma Street Luton Beds, LU1 2PJ Tel: Luton West CMHT Charter House Alma Street Luton Beds, LU1 2PJ Tel: Community Mental Health Teams 19

11 Hours of operation Monday - Friday 09:00-17:00 (some extended hours possible to suit patients and GPs) Bedford Day Resource Centre Kimbolton Road Bedford Tel: How to refer into the service & who can refer Referrals are accepted from the following: GPs; health professionals; mental health services; social services. Non-urgent referrals via the Assessment and Single Point of Access and CMHT (details above) How to contact service Bedford Locality A Single Point of Access (ASPA Team) Tel: Central Bedfordshire Locality Mid Beds CMHT Meadow Lodge, Steppingley Hospital Tel: Spring House Biggleswade Hospital Tel: South Beds CMHT Beacon House Tel: Crombie House Leighton Buzzard Tel: Central Beacon House 5 Regent St Dunstable Tel: Luton Locality Luton East CMHT Charter House Tel: Luton West CMHT Charter House Tel: Referral criteria Additional information to support referral criteria Urgent referrals via Crisis Resolution & Home Treatment (CRHT) teams Bedford: Luton: Patients must be 18 years and over Have severe or chronic mental illness e.g. schizophrenia or a severe affective disorder and are displaying florid symptoms and are not responding to treatment at a Primary Care level. Have severe depression - not responding to treatment at a primary care level Have suffered recurring mental health crises leading to frequent admissions or interventions and individuals who pose significant risk to their own safety or that of others Suffer substantial disability as a result of severe mental illness, preventing them from caring for themselves independently, sustaining relationships or employment. In all cases the referral must include GP name and address and indication that this has been discussed with the patient. Adult Community Mental Health Teams 21

12 Exclusions from service Patients where the primary concern is learning disability, autism or Asperger s Where there are no mental health symptoms present Luton Locality: Clinical Group Manager: Gail Robinson Tel: gail.rxxxxxxx@xxxx.xxx.uk What response Non-urgent: response from referral within 48 times to expect hours Further information SEPT management responsible for service Bedford Locality Interim Service Manager: Associate Director: Central / South Bedfordshire Locality: Clinical Service Manager: Associate Director: Urgent: response from referral within 4 hours Out of hours patients should access the local emergency services (Crisis Resolution & Home Treatment Teams, A&E, Help Lines) Debbie Buck Tel: debbie.xxxx@xxxx.xxx.uk Chris Bradley-Rushe Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Michael Farrington Tel: Michael.Farringtxx@xxxx.xxx.uk Jacqueline Palmer-Davis Tel: jacqueline.palmer-daxxx@xxxx.xxx.uk Paul Rix Tel: paul.rxx@xxxx.xxx.uk Community Services Manager: Mike King (Interim) Tel: mike.kxxx@xxxx.xxx.uk Associate Director: Paul Rix Tel: paul.rxx@xxxx.xxx.uk Director of Mental Declan Jacob Health Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Community Mental Health Teams 23

13 Assertive Outreach Teams Overview of service The Assertive Outreach Teams (AOTs) are a specialist service for adults with severe and enduring mental health problems, who have difficulty engaging with services, have repeat admissions to hospital and often have additional issues such as substance abuse, social isolation and homelessness. This client group is often at high risk of exploitation, self-neglect, self- injurious behaviour, and occasionally of aggression to others. The aims of the service are: to increase stability in the lives of patients and their carers / family; to improve social functioning and engagement in mental health services; to reduce hospital admissions and length of stay when hospitalisation is required; to increase housing stability. Care Co-ordinators in AOTs have small case loads so they can see their patients frequently and stay in contact, building trusting, supportive and therapeutic relationships with patients and their carers. The team aims to maximise an individual s strengths and abilities and acknowledge the limitations and problems imposed by their disorder through care plans tailored to an individual s needs. The multi-disciplinary teams offer: an assessment of the needs of family and carers including a care plan, practical support and family therapy; development of a relapse prevention plan which looks at triggers, symptoms as well as action for patients, family and carers; help in finding and keeping suitable accommodation; help in taking medication, including reviews and help with side effects; help to increase social networks and reduce isolation; help to improve physical health; help with daily living and social functioning, living skills training may be given to promote independence; help with substance abuse including referral to specialist services if needed; psychological therapy such as Cognitive Behavioural Therapy (CBT); support in finding suitable education, employment and training opportunities; rapid crisis intervention to prevent hospital admission or arrange in-patient care if necessary. Where service is based Bedford Bedford Assertive Outreach Florence Ball House Bedford Health Village 3 Kimbolton Road Bedford MK40 2NT Tel: Central / South Bedfordshire South Bedfordshire Assertive Outreach Crombie House 36 Hockliffe Street Leighton Buzzard Bedfordshire LU7 1HJ Tel: Hours of operation Daily 09:00 17:00 How to contact service How to refer into the service & who can refer Luton Luton Assertive Outreach Team Charter House Alma Street Luton Bedfordshire LU1 2PJ Tel: Bedford AOT: Tel: Central / South Bedfordshire AOT: Tel: Luton AOT: Tel: Referrals can be accepted from the following: GPs; Psychiatrist; other health professional recently involved in the patient s care. 25 Assertive Outreach Teams

14 Referral criteria Additional information to support referral criteria Exclusions from service What response times to expect 18 years and over A history of repeat referral to inpatient care or referrals to CRHT Difficulty in maintaining lasting contact with services and/or frequent periods of disengagement Severe and persistent mental illness, (e.g. schizophrenia, major affective disorder) which results in a high level of disability. Multiple complex needs, including a number of the following: violence, offending, significant risk of self-harm, neglect or exploitation, poor response to previous treatment plans, dual diagnosis of substance misuse and serious mental illness, detention under Mental Health Act (1983), unstable accommodation or homelessness. Need up to date Care Plan Approach (CPA) paperwork, if available. Referrals MUST be made using the AOT Referral Form supplemented with up to date CPA1 and CPA4 forms. Patients who suffer ONLY from a personality disorder or ONLY substance abuse will not be considered suitable. Assessment within 4 weeks of referral. Further information SEPT management responsible for service Bedford Locality Team Leader: Referrers will remain responsible for patients until a formal CPA has been conducted between the Care Co-ordinator and AOT. Patients not already known to the service will have all necessary forms completed by AOT staff. Sandra Harley Tel: sandra.harlex@xxxx.xxx.uk Service Manager: Debbie Buck (Interim) Tel: debbie.xxxx@xxxx.xxx.uk Associate Director: Central / South Bedfordshire Locality Team Leader: Clinical Group Manager: Associate Director: Chris Bradley-Rushe Tel: Mobile: chris.bradlexxxxxxx@xxxx.xxx.uk Tasha Newman Tel: Mobile: tasha.nexxxx@xxxx.xxx.uk Jacqueline Palmer-Davis Tel: jacqueline.palmer-daxxx@xxxx.xxx.uk Paul Rix Tel: paul.rxx@xxxx.xxx.uk Assertive Outreach Teams 27

15 Luton Locality Team Leader: Clinical Group Manager: Karen Weir Tel: Gail Robinson Tel: Community Services Manager: Mike King (Interim) Tel: Associate Director: Paul Rix Tel: Director Of Mental Declan Jacob Health Services: Tel: Executive Director of Richard Winter Integrated Services: Tel: Assertive Outreach Teams 29

16 Community Beds Provision Service Overview of Service The Community Beds Provision Service provides assessment of patients, short term support and interventions including personal care, Occupational Therapy (OT) and Physiotherapy, to prevent avoidable acute admissions and support appropriate early discharge. Patients need to have a potential for rehabilitation within four-six weeks to be accepted into the service The service aims: to ensure adults, who are medically stable and require assessment, treatments and rehabilitation, have an alternative to an acute hospital environment; to provide services based on patient need and choice to manage patient s health deterioration in a community environment. Where service is based Hours of operation How to contact service Biggleswade Hospital (29 beds) Potton Road Biggleswade SG18 0EL Tel: Archer Unit (20 beds) John Bunyan House Bedford Health Village 3 Kimbolton Road Bedford MK40 2NT Tel: hours, 365 days a year Biggleswade Hospital: Tel: Archer Unit, Bedford: Tel: How to refer into the service & who can refer Referrals are accepted from the following: GPs; acute hospitals; Allied Health Professionals; Ambulance Services; clinical support desk staff in EEAST Ambulance Control Centre; community matrons; community nursing; emergency care practitioners; palliative care services; Rapid Intervention Team; Rehabilitation and Enablement Service; social services; specialist nurses. Referrals need to go via OneCall Tel: (Monday Friday 09:00-17:00) Community Beds Provision Service 31

17 Referral criteria admission pathway GP/Clinician requests referral through OneCall Additional information to support referral criteria Out of Hours referrals should go through OneCall Tel: and then on to Rapid Intervention Services Office hours Patient assessed by Patient Pathway Triage Nurse, Clinician notified of decision Out of hours Patient referred to Rapid Intervention Team for assessment next working day What response times to expect Admission within four hours from referral Admission via A&E to avoid admission to acute services within two hours of referral Patient meets criteria. Bed offered Patient accepts bed/ Patient admitted. Bed manager contacts GP for history Patient not suitable, refer back to clinician Clinician notified of decision Patient not suitable, refer back to clinician Patient refuses Inpatient bed. Referral directed back to GP Practice & GP informed Patients are accepted into the service where: the patient is experiencing an acute alteration in their physical well being or social circumstance which requires rehabilitation and without the input of this service would result in an acute hospital admission; facilitated early discharge can be safely implemented within a community setting; patient has the potential for rehabilitation within 4-6 weeks. Patient meets criteria. Bed offered Patient accepts bed/patient admitted. Bed manager contacts GP for history SEPT management responsible for service Associate Director HMP Jane Lawson Bedford Heath Care, Shared Tel: Care and Inpatient Units: jane.laxxxx@xxxx.xxx.uk Directorof Integrated Adult Helen Smart Services and Lead Nurse: Tel: helen.smart:sept.nhs.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Community Beds Provision Service 33

18 Community Development Worker Team Overview of service The team engages with local communities and offers support to a wide range of professionals within the statutory and voluntary sector to help improve access, outcomes and experiences of mental health and social care for Black and Minority Ethnic (BME) Groups within Luton & Bedfordshire. What we do: The team works with a range of individuals, professionals and organisations involved in providing mental health and social care services in Luton and Bedfordshire to: build capacity within voluntary and community sector organisations; build sustainable partnerships; encourage access to mainstream providers; ensure patient s needs are identified and articulated; By engaging with local communities we hope to: provide advice and support to multi-agency partnerships; empower the voluntary/community sector; enhance BME service user & carer What we don t do: We don t provide individual advocacy or casework, but we do help signpost to relevant agencies. Where service is based ensure policies and procedures meet local needs; promote wellbeing; signposting to services; share good practice. involvement; improve care pathways; influence commissioning cycles; reduce mental health stigma. Charter House Alma Street Luton LU1 2PJ Tel : Hours of operation Monday Friday 09:00 17:00 How to contact service How to refer into the service & who can refer Referral criteria Exclusions from service What response times to expect SEPT management responsible for service Team Leader: Associate Director: Executive Director: Senior Community Development Worker Name: Levi Habashanti lexx.xxxxxxxxxx@xxxx.xxx.uk Referrals are accepted from the following: GPs; social services; mental health services. Referrals via the ASPA Team (Assessment Single Point of Access) Tel: BME (Black and Minority Ethnic); faith needs; significant cultural barriers to accessing mental health service. Additional Information to support referral criteria Patients outside the BME community Admission within seven days from referral Levi Habashanti Tel: lexx.xxxxxxxxxx@xxxx.xxx.uk Steve Porter Tel: steve.portxxx@xxxx.xxx.uk Amanda Reynolds Tel: amanda.rexxxxxx@xxxx.xxx.uk 35 Community Development Worker Team

19 Community Heart Failure Nurse Service Overview of Service The Heart Failure Nurse Service aims to enhance the care of patients with a diagnosis of heart failure, improving quality of life and ultimately preventing avoidable admissions to the acute sector. This is achieved by focusing on improving patient self-management, through education and support, also offering educational sessions to staff in primary care. The service provides both on-going clinical management of the condition by nurse prescribing, self-management advice and support components and actively encourages the involvement of the family and carers. The service enhances primary care through independent nurse prescribing. Where service is based Hours of operation Central Beds Unit 6 - Doolittle Yard Froghall Road Ampthill Beds, MK45 2NW South Beds Queensborough House Friars Walk Dunstable Beds, LU6 3JA Doolittle Yard, Bedford Monday - Friday 08:30-16:30 Queensborough House, Dunstable Monday to Friday How to contact service How to refer into the service Referral criteria Additional information to support referral criteria South Beds/ Central Beds Michelle Hammett Mobile: michelle.xxxxxxx@xxxx.xxx.uk Referrals are accepted from the following: GPs; acute care; community healthcare professionals; community matrons; community nurses; practice nurses. Patients should meet all of the criteria, however individuals are considered at the discretion of the Heart Failure Nurse. Patients must have a confirmed diagnosis of heart failure made by echocardiogram to be accepted onto the heart failure nurse caseload Left Ventricular Systolic Dysfunction diagnosed by echocardiogram and Heart Failure aetiology identified. Both to be documented in the patient s medical notes The patient must consent to the nurse s involvement Patients with preserved ejection fraction with heart failure symptoms will be accepted at the discretion of the heart failure nurse after a discussion with referrer. Recent blood results and access to pathology results on SystmOne. Community Heart Failure Nurse Sevice 37

20 Exclusions from service Patients registered with an NHS GP within North locality (Horizon PBC) What response times to expect Further information Assessment within one month from referral. SEPT Community Health Services Bedfordshire is not commissioned to provide a heart failure service in the North Locality SEPT Management responsible for service Lead Clinician: Michael Dimov Tel: michael.dimox@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Community Heart Failure Nurse Sevice 39

21 Community Matron Service Overview of Service The service comprises of Community Matrons with advanced clinical and diagnostic skills who are responsible for the case management of those with complex long term conditions. As well as case management, the Community Matron is responsible for providing treatment for their patients (except when treatment needs to be provided by a specialist provider). Each patient will have a personalised health plan offered and a Community Matron will oversee the care co-ordination and joined up services across health and social care. Telehealth monitoring is also available for patients with COPD and heart failure. Patients accepted onto a Community Matron caseload are frequent users of healthcare services and will have a complex, long-term condition. Each Community Matron will be aligned to a Locality Team, and their patient caseload will be taken from the population served by that team and group of GP practices. The Community Matron service incorporates: triaging referrals; carrying out advanced clinical assessment; the development of care plans; the case management and care co-ordination of the patient s care across various organisational boundaries; facilitating self care: educating patients, families and carers on how to move towards self management; health promotion; Medication management including non medical independent prescribing to avert hospital admission; managing unplanned episodes within the Community Matron s case load- assessing, providing / organising treatment at home or appropriate place of care; liaising with secondary care to facilitate safe, early discharge of patients on the Community Matron caseload; liaising with a range of specialist nurses and other primary, community and social care teams, to ensure quality palliative and end of life care is available to all patients and their carers; liaising with GP practices and primary care staff regarding assessments and care plans put in place; maintaining effective communication with GPs and practice teams throughout care delivery.; telehealth monitoring and triaging. Where service is based Hours of operation Community Matrons are based in a variety of local community settings within Community Nursing Teams. The majority of patient care is delivered in the patient s own home including care homes. When appropriate care may also be provided in health centres, clinics and GP surgeries. The Community Matron will also visit patients in hospital. The Community Matron Service is available: Monday to Friday 09:00 18:00 via the Community Matrons Out of Hours Service (for patients on the Community Matron caseload) is provided via Rapid Intervention Service During normal working hours patients are able to contact their Community Matron directly. Patients will be given the most appropriate number to call in an emergency. How to contact service Via OneCall Tel: South North Central Sara Drummond Tel: Julie Wood Tel: Beverly Houghton Tel: Gillian Hurley Tel: Dale Turland-Ord Tel: Viccy Cullip Tel: Leticia Sainty Tel: Community Matron Service

22 How to refer into the service Referral criteria Referrals are accepted from: GPs / practice staff; specialist nurses / Allied Health Professionals; social services / social workers; acute hospitals / hospices; voluntary services. Self referrals are also accepted when patients are known to the service Patients must be 18 years or over and be registered with a GP within Bedfordshire. Patients identified through PARR/Unique Calculator data and other methods including Local Authority referrals as risk of repeated hospital admission. Two or more unplanned admissions to hospital or A&E visits in the past six months (especially if of the same diagnosis). Additional Information to support referral criteria Additional Information to support criteria: two or more falls within the last six months; bereavement of close family member in the last 12 months with at least one other admission criteria; compliance/concordance difficulties with medication that Exclusions from Service have an adverse effect on care planning; complex social care needs that exacerbate their long term conditions; patients under 18yrs old; patients presenting with primary mental health condition once stable the patient can be re-referred to service for other long term conditions. What response times to expect SEPT management responsible for service Associate Director : Associate Director: Referrals are prioritised according to three levels and are based on health need. Referrals will be triaged within 48 hours and an appointment given. Where an urgent response is needed, the Community Matron will assess the situation and decide if it is appropriate for them to treat the patient directly, or whether to contact an alternative service e.g. Rapid Intervention Service, Emergency Care Practitioner / Emergency Response Service or 999. Urgent referrals are managed through the Rapid Intervention Team. Jane Lawson Tel: jane.laxxxx@xxxx.xxx.uk Anne Foley Tel: anne.folex@xxxx.xxx.uk Director of Integrated Adult Helen Smart Services and Lead Nurse: Tel: helen.smart:sept.nhs.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 43 Community Matron Service

23 Community Nursing Service Overview of Service The Community Nursing Service provides scheduled/planned care to predominantly house bound patients. The primary purpose of Community Nursing is to provide holistic health needs assessment for patients, families and carers. Community Nurses provide skilled clinical judgement to enable patients to improve, maintain or recover health and cope with health problems, achieving the best possible quality of life. They also support and manage end of life pathways through until death. The service offers: Assessment care planning single assessment; referral onto other services/agencies if required; holistic assessment of need, resulting in devising of relevant care plans, including nursing care interventions. Assessments include (this list is not exhaustive): care management needs; pain assessments; continuing health care; personal hygiene; continence; phlebotomy; disease specific risk assessments; risk assessments; manual handling assessments; teaching; nutrition assessment; wound care including leg ulcers. palliative care; Intervention Treatment to patients who are house bound include: bowel and bladder management; nurse prescribing; catheter care; palliative care/terminal care/ diabetic care; bereavement care; eye care; phlebotomy, venepuncture; intravenous therapy; pressure area care. medication management; Health promotion advise on diet and fluid intake; immunisation and vaccinations; Where service is based Hours of operation The service is divided into five localities within Bedford (two), Central Bedfordshire (three). Based within a number of different localities across the county some are within GP Practices. Seven days a week, 365 days a year, with access to OneCall 24 hour service: Community Nursing Service Core Teams 08:00 22:00 Rapid Intervention Team 22:00-08:00 How to contact service Via OneCall: Tel:(0845) How to refer into the service smoking cessation; maintain as appropriate links to health promotion agenda e.g. making every contact count Referrals can be accepted from the following: GPs; acute hospitals / hospices; allied health professionals; community matrons; health promotion; specialist nurses; social services / social workers; voluntary services; self referrals. Community Nursing Service 45

24 Referral Criteria The Referral form will request basic information regarding the patient: GP Details NHS Number ethnic group support network in place reason for referral Additional information to support referral criteria Exclusions from service What response times to expect relevant medical and surgical history details of the referrer including contact Number(s). Referral route Urgent referrals to go through OneCall. Urgent referrals are responded to at the earliest opportunity. Non urgent referrals referral form completed and either left in GP communication book within the GP surgery, or telephoned through to OneCall. patients under 18 years of age; patients who are not house bound (with the exception of patients requiring catheter care and bowel care. Palliative care patients will be offered a meet and greet assessment); domiciliary phlebotomy services to patients not on defined housebound caseload; leg ulcer dressings to mobile/non housebound patients. Urgent referrals assessment within two hours of referral and triage of the call to establish response required. Routine referrals referrals will be triaged within 24 hours and an appointment date given. Further information SEPT management responsible for service Bedford Locality a patient is not housebound if she or he is able to leave their home environment with minimal assistance; for example: unassisted/assisted visits to the Doctor, the dentist, the supermarket or the hairdresser. each patient will be individually assessed to determine their eligibility for home visits. Clinical Community Debbie Martin Service Manager: Tel: debbie.marxxx@xxxx.xxx.uk Associate Director Locality Jane Lawson Services: Tel: jane.laxxxx@xxxx.xxx.uk Central / South Bedfordshire Locality Clinical Community Jamie Stamp Service Manager: Mobile: jamie.xxxxx@xxxx.xxx.uk Associate Director Locality Anne Foley Services South: Tel: anne.folex@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Community Nursing Service 47

25 Community Beds Provision Short Stay Medical Unit (SSMU) Overview of Service The Community Beds Provision Short Stay Medical Unit (SSMU) provides a step up service for GPs and a step down option from Luton & Dunstable Hospital to help prevent hospital admission. The service provides medical, nursing, rehabilitation and social care assessments of patients, short term support and intervention, to prevent avoidable sub-acute hospital admissions and support appropriate early discharge for patients of 75 years or over who have a Bedfordshire GP. The unit aims to support and rehabilitate patients who have suffered a health crisis to help them return home. Suitable patients could be those suffering with: exacerbations of Long Term Care (LTC), e.g. Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), Arthritis and Parkinson s; patients post fall with a soft tissue injury with possible underlying LTC exacerbation; reduced mobility associated with infections that may require intravenous antibiotics, e.g. Urinary Tract Infections (UTIs), chest infections, also cellulitis. The service aims: to ensure adults, who are medically stable and require assessment, treatments and rehabilitation, have an alternative to acute hospital care; to ensure services are focused around patient need and choice, with a focus on the national agenda of community based care; to manage patients who have suffered a health crisis back to their home environment with or without support. The unit is supported by an integrated working team of Consultants, Senior House Officers (SHO), Pharmacists, Nursing staff, Occupational Therapists, Physiotherapists and Social Workers. Care and discharge planning is managed in a collaborative manner involving the patients and their representatives whenever available. SSMU also has a Virtual Ward at home option, for patients who need extra support following a health crisis (managed by the Rapid Intervention Team). Where service is based Short Stay Medical Unit - Houghton Regis (16 beds) Mayer Way Houghton Regis Dunstable Bedfordshire LU5 5BF Hours of operation 24 hours, 365 days a year How to contact service Tel: OneCall How to refer into the service & who can refer Referrals can be accepted from the following: Step Up (Monday - Friday only) GPs Community Matrons Practice Matrons Step Down (seven days a week, ) Navigation Nurses at Luton & Dunstable Hospital Contact OneCall, Tel: Access into the Virtual Ward is also via OneCall 24 hours a day, seven days a week Referral criteria aged 75 years or over; Abbreviated Mental Test (AMT) score registered with a Bedfordshire GP; 7/10 or greater (please discuss with requires two or more of the Triage Nurse as some flexibility is following: medical care, nursing care, allowed); therapy care (OT/PT), social care; able to swallow (or PEG tube in is medically stable, meaning: vital place); signs normal, does not require the patient has a reasonable rehab acute inpatient monitoring, potential; cardiac monitoring, neurological predicted Length of Stay 7 observation or complex nursing working days or less. interventions; 49 Community Beds Provision - SSMU

26 Additional Information to support referral criteria Step Up - GPs When contacting OneCall GPs should please state that they are requesting an admission to the SSMU. The triage nurse at the MDT will make contact with the SSMU and the SSMU Team Lead will contact the referrer immediately. Practice Matrons (Chiltern Vale practices) and Community Matrons will have access to step up beds, but must evidence a conversation with a GP prior to making the referral. The referrer will be responsible for arranging transport for the patient and must also ensure a Hospital style admission letter, including current medication, accompanies the patient to the SSMU. Step Down Luton & Dunstable Hospital Patients are identified and screened using the referral criteria by the Navigation Nurses in the Luton & Dunstable Hospital. The Navigation Nurse then contacts OneCall to make the referral and then completes the referral by speaking to the unit Band 6 staff member and faxing all necessary documentation. The hospital staff are responsible for arranging medication and transport for admission. Exclusions from service patients awaiting Continuing Health Care (CHC) assessment or funding, (unless referral will prevent hospital admission due to sudden health crisis); patient awaiting significant home adaptation; patients unwilling to go into the SSMU from home; patients who are only awaiting provision of Social or Respite Care; patients who only require end of life care; patients who require acute inpatient monitoring; patients who require cardiac monitoring; patients who require complex medical or nursing care; patients who require inpatient hospital investigations; patients who require isolation nursing; patients who require neurological observation; patients with significant behavioural disturbance or cognitive impairment. What response times to expect SEPT management responsible for service Clinical Service Manager Step Down Admission within eight hours from referral, dependent upon drugs, discharge letter and transport arrangements. Step Up Admission within eight hours from referral. Latest admission is 16:00 owing to Doctor s ward cover. Helen Glyn-Davies Tel: helen.glyn-daxxxx@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 51 Community Beds Provision - SSMU

27 Continence Service Overview of Service Bedfordshire Continence Service provides advice, support and treatment for people with continence needs. You can be referred for an assessment by your GP or any other health professional from whom you may be receiving care. Continence advisors are trained nurses who have undertaken specialist training in continence management and they can assess your individual continence needs and plan a treatment programme with you. Following assessment, your continence advisor may prescribe disposable incontinence products for you, which will be delivered to your home. Children from the age of four years can be referred to the service by a health professional This comprehensive continence service will: provide continence services to patients registered with a GP in Bedfordshire, living in their own home or a care home; ensure all patients referred to the service have access to appropriate continence advice and/or assessment; promote and develop the use of continence care pathways; lead on the procurement of the home delivery contract for supplies of continence products; provide a high quality, cost effective and productive service that enables innovative practice and meets individual patient needs; engage and support transitional planning for children transferring from paediatric to adult services; provide training, support and advice to carers and families; offer support and advice to patients with incomplete bladder emptying to become self managed; meet the 18 week target for appointment and treatment. Where service is based Hours of operation Monday - Thursday 08:45 16:45 Friday 08:45 16:30 Excluding bank holidays How to contact service How to refer into the service The main base for the service is: Disability Resource Centre Poynters Road Dunstable Beds LU5 4TP Assessments can be carried out in patient s own home or care home (non nursing care home) or clinic settings, these currently include: PCT Bedfordshire Bedfordshire Bedfordshire Bedfordshire Bedfordshire Bedfordshire Luton Luton Location Ampthill Health Centre Houghton Regis Health Centre Shefford Health Centre Leighton Buzzard HealthCentre Union Street Clinic, Bedford M.S Therapy Centre Liverpool Road Wigmore Lane Alternate Fridays Frequency Every Wednesday and occasional Tuesday and Thursday Every 3rd Thursday and alternate Fridays Every Monday Every Monday&alternate Wednesdays Monthly Every Friday and alternate Wednesdays Alternate Wednesdays Tel: from 08:30 12:30 and 14:00 16:00 Referrals for assessment to the service can be made by: GPs; Registered Nurse (in a nursing care home); Community Nurse; other professions e.g. social services. Continence Service 53

28 Referral criteria The continence service will accept a professional referral for assessment for any adult who is not on the Community Nurse s active caseload or under the care of a Registered Nurse in a (nursing) care home. SEPT management responsible for service Service Manager: Debbie Martin Tel: debbie.marxxx@xxxx.xxx.uk Patients may be assessed by Community Nurses and Registered Nurses in care homes. On receipt of the assessment and product order, it is then processed by the administration team and the patient will be supplied with product. Associate Director Locality Jane Lawson Services Central & South: Tel: jane.laxxxx@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Additional information to support referral criteria Exclusions from service What response times to expect Patient choice The service holds a contract with an NHS approved supplier, which in the majority is able to meet all patient requirements. If on the rare occasion these cannot be met, the patient is able to choose a product (s) from a comprehensive list, that matches the budget defined for their individual assessment needs - this may result in receiving fewer products and leave the individual responsible for purchasing the shortfall. The service does not supply anyone not registered with a Bedfordshire GP General patients are seen within 18 week target. Patients referred who require more intensive management of continence are contacted within three working days to arrange an appointment, will be seen within two working weeks. These patients are not patients who are in retention of urine. Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 55 Continence Service

29 Criminal Justice Service HMP Bedford and Criminal Justice Liaison Team Hours of operation Monday Friday 08:30-16:30 Overview of Service The Forensic Criminal Justice team provides a service for people aged 18 years and over, who are in the criminal justice system and have been identified as having a mental health condition or learning disability. The service: attends multi-agency public protection meetings to assist in the management of complex cases; identifies people with mental health conditions or learning disabilities at the earliest opportunity and ensures that their needs are met in the best setting, be it hospital, community or custody; provides assessments for individuals who are due for release from prison to ensure continued access to mental health or learning disability services; provides a prison in-reach service, working with prisoners at HMP Bedford. This extends to Police Stations, the Courts, Prisons and the Probation Service; provides one point of access for criminal justice agencies to information and advice, or assessment of people who appear to present symptoms of mental health/learning disability or have a history of mental health/learning disability; provides training on mental health and learning disability to criminal justice agencies. Where service is based Prison In-Reach Team HMP Bedford St Loyes Street Bedford Beds MK40 1HG Tel: Criminal Justice Liaison Team Charter House Alma Street Luton LU1 2PJ How to contact service Tel: Fax: How to refer into the service & who can refer Referral criteria Exclusions from service Referrals can be accepted from: Community Mental Health Teams Crown Prosecution Service Police Prison staff Probation Service Social Services Solicitors Voluntary Agencies Youth Offending teams Patients diagnosed with one or more of the following: Bipolar Affective Disorder Chronic depression Dual Diagnosis History or currently under Care Programme Approach History or currently under Community Mental Health Team History of Psychiatric hospital admissions Learning Disabilities Personality Disorders Schizophrenia/Psychosis Patients not within the Criminal Justice System 57 Criminal Justice Service - HMP Bedford

30 What Response Times to expect Non urgent; within three working days Police Station/Court Referrals; within four hours Further information The team is part of the SEPT Secure Services and operates as part of the Criminal Justice Liaison service in Bedfordshire. SEPT management responsible for service Criminal Justice Liaison Bryan Kvilums Team Leader: Tel: HMP Bedford Mental Health Angky Marsusi In reach Team Manager: Tel: Director of Secure Services: Executive Director: Denise Cook Tel: Sally Morris Tel: Criminal Justice Service - HMP Bedford 59

31 Criminal Justice Service HMP Bedford Primary Healthcare Team How to refer into the Referrals can be accepted from: Overview of service The Prison Primary Healthcare team provides a wide range of services for people aged 18 years and over, who enter HMP Bedford via court and other establishments and require physical and or primary mental health support. The Service: provides a comprehensive assessment of patients coming into the establishment in order identify their healthcare needs; offers a choice of screening and vaccination programmes to all patients; delivers a variety of clinics available to all patients providing assessment and support, including access to a GP, long term conditions, dentistry and podiatry; contains an In-Patient unit providing 24hour nursing care for patients with mental and physical health needs; has a 24 hour response team for medical emergencies throughout HMP Bedford; supports health promotion clinics. Where service is based Hours of operation Healthcare HMP Bedford St Loyes Street Bedford MK40 1HG Tel: hour Healthcare facility How to contact service Tel: / Fax: service & who can refer Referral criteria Exclusions from service What response times to expect SEPT management responsible for service Matrons: Associate Director: self-referral; prison staff; voluntary agencies; drug and alcohol services; outside agencies, including GPs, consultants and other professionals. Patients must be within the Criminal Justice System and be in HMP Bedford. Patients not within HMP Bedford. Patient request forms are collected on a daily basis, with an appointment system in operation Jackie Edwards Tel: jackie.edwarxx@xxxx.xxx.uk Tracey Healey Tel: tracey.healex@xxxx.xxx.uk David Robertson Tel: david.roberxxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers and Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 61 Criminal Justice Service HMP Bedford Primary Healthcare Team

32 Crisis Resolution / Home Treatment Teams Overview of service The Crisis Resolution / Home Treatment (CRHT) teams work with a group of patients, who, without this support, would need to be admitted to hospital, or who cannot be discharged from hospital without intensive support. The service enables patients who are in crisis, and not able to function at their normal level, to be supported in their own homes. Whereservice is based Hours of operation How to contact service Bedford and Mid Bedfordshire Crisis Team Floor 2, Weller Wing Ampthill Road Bedford MK42 9DJ Tel: Luton and South Bedfordshire Crisis Team Calnwood Court Calnwood Road Luton LU4 0FB Tel: :00 21:00 7 days per week Out of Hours via Accident & Emergency Liaison Bedford and Mid Bedfordshire: Tel: Luton and South Bedfordshire: Tel: How to refer into the service & who can refer Referral criteria Additional information to support referral criteria Exclusions from service What Response Times to expect Referrals can be accepted from the following: GPs; acute sector A&E Department; community mental health teams; community nurses; health professionals. patients in acute mental health crisis requiring mental health assessment and / or home treatment as an alternative to inpatient care; significant deterioration in mental health, risk to self or others with a possibility of hospital admission. Patients must have been seen within previous 24 hours by Community Coordinator. Drug & Alcohol as primary issue. Assessment within four hours from referral. Crisis Resolution / Home Treatment Teams 63

33 SEPT management responsible for service Clinical Team Lead (Bedford): Andrea Howe Tel: Clinical Team Lead Judith Anyang (Luton Acting): Tel: Clinical Group Manager Sylvie Downe (Bedford Acting): Tel: Clinical Group Manager Shaun French (Luton Acting): Tel: Acute and Crisis Service Sharon Jackson Manager (Acting): Tel: Associate Director: Chris Bradley- Rushe Tel: Director Of Mental Health Declan Jacob Services: Tel: Executive Director of Richard Winter Integrated Services: Tel: Crisis Resolution / Home Treatment Teams 65

34 Diverse Cultures Community Support Team Overview of Service The Diverse Cultures Team has an ethnically diverse staff team, providing a flexible, culturally competent service to meet the needs of black and ethnic minorities (BME), including those of Eastern European origin who have a diagnosed mental health condition. The team provides recovery-based intervention that respects patients language, cultural background, religious and spiritual beliefs. The service helps patients find ways of managing their journey of recovery and achieve their full potential. Service users are encouraged to complete their own Recovery Star to help evaluate progress and identify future goals. The service offers: one to one support at home and in the community based on the Care Programme Approach (CPA), which is sensitive to the patients cultural and linguistic needs; patients rehabilitation and care pathways, including reintegration into community following discharge from acute care; practical support enabling patient s to acquire life skills to achieve independent living and positive mental health; supporting patient s access to resources in the community, including mental health reviews and promoting access to services; carer s assessments; information and advice on health and social care issues; group work in the community - activities include information sharing, health awareness, discussion groups, anxiety management, creative workshops, outdoor activities, social meeting of patients with others experiencing similar issues; health and wellbeing workshops- health promotion and anti stigma campaign. Where service is based Twinwoods Health Resource Centre Whitbread Centre Twinwoods Clapham Bedford MK41 6AT Hours of operation 09:00 17:00 Monday Friday How to contact service Tel: Fax: diverse.culturxx@xxxx.xxx.uk How to refer into the following: service & who can refer Referral criteria Exclusions from service What Response Times to expect Referrals can be accepted from the GPs; Assessment and Single Point of Access (ASPA); care co-ordinator; community mental health team (CMHT); consultant psychiatrists. patients with a diagnosed mental health problem who will benefit from the support of a specialist service; patients must be resident in Bedford Borough or Central Bedfordshire. Additional Information to support referral criteria Referrals are through the Assessment and Single Point of Access (ASPA) contact centre Tel: Access to up to date CPA People living outside Bedford Borough and Central Bedfordshire. Within 5 working days from referral. 67 Diverse Cultures Community Support Team

35 Further Information SEPT Management responsible for service Team Leader: Associate Director: Executive Director: Patients need to meet social care eligibility criteria. with mental health needs who are at critical or substantial risk if their needs are not met. The referring Social Worker / CPN will be expected to remain as the patient s care coordinator whilst the patient s is subject to the CPA process and will be responsible for coordinating the periodic review of the patient s needs. Literature available: Diverse Cultures Booklet (BL0152) is available in various community languages. Further information is available from the Team Manager or Administrator Tel: Simran Kaur Khinder Tel: simran.kxxxxxx@xxxx.xxx.uk Steve Porter Tel: steve.portxxx@xxxx.xxx.uk Amanda Reynolds Tel: amanda.rexxxxxx@xxxx.xxx.uk Diverse Cultures Community Support Team 69

36 Drug & Alcohol Service - Luton Overview of Service The Drug & Alcohol team provides services for Luton residents over the age of 18 who experience drug or alcohol related problems. The service provides a substance misuse dependency treatment service, as well as outreach into the community, to support people with alcohol abuse, drug abuse and people with dual diagnosis of mental health problems and substance misuse within Luton Borough. Our multi-disciplinary team comprises of psychiatrists, mental health nurses, social workers and counsellors. The service offers: advice and information; assessment, counselling and relapse prevention; assessments for residential detoxification and rehabilitation; auricular acupuncture for stimulant withdrawal; care management; community detoxification; facilitation of rehabilitation; liaison with GPs, hospitals and rehabilitation units; maintenance prescribing; stabilisation; motivational interviewing; methadone programmes; open reach service; pre-sentence reports and liaison with justice services for those who have drug or alcohol related offences; support for patients, relatives and carers. Where service is based Luton Drug & Alcohol Specialist Service (LDASS) Cardiff Road Luton LU1 1PP Tel: Hours of operation 09:00 19:00 Monday, Wednesday, Thursday 09:00 19:30 Tuesday 09:00 16:30 Friday How to contact service Tel: Fax: How to refer into the service & Who can refer Referral criteria Additional information to support referral criteria Exclusions from service Referrals can be accepted from the following: GPs; health professionals; social care; self referrals; friends and family. Patients diagnosed with an opiate and/or alcohol dependency with a cooccuring mental health problem. Patients with alcohol dependency requiring medically supervised detoxification. Social Services referral of parents or guardians, who are high risk injectors and diagnosed with a blood borne virus, whose child or children are classified as being in need and requiring child protection. Patients must be living within Luton Borough. Patients who have an opiate dependency who do not have a mental health problem or an alcohol problem. 71 Drug & Alcohol Service - Luton

37 Drug & Alcohol Service - Luton What response times to expect Admission within 21 days of referral. SEPT Management responsible for service Team Leader: Dermot Flynn Tel: dermot.xxxxxx@xxxx.xxx.uk Executive Director: Amanda Reynolds Social Care and Partnerships Tel: amanda.rexxxxxx@xxxx.xxx.uk 73

38 Early Intervention in Psychosis Service Overview of service This specialist service works with people aged years who are experiencing their first episode of psychosis, no matter what the cause of symptoms, whether it is drug induced or related to a bipolar disorder or a primary psychotic illness. This intensive service is available to people with psychosis and their carers for a maximum of three years. Psychosis is a term used to describe conditions that affect the mind, where there has been some loss of contact with reality. Hallucinations, such as hearing voices, delusions (false beliefs), paranoia and disorganised thoughts and speech are some of the symptoms that may be experienced. These symptoms can seem so real that often the person does not realise that they are experiencing psychosis. Psychosis also affects feelings and behaviour. The service also works with people with low level psychotic symptoms such as, odd beliefs, altered sensations particularly in their hearing and vision, a family history of psychosis, fleeting psychotic symptoms and/or changes in their mental state. The service is comprised of a community based multi-disciplinary team which provides assistance and interventions at a time and location that are convenient to the person with psychosis. The team aims to reduce both the duration and severity of acute psychosis and to improve a person s social functioning and assist them in staying or getting back into employment or education. The service offers: advice, information and assessment; an assessment period of up to three months; assertive outreach approach youth friendly services, emphasising social recovery; comprehensive package of care for a duration of two-three years; cognitive behavioural therapy for hallucinations and delusions; family intervention; help with returning to work or education; hospital admission arranged when necessary; low dose neuroleptic medication; relapse prevention strategies; seeing people in their homes or other non stigmatising settings; support/advice for family, carers and friends. Where service is based Hours of operation Twinwoods Health Resource Centre Milton Road Clapham Beds, MK41 6AT Tel: :00 to 17:00 Monday to Friday How to contact service Tel: Fax: ei.txxx@xxxx.xxx.uk How to refer into the service & Who can refer Referral criteria Referrals can be accepted from the following: GPs; health professionals; related professionals such as social services, youth workers; self referrals; families & friends. All our patients must be: aged 14 to 35 (inclusive); registered with a Bedfordshire GP; suspected of having experienced a first episode of psychosis. Early Intervention in Psychosis Service 75

39 Additional information to Please contact the service on support referral criteria where someone can discuss any additional information that would be useful e.g. when and what has raised your concerns. For other agencies / professionals a brief referral form is available by contacting the team. Exclusions from service There has been treatment for psychotic symptoms greater than 12 months ago. What response times to expect SEPT Management responsible for service Confirmation of referral within 24 hours. Assessment within 14 days from confirmation. Team Manager: Alison Bass (Interim) Tel: xxxxxx.xxxx@xxxx.xxx.uk Community Services Manager: Mike King (Interim) Tel: mike.kxxx@xxxx.xxx.uk Associate Director: Paul Rix Tel: (5513) paul.rxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Early Intervention in Psychosis Service 77

40 Eating Disorder Service Overview of Service The Eating Disorders service is a countywide outpatient therapy service which offers multi-disciplinary assessment and treatment for adults with eating disorders aged 18 and over. The Eating Disorder team provide the following services: Bulimia Nervosa and Binge Eating Disorder; Anorexia Nervosa; Gate keeping to inpatient services out of area; EDNOS. The Eating Disorders service has a multi-disciplinary team which consists of: Clinical Nurse Specialist; Dietitian; Clinical Psychologist; Administrative support; Assistant Psychologist; Consultant Psychiatrist. Where service is based Hours of operation Disability Resource Centre Poynters House Poynters Road Dunstable Beds, LU5 4TP Tel: :00 17:00 Weekdays How to contact service Tel: Out of hours emergencies will be managed by existing emergency services How to refer into the service & who can refer Referral criteria Additional information to support referral criteria Referrals can be made by the following: GPs; health professionals. Referrals should be made either by letter or using the referral form and sent by post to the Eating Disorders service, or faxed to Safe Haven Fax: (01582) All our patients must: be over 18 years of age; be registered with a Bedfordshire GP; meet the criteria for an Eating Disorder as defined by the Diagnostic Statistical Manual (DSM IV-TR). The following information should be provided: current weight and height (please include most recent measurements); information regarding past weight history (if known); current eating behaviours including restricted eating, over-eating, bingeing, vomiting, use of laxatives and level of exercise; how does the person feel about his/her problem? current health and results of recent investigations including: full blood count and Urea & Electrolytes tests ECG when appropriate; past psychiatric history and relevant Psychology/Psychiatry; any other services which are currently involved. 79 Eating Disorder Service

41 Exclusions from service We are currently not able to see the following groups of people: those with eating/food phobias/food fads ; those who fear choking; those whose eating problems are secondary to other mental health or physical health issues (but we can offer consultation to CMHTs); if there is a risk of suicidal behaviour or selfharm (in these cases we can co-work); self-referrals are not accepted. What response times to expect Admission within 18 weeks from referral. Urgent referrals within two weeks if possible. SEPT Management responsible for service Team Leaders: Associate Director: Executive Director: Faith Whittle Tel: xxxxx.xxxxxxx@xxxx.xxx.uk Hugh Johnston Tel: hugh.johnstxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk Adult Eating Disorder Service 81

42 Employment & Motivation for people who wish to work - EMPoWA Overview of Service EMPoWA - is a specialist employment support service for people who wish to work within Bedford Borough and Central Bedfordshire. EMPoWA offers support and guidance to help people with a mental health diagnosis to seek, gain, and maintain employment. Using an Individual Placement and Support (IPS) model to help people find employment means that the service is tailored to the individual s needs and specific difficulties relating to the job search can be addressed. EMPoWA can also support individuals who are already employed with any work retention issues they may be facing. The team can provide advice about what to say to an employer about a health problem and an individual s rights if such a health problem is declared. Support and advice is offered to those in existing employment as well as information about other agencies and services which can be contacted to help achieve employment goals. The teams offer support with the following: addressing barriers to employment; benefits advice; confidence building; contacting employers; job searching; making applications; negotiating reasonable adjustments in workplace; ongoing post employment support; support with interviews; work trials; writing CVs. Where service is based EMPoWA 3 Woburn Road Bedford MK40 1EG Hours of operation 08:30 17:00 Monday - Friday How to contact service Tel: Fax: empoxx@xxxx.xxx.uk How to refer into the service & who can refer Referral criteria Additional information to support referral criteria Exclusions from service What response times to expect Referrals can be accepted from the following: Nurses; Occupational Therapists; Psychiatrists; Social Workers; Therapists in the Mental Health team acting as Care Co-ordinators. those who have a diagnosis of a Severe and Enduring Mental Health condition; anyone with a Care Co-ordinator in the Mental Health Team (Social Workers, Nurses, Psychiatrists, Occupational Therapists, other Therapists). Completed EMPoWA referral form accompanied by appropriate CPA documentation or Risk Assessment and Care Plan. Residents outside Bedford Borough or Central Bedfordshire. Assessment within 28 days from referral. Ongoing appointments as required (minimum fortnightly). 83 EMPoWA

43 Further information Available by contacting the EMPoWA office Leaflet BLO239. SEPT management responsible for service Team Leader: Associate Director: Executive Director: Julie Bailie Tel: Steve Porter Tel: Amanda Reynolds Tel: EMPoWA 85

44 Enhanced Care Service Overview of Service The Enhanced Care Service is a Specialist (Social Work) Substance Misuse Team working throughout Bedfordshire (but excluding Luton). The team is made up of both Qualified Social Workers and Social Work Assistants. The targeted client group are those with a Primary Substance Misuse with very high and complex social care needs. The Service Provides: community care assessment and assessment of social care need; carer s assessment; identification and commissioning of appropriate services matched to need and eligibility; short and medium term social interventions, support and aftercare; co-ordination of services where several are involved and need joining up ; joint working with other services where there is a Dual Diagnosis; liaison with Criminal Justice Services subject to eligibility; signposting to other more appropriate specialist services. Where service is based Hours of operation 21 The Crescent Bedford MK40 3JJ 09:00 17:00 Monday to Friday How to contact service Tel: How to refer into the service & who can refer GPs; acute sector (A&E); social workers; health professionals; self-referral. The patient must consent prior to the referral being accepted by the service. Referral criteria Additional information to support referral criteria Exclusions from service What response times to expect SEPT management responsible for service Assistant Director: Substance Misuse issues, that have alcohol and/or drug related problems and which meet the International Classification for Disease 10/diagnostic Statistical Manual IV ICD-10/DSMIV Have an identified Social Care need that qualifies for a service under Fair Access to Care Services (FACs) applying to the local authorities service threshold. People must ordinarily reside within Bedford Borough or Central Bedfordshire. Those that do not meet the referral criteria OR do not ordinarily reside in the Bedford Borough or Central Bedfordshire. Response to referrals within five days and assessment within 21 days. Steve Porter Tel: steve.portxxx@xxxx.xxx.uk Executive Director: Amanda Reynolds Social Care and Partnerships Tel: amanda.rexxxxxx@xxxx.xxx.uk Enhanced Care Service 87

45 Forensic Low Secure Inpatient Service Overview of Service The Forensic Low Secure Inpatient Service is provided to adults who are detained under the Mental Health Act 1983 and who: have been identified as requiring hospital admission for assessment or treatment but do not require intensive care. (the patient would usually be involved in criminal proceedings, requiring transfer from custodial settings); have been identified as requiring a rehabilitation programme within a low secure setting and are able to participate in such a programme. The service provides individualised care and evaluation of the patient s progress and recovery. People are encouraged to be involved in their care planning and, where possible, the family is also involved. Where service is based Hours of operation Robin Pinto Unit Calnwood Road Luton Beds LU4 OFB Tel: hours, 365 days How to contact service Tel: Fax: How to refer into the service & who can refer Therapies staff: Monday - Friday :00 Referrals are accepted from the following: courts; consultant psychiatrists; prisons; medium secure services; mental health units. Referral criteria Exclusions from service What response times to expect SEPT Management responsible for service Team Leader: Director of Secure Services: Executive Director: Patients requiring hospital admission for assessment or treatment that cannot be managed in an acute inpatient setting. Patients involved in criminal proceedings, requiring transfer from custodial settings. Assessed as being unable to engage in a low secure rehabilitation programme. Patient requires medium/high secure care. Admission within 14 days from assessment following referral. Karina Moriarty Tel: karina.moriartx@xxx.xxx.uk Denise Cook Tel: denise.xxxxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk Forensic Low Secure Inpatient Service 89

46 Macmillan Specialist Palliative Care Overview of Service The goal of specialist palliative care is to ensure the best quality of life for and Older with life limiting conditions and their families both through the direct care of those with complex needs by links with specialist services / teams and the indirect care of those with palliative care needs through expert advice, support, education and training and governance. The role of the Macmillan Clinical Nurse Specialist is to work in partnership with the primary care team and hold a caseload of those patients with complex specialist palliative care needs. Each patient with a life limiting condition will be assessed holistically using an agreed tool at the beginning of their palliative diagnosis and at appropriate points of the care pathway. Referral is made to other services and agencies as appropriate and the team will work with the relevant key worker at any given time. The Macmillan Specialist Palliative Care team includes a Specialist Palliative Care Physiotherapist whose aim is to maximise patients ability to function, promote independence and assist them to adapt to their condition. This is available to patients in north and mid Beds localities. The Specialist Palliative Care Physiotherapist will also give educational support to South Beds locality. The team also work in partnership with Bedfordshire Partnership for Excellence in Palliative Support (PEPS). Where service is based Within localities across Bedfordshire, working in neighbourhoods with community nursing and aligned GP practices. Hours of operation Monday - Friday Weekends On Call for specialist assessment, advice and support through PEPS. How to contact service How to refer into the service Referral criteria Bedford Team Gladys Ibbett House Bedford Tel: Central / South Bedfordshire Team Doolittle Yard Ampthill Beds Tel: The service is available for all adults (18 years and over) with a life limiting illness registered with a Bedfordshire GP. Referrals are accepted from: GPs; health care professionals. The team provide visits to where the patient resides and in other settings including care homes, acute hospitals, hospices and prison. All adults with a life limiting illness -18 years of age onwards. Additional Information to support referral criteria. Fax: referral form for Mid and South teams Fax: referral form for Bedford team Macmillan Specialist Palliative Care 91

47 Exclusions from service What response times to expect Under 18 years and those without specialist palliative care needs. Referrals are prioritised using a RAG status system, which clearly states the response rate of the service, depending on the individualised needs of the patient. SPECIALIST PALLIATIVE CARE SERVICE RESPONSE (community) RED: PEPS co-ordinator to return call to referrer; assessment via telephone and response appropriate to need e.g. advice or home visit. inform District Nurse of plan of action; give appropriate contact numbers (including PEPS). AMBER: nurse to make phone contact to patient / family within one working day; offer clinic appointment / joint home visit with District Nurse; visit within three working days or agreed timescale according to need; give appropriate contact numbers (including PEPS). GREEN: refer to Primary Health Care Team monitor and support indirectly through practice GSF meetings or base meetings with DNs. SEPT management responsible for service Associate Director Locality Jane Lawson Services North Tel jane.laxxxx@xxxx.xxx.uk Associate Director Locality Anne Foley Services South: Tel: anne.folex@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Macmillan Specialist Palliative Care 93

48 Mental Health Assessment Units (MHAU) Overview of Service The Mental Health Assessment Units (MHAU) are 24-hour dedicated inpatient units designed for supporting adults who are in a mental health crisis, requiring an in-depth assessment period, and are willing to accept an informal inpatient stay. A full psychosocial assessment is carried out, in most cases within 24 hours. The maximum stay at the Assessment Unit is five days. The assessment looks at the best way of treating the person referred to the unit, either at home, through the new Crisis Resolution Home Treatment Teams or admission to a day unit or an appropriate admission to a ward. The service offers: 24 hour, 365 days a year services; active involvement of the patient, family and carers; choice and autonomy, where possible; intensive assessment, intervention and support in the early stages of a crisis; rapid response following referral to the Unit; recovery planning with patient focussed outcomes; sensitive approach to ethnic and cultural issues; share learning from the crisis; time-limited interventions that are able to respond to patient s needs; to provide practical support and assistance with problems of daily living. The Assessment Units consist of multi-disciplinary teams including Mental Health Nurses, Clinical Support Workers, Clinical Psychologists, a Consultant Psychiatrist and medical staff. They work in partnership with the Outpatients Team, Care Co-ordinators, Social Workers and GPs to support the patient through their inpatient stay. Where service is based Hours of operation Jade Ward Luton (10 Beds) Mental Health Assessment Unit (MHAU) Luton & Central Bedfordshire mental Health Unit Off Calnwood Road Luton Beds LU4 0FB Tel: Weller Wing Bedford (7 Beds) Mental Health Assessment Unit (MHAU) Bedford Hospital Kempston Road Bedford Beds MK42 9DJ Tel: hours, 365 days How to contact service Jade Ward Luton Tel: Weller Wing - Bedford Tel: How to refer into the service & who can refer Referrals are accepted from the following: GPs; Care Co-ordinator; Community Mental Health Teams; Community Nurse; health professionals; Hospital Liaison Nurse; social services. Referral via Crisis Home Treatment Team: Luton Tel: Bedford - Tel: Mental Health Assessment Units (MHAU)

49 Referral criteria Patients presenting in psychiatric crisis, for whom at the point of initial assessment, or assessment following rereferral, there does not appear to be any alternative to in-patient admission at that time. Over 18 years old SEPT management responsible for service Luton Locality Charge Nurse: Christmas Musonza Tel: Additional information to support referral criteria Exclusions from service What response times to expect Past psychiatric history of the patient and current presentation should be provided to Crisis Team on referral. patients from outside Luton and Bedfordshire; patients under 18 years old; patients detained under the Mental Health Act, although may accommodate patients who are recalled from a Community Treatment Order (CTO); patients who do not present with an acute mental health crisis but who would benefit from other specialist mental health interventions- these patients will be passed on to the relevant service; the service will not accept any patients from Accident & Emergency who have not been declared medically fit. Assessment within four hours from referral. Admission dependent on bed availability. Clinical Group Manager (Acting): Bedford Locality Ward Sister (Acting): Shaun French Tel: shaun.frxxxx@xxxx.xxx.uk Karan Campbell Tel: kxxxx.xxxxxxxx@xxxx.xxx.uk Clinical Group Manager Sylvie Downe (Acting): Tel: sylvie.doxxx@xxxx.xxx.uk Acute and Crisis Service Sharon Jackson Manager (Acting): Tel: sharxx.xxxxxxx@xxxx.xxx.uk Associate Director: Chris Bradley-Rushe Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Mental Health Assessment Units (MHAU) 97

50 Nutrition and Dietetics Overview of service The Nutrition and Dietetic Service is hosted by SEPT The service provides: therapeutic diets (clinical services with identified patient care pathways to inpatients, outpatients, people in care homes and at home); public health projects, Healthy Under 5s Programme, Family Cooking Clubs; Home Enteral Feeding Services (hosting, management and delivery of the services); training, for health and community-based professionals and the general public; development of local nutrition guidelines and resources; expert nutrition advice for health professionals and the general public; Food First Project, Mid, South Bedfordshire and Luton. Where Service is Based The main department is based at Dunstable Health Centre, The service is also delivered from the following venues: Luton and Dunstable Hospital wards, Intensive Care, Outpatients, Diabetes Centre Outpatients in Leighton Buzzard and Dunstable, Houghton Regis Medical Centre, Liverpool Road Health Centre and children s centres Domiciliary Visits in South Bedfordshire (as required) Acute and community mental health units Care homes and mental health units (Poplars and Townsend Court, Houghton Regis) Luton Treatment Centre Disability Resources Centre Children s Centres in Luton and Bedfordshire Hours of operation Monday - Friday How to contact service Diabetes Centre Dunstable Health Centre (main office) Priory Gardens Dunstable Beds LU6 3SU Tel: Fax: foodxxxxxx@xxxx.xxx.uk Luton and Dunstable Hospital Lewsey Road Luton Beds LU4 ODZ Tel: xxxxxxxxxx@xxx.xxx.uk How to refer into the service Referrals are accepted from: GPs; Community Nurses; Health Visitors; Community Medical Officers; Consultants and Dental Practitioners. Patients can be referred for individual therapeutic dietetic support. The majority of referrals are for individuals to receive specialist therapeutic advice. Nutrition and Dietetics 99

51 Referral criteria Patients with Diabetes under the sole care of the GP newly diagnosed where HbA1c is > 7.5% at 3/12 or where HbA1c is > 7% at 6/12) despite dietary change initiated by practice staff and attendance at DESMOND training; patients with well-controlled diabetes and persistent dyslipidaemia; patients with Diabetes and other significant dietary restrictions or eating difficulties; patients with Diabetes who have a BMI in excess of 35; patients requiring detailed clarification of their dietary goals. Hyperlipidaemia / Coronary Heart Disease Patients identified by the Coronary Heart Disease National Service Framework as requiring dietary advice where more specialised advice is needed or where the practice nurse has not had recent nutrition training. All inpatients at L&D who have had a MI will be directly referred to the Cardiac Rehabilitation Team and receive generic nutrition advice. Inpatients who meet the following criteria of the Cardiac Rehabilitation Policy will be referred directly to the Cardiac Rehabilitation Dietitian patients with BMI < 20 or patients who have lost 5-10 % of their body weight in last 2-3 months; BMI > 28; patients newly diagnosed with Type 2 Diabetes or with uncontrolled diabetes; patients commenced on insulin as part of DIGAMI protocol; patients expressing concern about making dietary changes; patients who have particular dietary needs. Obesity Obese patients i.e. BMI > 35 or if patient is of South Asian origin, a BMI >27 and at high risk of complications, where appropriate and adequate advice from the practice staff has been unsuccessful: excessive weight gain in pregnancy. Underweight/at risk of malnutrition patients with unintentional weight loss of known origin or to reverse or stabilise weight loss while under medical investigation; patients with a MUST Score of two or more, where Food First advice has been tried for a month with no or limited success. Coeliac Disease All patients referred to the L&D Gastroenterology Team with newly diagnosed Coeliac disease will be directly referred by the team to the Gastroenterology Dietitian for an initial consultation and follow-up. patients with known Coeliac disease requiring additional advice on diet or not under the care of the Gastroenterology Team can be referred to the Community Dietitian. Irritable Bowel Syndrome (IBS) patients who have been diagnosed with IBS and who have symptoms that may be relieved by dietary change e.g. bloating, diarrhoea, constipation, gastro-oesophageal reflux. Malnutrition or Nutritional Deficiencies patients with malnutrition of known origin or under medical investigation; patients diagnosed with nutritional deficiencies; patients with malabsorption of known origin or under medical investigation; patients with progressive diseases affecting nutritional intake and status, e.g. Multiple Sclerosis, Parkinson s Disease; patients prescribed nutritional supplements. Home Enteral Feeding/Nutritional Support Patients who require nutritional support via oral nutritional supplementation or a feeding tube. These patients may be able to swallow but unable to meet their nutritional needs with food alone. They may require oral nutritional supplementation, full feeding via a feeding tube or supplementary feeding via a feeding tube e.g. cancer, Motor Neurone Disease. HIV Positive/AIDS Any patient requiring advice and nutritional support to help prevent weight loss and improve or maintain nutritional status. 101 Nutrition and Dietetics

52 Food Allergy All patients with known food allergy especially if the patient has anaphylactic symptoms. Children and adults with suspected food intolerance or allergy requiring an exclusion diet. Where appropriate, patients with food allergies and intolerances should also be referred to an allergy specialist or relevant medical team for investigation and diagnosis. Eating Disorders. Adult patients suspected of or diagnosed with an eating disorder should be referred to the Eating Disorders Team. Additional information to support referral criteria Exclusions from service Dietitians require relevant medical information and diagnosis from the patient s medical or dental practitioner before they are able to offer dietetic advice. This is a requirement under the Standards of Conduct, Performance and Ethics from the Health and Care Professions Council; the registration body that qualified Dietitians must be registered with. We are unable to provide one-to-one consultations to all patients requiring dietary advice. There are two categories of referred patients those requiring specialised advice from the Dietitian and those requiring advice from practice staff with written resources, recent training and support from the Nutrition and Dietetic Service. Resources to support Primary Care are currently available in Luton and South Bedfordshire. There are no patients who we will refuse to see if they are at risk of malnutrition, although we do not accept self-referrals, all referrals for therapeutic diets must be accompanied by a medical signature. Patients who live in the north or middle of the What response times to expect Further information county who require home Enteral feeding or a therapeutic diet should be referred to the Dietetic Department at Bedford Hospital. The service does not operate a waiting list. Referrals are prioritised and all patients are either sent an appointment or are written to, inviting them to contact the clinic and book an appointment time of their preference: five-day turnaround of receipt of referral letter into the department to appointment arrangement; outpatient appointments within 18 weeks from referral; waiting times in clinic of less than 30 minutes; inpatients should be seen within 48 hours of referral; domiciliary routine visits - 18 weeks from referral. SEPT management responsible for service Clinical Service Manager: Leanne Fishwick Tel: leanne.fishxxxx@xxxx.xxx.uk Associate Director Allied Jill Stephen Health Professions Tel: jill.stxxxxx@xxxx.xxx.uk Deputy Director of Children s Chris Myers and Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 103 Nutrition and Dietetics

53 Older People Assessment Inpatient Service Overview of Service Older People Assessment Inpatient Services are provided for people over the age of 65 years with a functional or organic mental illness. The service offers: 24 hour service, 365 days a year; active involvement of the patient, family and carers; assessment, intensive treatment, intervention and support in the early stages of a mental health crisis; choice and patient autonomy; practical support and assistance with problems of daily living; rapid response following referral to the ward; recovery planning with patient focused outcomes; time-limited interventions that are able to respond to patient need. Functional mental illness describes conditions of acute psychiatric illness such as depression, anxiety or psychosis. Organic mental illness mostly describes dementia as well as other conditions which result from brain injury. Where service is based Crystal Ward (16 beds) Functional Mental Illness Luton and Central Bedfordshire Mental Health Unit Off Calnwood Road Luton Beds LU4 0FB Tel: Townsend Court (16 beds) - Organic Mental Illness Mayer Way Houghton Regis Bedfordshire LU5 5BF Tel: Hours of operation How to contact service How to refer into the service & who can refer Fountains Court (15 beds) Organic Mental Illness Bedford Health Village 3 Kimbolton Road Bedford Beds MK40 2NT Tel: Chaucer Ward (15 beds) Functional Mental Illness Weller Wing Kempston Road Bedford Beds MK42 9DJ Tel: hours, 365 days Crystal Ward, Luton: Tel: Townsend Court, Houghton Regis: Tel: Fountains Court, Bedford: Tel: Chaucer Ward, Bedford: Tel: Referrals are accepted from the following: GPs Acute Sector (A&E) Community Mental Health Teams (CMHT) Crisis Team (CRHT) Residential or Nursing Homes Yellow Board from Luton & Dunstable Hospital 105 Older People Assessment Inpatient Service

54 Referral criteria must be over 65 years old patients with a functional (acute psychiatric) illness or organic (dementia or progressive) illness Bedford Locality Ward Sister: Alison Wilkinson Fountains Court Tel: alison.wilkxxxxx@xxxx.xxx.uk Children Exclusions from Service Under 65 years old (unless with early onset dementia) Alcohol /Drug induced state Clinical Group Manager Lynn Moore (Acting): Tel: lynn.moorx@xxxx.xxx.uk What response times to expect SEPT management responsible for service Luton Locality Admission into vacant bed, average stay six - eight weeks Ward Sister: Lynn Moore Crystal Ward Tel: lynn.moorx@xxxx.xxx.uk Ward Sister Paula Mansfield Townsend Court: Tel: paula.mansxxxxxx@xxxx.xxx.uk Clinical Group Manager (Acting): Lynn Moore Tel: lynn.moorx@xxxx.xxx.uk Ward Sister: Sue Inskip Chaucer Ward Tel: sue.inskxx@xxxx.xxx.uk Clinical Group Manager Sylvie Downe (Acting): Tel: sylvie.doxxx@xxxx.xxx.uk Acute and Crisis Service Sharon Jackson Manager (Acting): Tel: sharxx.xxxxxxx@xxxx.xxx.uk Associate Director Chris Bradley-Rushe Acute and Crisis: Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Older People Assessment Inpatient Service 107

55 Older People Community Mental Health Teams Overview of Service Older People Community Mental Health Teams (Older People CMHTs) are multi-disciplinary, multi-agency assessment teams for adults over the age of 65 who require specialist mental health services in Bedfordshire and Luton. Patients under the age of 65 with early onset dementia may also be accepted. Older People CMHTs are comprised of community psychiatric nurses, occupational therapists, psychologists, approved social workers, support workers, psychiatrists and staff grade doctors. The teams provide: assessment; care planning, co-ordination and monitoring; domiciliary support; occupational therapy; rehabilitation. The teams work with patients in their own homes which can include: private and local authority residential homes; private and NHS nursing homes; Trust s community resource centers; warden controlled complexes. Where service is based Bedford Older Peoples CMHT Florence Ball House Bedford Health Village 3 Kimbolton Road Bedford Beds MK40 2NT Tel: Mid Bedfordshire Older Peoples CMHT The Lawns Resource Centre The Baulk Biggleswade Beds SG18 0PT Tel: South Bedfordshire Older Peoples CMHT Townsend Court Mayers Way Off Houghton Road Houghton Regis Beds LU5 5BF Tel: Luton Older Peoples CMHT Charter House Alma Street Luton Beds LU1 2PJ Tel: Hours of operation Monday - Friday How to contact service Florence Ball House, Bedford: Tel: Lawns Resource Centre, Mid Beds: Tel: Townsend Court, South Beds: Tel: Charter House, Luton: Tel: Older People Community Mental Health Teams

56 How to refer into the service & who can refer Referral Criteria Referrals are accepted from the following: GPs; health professionals; mental health services; social services. The CMHT service criteria are as follows: adults over 65 years (ages in accordance with CMHT criteria); those whose primary need is a complex, severe and an enduring mental health one which includes severe functional impairment, organic impairment with challenging behaviour; failure to engage in standard treatment which presents a significant risk to themselves or others resulting in deterioration in their mental health; those with a formally diagnosed dementia related mental health problem whose behaviour requires the intervention of a specialist service.; patients who meet either the critical or substantial social care criteria specified in the document Fair Access to Care ; The presence of significant risk of one or more of the following: - self-harm; - self -neglect; - suicide; - violence; - vulnerability. Additional information to support referral criteria Exclusions from service What response times to expect Further information Referrals for the memory assessment service which is provided within the CMHTs are for individuals where there is a concern for their memory. In all cases, the referral must include GP name and address, and indication that this has been discussed with the patient. patients where the primary concern is learning disability, autism or Asperger s; where there are no mental health symptoms present. Assessment within two weeks from referral. Out of hours patients and carers should access the local emergency services (Crisis Resolution Home Treatment teams, A&E, help lines). Older People Community Mental Health Teams 111

57 SEPT management responsible for service Luton Locality Bedford Locality Team Leader: Interim Service Manager: Associate Director: Mid Bedfordshire Locality Team Leader: Clinical Group Manager: Associate Director: South Bedfordshire Locality Clinical Group Manager: Associate Director: Busani Khumalo Tel: Debbie Buck Tel: Chris Bradley-Rushe Tel: Patrick Moore Tel: Michael Farrington Tel: Paul Rix Tel: Jacqueline Palmer - Davis Tel: jacqueline.palmer-daxxx@xxxx.xxx.uk Paul Rix Tel: paul.rxx@xxxx.xxx.uk Team Leader Clinical Group Manager: Trisha Nichols Tel: trxxxx.xxxxxxx@xxxx.xxx.uk Gail Robinson Tel: gail.rxxxxxxx@xxxx.xxx.uk Community Services Manager: Mike King (Interim) Tel: mike.kxxx@xxxx.xxx.uk Associate Director: Paul Rix Tel: paul.rxx@xxxx.xxx.uk Director Of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Older People Community Mental Health Teams 113

58 Older People Continuing Health Care Inpatient Service Additional information to exclusion of any physical problems prior to Overview of Service Older People Continuing Care Inpatient Service is provided for adults over the age of 65 years with dementia or other organic mental illness, in Bedfordshire and Luton. Patients under the age of 65 years with early onset dementia may also be accepted. The service offers the following treatments and therapies available: Art and Crafts Ball Games Hand Massage Music Therapy Religious Services Reminiscence Organic mental illness mostly describes dementia as well as other conditions which result from brain injury. Where service is based Hours of operation Fountains Court (9 beds) Bedford Health Village 3 Kimbolton Road Bedford Beds MK40 2NT Tel: hours, 365 days How to contact service Tel: How to refer into the service & who can refer Referral criteria All referrals must come through Continuing Care. Must be 65 years or older with an organic illness (unless with early onset dementia). support referral criteria Exclusions from service What response times to expect admission; referrals are also accepted for people under the age of 65 with early onset dementia following full assessment of individual needs. Under 65 years SEPT management responsible for service Ward Sister: Admission into vacant bed - length of stay dependent on patient s on-going needs. Alison Wilkinson Tel: alison.wilkxxxxx@xxxx.xxx.uk Clinical Group Manager Lynn Moore (Acting) : Tel: lynn.moorx@xxxx.xxx.uk Acute and Crisis Sharon Jackson Service Manager (Acting): Tel: sharxx.xxxxxxx@xxxx.xxx.uk Associate Director Chris Bradley-Rushe Acute and Crisis: Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Older People Continuing Health Care Inpatient Service 115

59 Memory Assessment Service Overview of service The Memory Assessment Service aims to meet the needs of people who are concerned that they may have a memory problem. The initial stage will be to assess and diagnose the nature of the person s memory difficulties, report this to their GP and advise on further treatment or intervention. The team is made up of specialist doctors, nurses, occupational therapists and psychologists. The team will continue to be involved after diagnosis, when appropriate, and can offer information, advice and support to the person with memory problems and their family. Where service is based Bedford Weller Wing Bedford South Wing Ampthill Road Bedford Beds MK42 9DJ Tel: Luton Charter House Alma Street Luton Beds LU1 2PJ Tel: South Bedfordshire Townsend Court Mayer Way Houghton Regis Beds LU5 5BF Tel: Central Bedfordshire The Lawns The Baulk Biggleswade Beds SG18 OPT Tel: Hours of operation Monday - Friday How to contact service How to refer into the service & who can refer Weller Wing (Bedford) Tel: Townsend Court (South Bedfordshire) Tel: Charter House (Luton) Tel: The Lawns (Central Bedfordshire) Tel: Referrals are accepted from: GPs; acute sector; community matrons. Referrals are made via the Community Mental Health Teams (CMHT): Bedford CMHT for Older People Tel: Mid Beds CMHT for Older People Tel: Memory Assessment Service 117

60 Referral criteria the person is presenting with symptoms consistent with suspected dementia rather than a physical or functional mental illness; the person does not have an existing clinical diagnosis of dementia; possible other medical reasons have been excluded. SEPT management responsible for service Bedford Locality Dementia Nurse Specialist: Alison Lawrie-Skea Tel: alison.lawrie-skxx@xxxx.xxx.uk Additional Information to support referral criteria Exclusions from service What response times to expect Further information following information must be provided in the referral to the clinic: exclusion of other acute medical reasons such as delirium - by physical examination and investigations, together with a brief measure of cognition; referral provides contact information for the patient and carer; review of past history. The GP/ referrer will undertake initial dementia screening prior to referral, consistent with NICE Clinical Guideline 42. Patients with an existing diagnosis of dementia. Confirmation of referral within one week. Assessment and diagnosis within 12 weeks from confirmation. The referrer will confirm that the patient has consented to the referral or provide a copy of a capacity assessment if the patient lacks capacity. Interim Service Manager: Associate Director: South/ Mid Bedfordshire Locality Dementia Nurse Specialist: Clinical Group Manager South: Clinical Group Manager Mid: Associate Director: Debbie Buck Tel: debbie.xxxx@xxxx.xxx.uk Chris Bradley-Rushe Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Marian Fievez Tel: marian.fievxxx@xxxx.xxx.uk Jacqueline Palmer-Davis Tel: jacqueline.palmer-daxxx@xxxx.xxx.uk Michael Farrington Tel: Michael.Farringtxx@xxxx.xxx.uk Paul Rix Tel: paul.rxx@xxxx.xxx.uk Memory Assessment Service 119

61 Luton Locality Dementia Nurse Specialist: Clinical Group Manager: Clare Warren Tel: Gail Robinson Tel: Community Services Manager: Mike King (Interim) Tel: Associate Director: Paul Rix Tel: Director of Mental Health Declan Jacob Services: Tel: Executive Director of Richard Winter Integrated Services: Tel: Memory Assessment Service 121

62 Parkinson s Disease Service Overview of service The Parkinson s Disease Service provides face to face contact, medication review and monitoring of specialist drug therapy, screening, specialist telephone advice, specialist education and support for patients and carers. Parkinson s disease is a chronic, progressive neurological condition, affecting different aspects of life at different times of the disease process. This in turn determines the appropriate care required to improve patients and carers quality of life, while maximising clinical effectiveness, best practice and cost effectiveness. Where service is based John Bunyan House Bedford Health Village Kimbolton Road Bedford Beds MK40 2AW Tel: Hours of operation Monday - Thursday Fridays How to contact service Tel: Appointment enquiries Tel: How to refer into the service Referrals will be accepted from the following: GPs; allied health professionals; care agencies/care workers; community psychiatric nurse; consultants; community nurses; local agencies; local and other hospitals; occupational therapists; practice nurses; Referral criteria physiotherapists; social workers; specialist nurses; speech and language therapists; voluntary agencies. adults diagnosed with Parkinson s or a Parkinsonian syndrome; registered with a Bedfordshire GP. Additional information to The service is limited to a caseload of 600 support referral criteria patients. This equates to 300 per specialist nurse (Parkinson s Disease Society recommendations) and 300 for support nurse. The service has restricted access to patients who see a Consultant in the outlying hospitals which include Luton and Dunstable, Lister, Stoke Mandeville and Milton Keynes. No home visits can be offered to these patients; however appointments in our Community clinics at Dunstable Health Centre and Woburn GP surgery are available. Telephone advice and support is offered to all patients registered with a GP practice in Bedfordshire. Equitable service delivery is dependent on additional funding to support home visits, medication reviews, specialist education and support to house bound patients seeing Consultants in outlying hospitals. Newly diagnosed patients and patients requiring advice and support are referred to the Parkinson s Society information support worker. 123 Parkinson s Disease Service

63 Exclusions from service What response times to expect Further information patients without a definitive diagnosis of parkinson s disease; patients with primary diagnosis of dementia. Referral priority: confirmation within 48 hours of referral new referrals assessment at home or clinic within four - six weeks newly diagnosed assessment within two weeks. The following is available direct from the service: Information folders for newly diagnosed patients 10 week Education Programme for patients with complex needs Booklets and patient information leaflets available in different languages Education Programme for newly diagnosed patients. SEPT management responsible for service Specialist Nurse Lead: Lead Clinician: Debbie Blake Tel: debbie.blakx@xxxx.xxx.uk Michael Dimov Tel: michael.dimox@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Parkinson s Disease Service 125

64 Patient Benefits Team Overview of service The Patient Benefits Team provides practical assistance and advice to inpatients on Mental Health wards across Bedfordshire and Luton. The team can help with benefit claims and advises on benefit entitlement for patients. The team visits in-patients within Bedfordshire and Luton, where all new patients are asked if they require help with their finances and offered the help of the Benefits Adviser. Referral criteria Exclusions from service What response times to expect Must be an in-patient on a mental health ward in Bedfordshire or Luton. Patients not registered with a Bedfordshire GP. Immediate advice provided during consultation, in person or over the phone. The service is also available to advise and assist Social Workers, Community Practice Nurses or GPs regarding benefits for their patients. Where service is based Luton and Central Bedfordshire Mental Health Unit Robin Pinto Admin Block Off Calnwood Road Luton LU4 0FB Tel: / Hours of operation Monday - Friday How to contact service Tel: / How to refer into the service & who can refer Referrals are accepted from: health professionals; mental health unit staff; self-referral to benefits adviser during weekly visits. A GP, social worker, community practice nurse, or any other staff responsible for an inpatient at any of the units can telephone for advice and help at any time. SEPT management responsible for service Patient Benefits Specialist: Patient Benefits Officer: Clinical Group Manager (Acting) : Lyn Collins Tel: xxx.xxxxxxx@xxxx.xxx.uk Christina Laurence Tel: christina.laurxxxx@xxxx.xxx.uk Lynn Moore Tel: lynn.moorx@xxxx.xxx.uk Acute and Crisis Service Sharon Jackson Manager (Acting): Tel: sharxx.xxxxxxx@xxxx.xxx.uk Associate Director: Chris Bradley-Rushe Tel: chris.bradlexxxxxxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk 127 Patient Benefits Team

65 Podiatric Surgery Overview of Service The Podiatric surgery service aims to provide a comprehensive, high quality podiatric surgical (foot and sub-ankle) and specialist diagnostic service to the population of Bedfordshire. The podiatric surgery service is a community based service which is accessible to people regardless of age with a foot problem that have a referral from a health professional. Referrals are assessed by the service and are then further reviewed for their surgical suitability in clinic. The service aim is to improve the foot health of individuals by developing problem specific targeted episodes of day case surgery to achieve a curative resolution of their presenting foot pathology. This approach significantly reduces the need for on-going palliative care and minimises the need for referral into secondary care for evaluation and surgical treatment of foot pathologies. The outpatient element of this service is delivered in the community. Radiological patient evaluation and any surgical interventions are performed at the Luton and Dunstable Hospital NHS Foundation Trust. Hours of operation How to contact Service Outpatient clinics are held on Monday, Tuesday, Wednesday (new patients) Thursday and Friday from (except on those days when operating sessions are booked). Operating Sessions are carried out on Monday and Thursday evenings at the Luton and Dunstable Hospital. Mr J W Bramall Consultant Podiatric Surgeon Podiatric Surgery Marsh Farm Health Centre The Moakes Purley Centre Luton LU3 3SR Tel: Fax: Where service is based Out patient clinics are run at : Marsh Farm Health Centre The Moakes Purley Centre Luton LU3 3SR Tel: For patients requiring radiotherapy or surgical intervention, this is provided at the Luton and Dunstable Hospital NHS Foundation trust, Lewsey Road, Luton. How to refer into the service Referrals are accepted from: GPs; hospital consultants; podiatry service. Referral criteria Patients presenting with an acquired or congenital foot pathology or deformity may be referred to the service. Podiatric Surgery 129

66 Podiatric Surgery Exclusions from service Patients will not be accepted by the service in the following situations: if there is inadequate homecare to facilitate safe return home after surgery; the patient s presenting problem/health is unsuitable for Day-case surgery. What response times to expect Within 18 weeks of referral SEPT management responsible for service Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk 131

67 Podiatry Service Overview of service The Podiatry Service provides a range of specialities and techniques aimed at reducing risk from foot pathology. In association with other agencies and professionals, the service delivers care to address the general and specific needs of this population. The main aim of the service is to offer assessment, diagnosis, treatment, training and advice with an emphasis on prevention and self-management in order to reduce pain and maximise improvement in foot and lower limb conditions, thus improving or maintaining the patient s mobility and quality of life. Where service is based Health Centres and Clinics Podiatry services are currently delivered at the following locations: Hours of operation Monday - Friday South Locality Friday How to contact service Clinical Service Manager: Bedford and Central Beds Andrew White Tel andrew.whitx@xxxx.xxx.uk Clinical Service Manager: South Beds Emma Stoneman Tel: emma.stxxxxxx@xxxx.xxx.uk Flitwick Health Centre Ampthill Health Centre Shefford Health Centre Biggleswade Health Centre Sandy Health Centre Dunstable Health Centre Union Street Clinic Liverpool Road Health Centre Houghton Regis GP practices Larksfield Surgery, Stotfold Eleanor Close Surgery, Woburn Asplands Surgery, Woburn Sands Putnoe Health Centre London Road Health Centre Twinwoods Health Resource Centre Queens Park Medical Centre Kempston Clinic Leighton Buzzard Clinic Marsh Farm Clinic Wigmore Health Centre Podiatry services are also provided at patients homes where patients are totally bed or chair bound, as well as at residential and nursing homes where necessary. How to refer into the service Referral criteria Referrals are accepted from: GPs; 0-19 Team; Community Nurses; Consultants; Practice Nurses. Eligible patients are assessed using a common assessment tool. An individual treatment plan is developed with the patient. 133 Podiatry Service

68 Additional Information to support referral criteria Medical Need A D B C High risk group Diabetic patients Low risk group Factors which with a podiatry need prevent bending At risk pharmaceutically Insulin and noninsulin Arthropathies At risk systematically, dependent causing foot e.g. steroids; warfarin; pathology vascular disease i.e. PVD; claudication; Reynaud s. Neurological deficit in feet; HIV; immunosuppressed. Podiatric Need (Grades 1-4: 1 = high need; 4 = low need) Acute conditions Chronic painful lesions Chronic non painful lesions Ulcerations Infections Acute biomechanic problems Patient Assessment Matrix Fibrous lesions Neurovascular corns Moderate/heavy callous Neurological callous Chronic biomechanics Foot deformities Painful nails e.g. Involution Minimal diffuse callous Pressure points Nail & skin conditionsandsimple nail care Care of dermatological conditions e.g. Fungal Psoriatic infections of skin and nails Verruca Chilblains Other nail pathologies e.g. onychogryphosis Medical Need A D B C Podiatric Need May qualify for NHS treatment Do not qualify for NHS Treatment 4 Patients in categories C3 and C4 will not qualify for NHS provision. The podiatrist Patients in categories C3 and C4 will not qualify for NHS provision. The podiatrist will provide any advice and information which may be useful, to enable them to maintain their own basic foot care and be discharged from the system. Patients in categories B3 and B4 may not qualify for NHS provision, depending on their podiatric needs identified by the assessment. Patients in categories C1 and C2 should be devised a care plan which will lead to the resolution of the problem and a discharge from the system, e.g. nail surgery; orthotic/insole with a short course of treatments. Patients in all other categories will have a treatment plan devised, appropriate to their needs, which will be reviewed on a regular basis and altered accordingly. Exclusions from service What response times to expect The service does not provide: a nail cutting service for non pathological nails on low risk patients; this includes factors which prevent bending; treatment for non pathological lesions; treatment for verruca. All referrals are triaged by a senior clinician within 14 days of receipt. Routine referrals - Assessment within 18 weeks of referral Urgent referrals - Assessments are fast tracked Podiatry Service 135

69 Podiatry Service SEPT management responsible for service Clinical Service Manager: Andrew White Bedford and Central Beds Tel Clinical Service Manager: Emma Stoneman South Beds Tel: Associate Director Allied Jill Stephen Health Professions Tel: Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 137

70 Psychology - Direct Access Overview of service The Direct Access Service works closely with Community Mental Health Teams (CMHT) to provide psychological therapy service for adults age 16 and over. The service offers time-limited, medium term treatment to people with a range of moderate to severe mental health problems including: Anxiety disorders - Body Dysmorphic Disorder (BDD), Generalised Anxiety Disorder(AD), Obsessive Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), Panic/Agoraphobia, Social Anxiety Depression Somatoform Disorders Exclusions from service What response times to expect SEPT management responsible for service milder problems which can be treated in Primary Care (Improving Access to Psychological Therapies programme (IAPT) or Counselling). significant social instability/issues requiring practical support or advocacy. Admission within 13 weeks of referral. Where service is based Gilbert Hitchcock House 21 Kimbolton Road Bedford Beds MK40 2AW Tel: Team Leader: Clinical Service Manager: Dr Helen Donovan Tel: helen.donoxxx@xxxx.xxx.uk Prof Gary Kupshik Tel: gary.kxxxxxx@xxxx.xxx.uk Hours of operation Monday - Tuesday Wednesday Friday How to contact service Tel: How to refer into the service & who can refer Referral criteria Referrals are accepted from: GPs; health professionals; social workers. Moderate to severe mental health problems where psychological therapy is indicated as primary treatment, without risk or complexity requiring multi-disciplinary team input. Associate Director: Executive Director: Hugh Johnston Tel: hugh.johnstxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk Psychology - Direct Access 139

71 Psychology - Complex Needs Service Overview of service The Complex Needs Service works closely with Community Mental Health Teams (CMHT) to improve the community-based care delivered to patients with diagnoses of personality disorder. The specialist multi-disciplinary team operates as a hub, reaching into CMHTs to provide awareness training and to promote thorough assessment, formulation, goal planning and a stepped-care approach to interventions, thereby aiming to alleviate symptom distress, as well as to improve psychosocial outcomes and public protection. Where service is based Bedford / Central Bedfordshire The Lawns The Lawns Complex The Baulk Biggleswade Beds SG18 0PT Tel: Gilbert Hitchcock House 21 Kimbolton Road Bedford Beds MK40 2AW Tel: Day Resource Centre Bedford Health Village 3 Kimbolton Road Bedford Beds MK40 2NT Tel: Meadow Lodge Steppingly Hospital Ampthill Road Steppingly Beds MK45 1AB Tel: South Bedfordshire Crombie House 36 Hockliffe Street Leighton Buzzard Beds LU7 1HJ Tel: Beacon House 5 Regent St Dunstable Beds LU6 1LP Tel: Disability Resource Centre Poynters House Poynters Road Dunstable Beds LU5 4TP Tel: Hours of operation Monday - Friday How to contact service Bedfordshire Complex Needs Service Disability Resource Centre Poynters House Poynters Road Dunstable LU5 4TP Tel: Fax: xxxxxxxxxxxx@xxxx.xxx.uk 141 Psychology - Complex Needs Service

72 How to refer into the service & who can refer Referral criteria Additional information to support referral criteria Referrals are accepted from: care co-ordinators in Community Mental Health Teams Complex Needs Service provision is available to people who: are over 18 years of age; have a comorbid diagnosis of personality disorder; have complex needs and significant associated distress; present with moderate / high levels of risk to self and / or others; are on enhanced care plans, and have care co-ordinators. All referrals must be accompanied by: a copy of the service user s current CPA care plan; a current detailed risk assessment; and a copy of the most recent community psychiatric review letter. Referrals must be made in writing to the Complex Needs Service, either by posting or ing a completed Complex Needs referral form. To make best use of the limited resource, all referrals to the Complex Needs Service must be discussed with the service user and multidisciplinary community or specialist mental health team (CMHT), including the team manager and responsible medical officer (RMO). Exclusions from service What response times to expect SEPT management responsible for service Team Leader: Associate Director: Executive Director: Referral to the Complex Needs Service does not constitute a transfer of care. As this is a community in-reach service, the service user s care will remain the primary responsibility of the care co-ordinator and responsible medical officer within the community or specialist mental health team. The Complex Needs Service is not able to provide a service to: people with a moderate or severe learning disability, and / or an acquired brain injury; people who are under the care of CMHTs outside of the Bedfordshire. Receipt of referrals will be acknowledged within one week, and referrers and patients notified of the outcome within two weeks. Carol-Ann Sargent Tel: carol-ann.sarxxxx@xxxx.xxx.uk Hugh Johnston Tel: hugh.johnstxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk Psychology - Complex Needs Service 143

73 Rapid Intervention Services Overview of Service The Rapid Intervention Service is a team that assesses and organises nursing and social care for patients with acute conditions who would otherwise be admitted to hospital. The service consists of a multi-disciplinary team of nurses and health care assistants, who will attend a patient in their own home to organise and if appropriate, deliver acute home based care. Within the assessment of patient care if necessary, the Rapid Intervention Team will organise diagnostic tests, organise admission to a community bed or if appropriate an acute setting. The period of care delivery within the community is up to a maximum of 72 hours and the team will commence discharge planning as soon as patients are admitted to the caseload. Patients accepted for care under the Rapid Intervention Team will include those with a non-life threatening condition, which would alternatively be admitted to hospital. Where service is based Hours of operation How to contact service East of England Ambulance Trust Hammond Road Bedford MK41 0RG Tel: hours, 365 days Via OneCall Tel: How to refer into the service Referral criteria Referrals are accepted from: GPs; community nursing; social services; acute hospitals; palliative Care Services; allied health professionals; community matrons; specialist nurses; ambulance services; emergency care practitioners, paramedics; clinical support desk staff in EEAST ambulance control centre; scheduled rehabilitation and enablement service; care homes; warden controlled facilities; voluntary sector; discharge planning. Referrals accepted from Care Homes and Housing Associations wardens are to avoid unnecessary attendance at the hospitals Accident and Emergency departments. Patients accepted into the service are experiencing an acute alteration in their physical well being which without the input of this service would result in an acute hospital admission or where facilitated early discharge can be safely implemented within a community setting. Rapid Intervention Services 145

74 Additional Information to support referral criteria Rapid Intervention can provide all aspects of care including assessment and treatment, therapy and provision of equipment, nursing and personal care. Exclusions from service patients under 18 years of age; out of area patients, patients without a GP aligned to Bedfordshire and who are resident outside of Bedfordshire s geographical boundaries; patients where mental health condition is the primary diagnosis - these patients will be referred to a specialist service; patient is not medically stable (GP supports medical needs). What response times to expect SEPT management responsible for service Associate Director: The patient will be contacted by a triage professional and if an assessment is required this will take place within two hours of receipt of the referral. David Robertson Tel: david.roberxxxx@xxxx.xxx.uk Director of Integrated Adult Helen Smart Services and Lead Nurse: Tel: helen.smart:sept.nhs.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Rapid Intervention Services 147

75 Rehabilitation and Enablement Overview of Service The Rehab and Enablement service incorporates 4 aspects:- Intermediate Care 7 day service which aims to support patients following a physical injury or an acute medical condition through activities of daily living. Physiotherapists and Occupational Therapists work with Rehab support staff to enable patients to regain abilities and independence within their own homes. Community Physiotherapy provides assessment and treatment for patients who are having difficulties with their mobility. Community Occupational Therapy provides assessment of a patient s main place of residence and makes recommendations for equipment or ways to promote independence in everyday activities. Neuro Rehab Team provides a specialist rehab service to patients who have a newly diagnosed neurological condition or exacerbation of an existing neurological condition and who would benefit from rehabilitation to improve their quality of life. Where service is based John Bunyan House Bedford Health Village Kimbolton Road Bedford MK40 2NT Tel: Unit 6 - Doolittle Yard Froghall Road Ampthill Beds MK45 2NW Tel: Hours of operation How to contact service How refer into the service Orchard Therapy Office Biggleswade Hospital Potton Rd Biggleswade SG18 0EL Tel: Disability Resource Centre Poynters Road Dunstable Beds LU5 4TP Tel: The Intermediate Care Service (IMC) offered by the community rehabilitation and reenablement service is available seven days Other therapy services work alongside IMC but operate Monday - Friday John Bunyan House Tel: Unit 6 - Doolittle Yard Tel: Disability Resource Centre Tel: Biggleswade Hospital Tel: Referrals are accepted from: GPs; all health and professionals social care; voluntary services; self-referral. Referal to the service is via OneCall Rehabilitation and Enablement

76 Referral criteria Additional information to support referral criteria Exclusions from service Patients are accepted into the service where:- the patient is experiencing an acute alteration in their physical well-being or social circumstance which without the input of this service would result in an acute hospital admission. an exacerbation of a long term health condition facilitated early discharge from hospital can be safely implemented within a community setting. the main reason of referral is related to a physical condition the patient wishes to work towards maximising their level of independence and agrees to engage and participate in their rehabilitation intervention Out of Hours - all referrals out of hours and information is sent directly to the ward staff. Patients will be excluded from the service for the following reasons:- based on assessment are unsuitable for intervention in these situations, referral to a more appropriate service will be arranged with patient s consent where no valid consent has been obtained (following assessment of mental capacity); under 18 years of age if the patient is not medically stable to benefit from a rehabilitation programme following assessment by their GP What response Depending on the type of the referral times to expect response can be from 48 hours on receipt of referral for urgent cases to 18 weeks for routine situations SEPT management responsible for service Associate Director: David Robertson Tel: david.roberxxxx@xxxx.xxx.uk Director of Integrated Adult Helen Smart Services and Lead Nurse: Tel: helen.smart:sept.nhs.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Rehabilitation and Enablement 151

77 Rehabilitation In-patient Overview of Service In-patient rehabilitation is provided for people who have severe and enduring mental health problems and associated behavioural problems. Those who are admitted to the service will be experiencing an episode of enduring mental illness, most usually: schizophrenia; schizoaffective disorder; bipolar affective disorder, depressive disorder or anxiety disorder. There are three rehabilitation units: Cedar House and Whichellos Wharf are medium to long term mental health rehabilitation units (length of stay 12 months+). London Road is a short term mental health rehabilitation unit (length of stay from 0-12 months) with two short term management beds (length of stay from two - six weeks). Patients and their relatives and carers are encouraged to jointly agree a programme of care with staff. The programme includes the learning or relearning of basic life skills as well as participation in group and individual occupational therapy. As far as possible, patients are encouraged to be selfcaring but where assistance is required it will be provided. Patients are encouraged to take personal responsibility and actively participate in the development of their therapeutic programmes. They are encouraged to make their own drinks and snacks and also do the same for their visitors. They are encouraged to complete their own laundry and room cleaning. Where service is based Cedar House (12 bed) Long Term stay Bedford Health Village 3 Kimbolton Road Bedford Beds MK40 2NU Tel: Hours of operation Whichellos Wharf (16 bed) Long Term stay The Elms Stoke Road Leighton Buzzard Beds LU7 2TD Tel: London Road (16 bed) Short Term stay 105 London Road Luton Beds LU1 3RG Tel: hours, 365 days How to contact service Cedar House Tel: Whichellos Wharf Tel: London Road Tel: How to refer into the service & who can refer Referrals are accepted from: acute mental health admission units; assertive outreach teams; community mental health teams. Rehabilitation In-patient 153

78 Referral Criteria What response times to expect Further information People who live in Luton and Bedfordshire have not acted upon any suicidal ideation or subject to any high-risk incident of selfharm or physical aggression towards others in the previous six weeks - the patient should not require constant observation; not in an acute psychiatric crisis although may have persistent symptoms; patients are in agreement with the placement; preferably not detained under the Mental Health Act; previously displayed an adequate level of independent functioning and now require help and support to regain those skills; requires intervention and support to regain their social functioning and management of their mental illness. Assessment within two weeks from referral. Admission dependent on bed availability. 105 London Road offers a unique service of follow-up on discharge in the community for up to three months to assist housing and community stability. SEPT management responsible for service Ward Sister: Tracey Tebbutt Cedar House Tel: tracey.txxxxxx@xxxx.xxx.uk Ward Sister: Sarah Adansi Whichellos Wharf Tel: xxxxx.xxxxxx@xxxx.xxx.uk Charge Nurse Harry Sookraj London Road Tel: & Interim Clinical Group Manager: harry.sookxxx@xxxx.xxx.uk Associate Director: Paul Rix Tel: paul.rxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Rehabilitation In-patient 155

79 Resource Centres ACE Enterprises Overview of service ACE Enterprises provides a flexible and person centered employment and day service for adults with mental health problems. ACE promotes social inclusion through supporting people who use the service to access mainstream opportunities in employment, voluntary work, education, arts, sports and leisure. People are allocated a named support worker who will provide general support and work with the individual to devise recovery action plans and review progress regularly. The support worker is a point of contact for the referrer, other practitioners and agencies involved in the person s care. The service offers: art groups; computer courses with Barnfield College; cookery; employability skills; music group; luton adult learning course (flower arranging, sugarcraft, soft furnishings); social groups; support to access voluntary work; support to access employment; support to access mainstream education, sports, arts and leisure facilities; work placements in printing and T-shirt printing department. Sports: badminton; football; golf; gym groups; pool group; walkabout group; women s exercise group. Where service is based ACE Enterprises Collingdon Street Luton LU1 1RX Tel: Hours of operation Monday - Thursday Friday How to contact service Tel: Fax: xxx@xxxx.xxx.uk How to refer into the service & who can refer Referral criteria Additional information to support referral criteria Exclusions from service What response times to expect SEPT management responsible for service Team Leader: Associate Director: Executive Director: Referrals must come through SEPT Adult Mental Health Services in Luton. Patients must be under the care of SEPT Adult Mental Health Services in Luton. All referrals of people on the Care Plan Approach (CPA) must include full care plan and risk assessment. Direct GP referrals all referrals via SEPT Adult Mental Health Services in Luton. Assessment within four weeks of referral. Joseph Mandizha Tel: xxxxxx.xxxxxxxx@xxxx.xxx.uk Gail Dearing Tel: gail.dearxxx@xxxx.xxx.uk Amanda Reynolds Tel: amanda.rexxxxxx@xxxx.xxx.uk 157 Resource Centres ACE Enterprises

80 Resource Centres Ashanti Resource Centre Overview of Service The Ashanti Community Support Team works with adults from African and Caribbean backgrounds who are experiencing mental health difficulties. The service acts as a gateway for people who are struggling to engage with mental health services. The team works to ensure patients receive the right support in the community so they can maintain their mental health and independence. The service can be contacted directly by the patient or someone on their behalf. The members of staff speak several African and Caribbean languages and will arrange to meet the patient and, together, plan the right support for them. The service offers: assistance and support to GPs and hospital staff; assistance with making claims for benefits; encouragement for physical and mental well being; encouragement to use community resources; help in getting hospital appointments; help to advance on to independent living skills; help to enhance patient s experience; help with housing matters; home visits Informal counselling; support for carers; various groups to build self confidence and social inclusion. Where service is based Ashanti House 93b Marsh Road Luton LU3 2QG Tel: / / Hours of operation Monday Thursday Friday How to contact service Tel: / / Fax: How to refer into the service & who can refer Referral criteria Referrals are accepted from: GPs; community practice nurses (CPN); community social workers; health professionals; mental health agencies; social workers; self-referrals. must be over 16 years of age, from African or Caribbean communities and resident in Luton; individuals who have little or no choice and control over vital aspects of their immediate environment because of their mental illness; individuals whose lives are, or will be, at risk because they have significant mental health issues; individuals who are vulnerable to abuse or exploitation to and from others; individuals who face significant risk of neglect or risk to themselves or others; individuals who may face homelessness with or because of a defined mental illness; individuals who need to access employment and training with a mental illness; individuals who respond poorly to treatment from mainstream mental health services; individuals with whom there is a risk of disengagement from the mainstream services; 159 Resource Centres Ashanti Resource Centre

81 where serious abuse has occurred or might occur because of the mental health condition of the patient; where there is a serious risk of deterioration in the mental health that may affect the patient in the near future. Additional information to Recent risk assessment & care plan support referral criteria Referral form can be requested from Roshni / Ashanti House by phone or . What Response Times to expect Further Information Assessment within five working days of referral. Referrals will be based on a full assessment of need conducted through the Care Programme Approach (CPA) process. The referring social worker / CPN will be expected to remain as the client s care coordinator whilst the client is subject to the CPA process and will be responsible for coordinating the periodic review of the client s needs. SEPT management responsible for service Team Leader: Associate Director: Executive Director: Fitzroy Wilson Tel: fitzroy.xxxxxx@xxxx.xxx.uk Steve Porter Tel: steve.portxxx@xxxx.xxx.uk Amanda Reynolds Tel: amanda.rexxxxxx@xxxx.xxx.uk Resource Centres Ashanti Resource Centre 161

82 Resource Centres - Barford Avenue Overview of Service The Barford Avenue Resource Centre offers a service for adults over the age of 16 who are experiencing mental health difficulties and who live in Bedford Borough or Central Bedfordshire. The Centre works in conjunction with The Day Resource Centre and the employment Service (EMPoWA). The approach is planned to enable people to find ways of overcoming, or reducing their distress and to feel in control of their lives. The services help people to safely experience contact with others again and to develop a real sense of trust in themselves and people around them. The ethos of social inclusion is a fundamental part of the Centre s method of working. People will be seen in confidence, following a referral, and can be accompanied by the referrer, an advocate or other trusted third party. A full assessment of needs will be carried out together, resulting in an agreed care plan. If the individual is part of a Care Programme Approach (CPA) we will work closely with the care co-ordinator to ensure consistency. The centre offers: 1:1 support; alternative craft group; anxiety management course ; art and design co-operative; Biggleswade swimming group; bite size art courses; counselling; developing confidence course; forum meeting; Friday Biggleswade group; gardening group; Where service is based guitar group; gym group; music group; Sandy support group; Shefford support group; social discussion group; Stotfold group; support to access voluntary work; support to access training/ education courses; textiles group. Barford Avenue Resource Centre 29 Barford Avenue Bedford MK42 0DS Tel: Hours of operation Monday Thursday Friday How to contact service Tel: Fax: barford.avxxxx@xxxx.xxx.uk How to refer into the service & who can refer Referral Criteria Additional information to support referral criteria Exclusions from service What response times to expect Referrals are accepted from: GPs via Assessment and Single Point of Access (ASPA); Assessment and Single Point of Access (ASPA); care co-ordinator; community mental health team (CMHT); consultant psychiatrists. 16 years of age and older; mental health diagnosis; resident in Bedford Borough or Central Bedfordshire. Care Plan Approach (CPA) paper work and risk assessment copy of current consultant report, if available People living outside Bedford Borough and Central Bedfordshire. Assessment within 28 days from referral. Resource Centres - Barford Avenue 163

83 Further information Further information is available from the Team Leader Tel: Literature available: Barford Avenue Centre Booklet (BL0152) SEPT management responsible for service Team Leader (Interim): Associate Director: Executive Director: Julie Bailie Tel: Steve Porter Tel: Amanda Reynolds Tel: Resource Centres - Barford Avenue 165

84 Resource Centres The Day Resource Centre (Bedford) Where service is based The Day Resource Centre Overview of Service The Day Resource Centre provides a service that is flexible and responsive to the adults experiencing mental health issues. The Centre provides a service which promotes the recovery approach, and recognises individual aspirations and supports person centred goals and aspirations. The team supports patients to identify their own needs and encourages them to complete their own individualised action plan based on their needs and goals. Engagement and discharge from the Day Resource Centre is patient led i.e. patients choose to attend. The team believes in working in a recovery focused partnership with the individual in an empowering way. This helps the patient to access educational and vocational opportunities to maintain and improve wellbeing, empowerment and combat social exclusion. There is also the opportunity to access a wide range of talking therapies, brief and long term interventions. The service offers: arts psychotherapies; computer and internet access; drop in support with staff and peers; HOPE (Help Over Coming Eating issues); keeping fit with aerobics and walking; lesbian, gay, bisexual, transgender (LGBT) support group and forum; managing anxiety using yoga, relaxation; peer support through support groups for women; psychosocial Interventions; psychotherapy; social activity based groups, gardening, art, photography, community café; support with benefit issues; the Café Project for work experience and CV building; use of Wellness Recovery Action Plan (WRAP) planning and Recovery STAR; Voice Hearers Support Group. Bedford Health Village 3 Kimbolton Road Bedford MK40 2NT Tel: Hours of operation Monday - Friday How to contact service Tel: Fax: dayresourcecentrx@xxxx.xxx.uk How to refer into the service & who can refer Referral criteria Additional information to support referral criteria Exclusions from service What response times to expect Referrals are accepted from: Assessment and Single Point of Access (ASPA); care co-ordinator; community mental health team (CMHT); consultant psychiatrists. This team supports those with severe and enduring mental health issues. Care Programme Approach (CPA) paper work with clear assessment of needs. Completed referral form. Those who don t have a severe and enduring mental health problem. Initial contact within two weeks of referral. Resource Centres The Day Resource Centre (Bedford) 167

85 SEPT management responsible for service Team Leader: Interim Service Manager: Associate Director: Paul Wrake Tel: Debbie Buck Tel: Chris Bradley-Rushe Tel: Director Of Mental Health Declan Jacob Services: Tel: Executive Director of Richard Winter Integrated Services: Tel: Resource Centres The Day Resource Centre (Bedford) 169

86 Resource Centres Roshni Resource Centre Overview of Service The Roshni Community Support Team works with adults from South Asian backgrounds who are experiencing mental health difficulties. The service acts as a gateway for people from the South Asian communities who are struggling to engage with mental health services. The team works to make sure its patients receive the right support in the community so they can maintain their mental health and independence. The service can be contacted directly by the patient or someone on their behalf. The members of staff speak several South Asian languages and will arrange to meet the patient and, together, plan the right support for them. The service offers: assistance and support to GPs and hospital staff; assistance with making claims for benefits; encouragement for physical and mental well being; encouragement to use community resources; help in getting hospital appointments; help to advance on to independent living skills; help to enhance patient s experience; help with housing matters; home visits; informal counselling; support for carers; various groups to build self confidence and social inclusion. Where service is based Roshni / Ashanti House 93b Marsh Road Luton LU3 2QG Tel: Hours of operation Monday - Thursday Friday How to contact service Tel: / Fax: How to refer into the service & who can refer Referral criteria Referrals are accepted from: GPs community psychiatric nurses (CPN); community social workers; health professionals; mental health agencies; social workers; self referrals. must be over 16 years of age, from South Asian communities and resident in Luton; individuals who are vulnerable to abuse or exploitation to and from others; individuals who face significant risk of neglect or risk to themselves or others; individuals who have little or no choice and control over vital aspects of their immediate environment because of their mental illness; individuals who may face homelessness with or because of a defined mental illness; individuals who need to access employment and training with a mental illness; individuals who respond poorly to treatment from mainstream mental health services; individuals whose lives are, or will be, at risk because they have significant mental health issues; Resource Centres Roshni Resource Centre 171

87 Additional information to support referral criteria Exclusions from Service What response times to expect Further information individuals with whom there is a risk of disengagement from the mainstream services; where serious abuse has occurred or might occur because of the mental health condition of the patient; where there is a serious risk of deterioration in the mental health that may affect the patient in the near future. Recent risk assessment & care plan. People resident outside of Luton. Response within five working days of referral, advising of the anticipated timescale to see the patient. All referrals are triaged and depending upon the individual need, are prioritized for an appointment accordingly. All patients are seen within a maximum of 12 weeks. Referrals will be based on a full assessment of need conducted through the Care Programme Approach (CPA) process. The referring social worker / CPN will be expected to remain as the client s care coordinator whilst the client is subject to the CPA process and will be responsible for coordinating the periodic review of the client s needs. SEPT management responsible for service Team Leader: Associate Director: Executive Director: Prafulla Sanghrajka Tel: /92/52 prafulla.sanghrajkx@xxxx.xxx.uk Gail Dearing Tel: gail.dearxxx@xxxx.xxx.uk Amanda Reynolds Tel: amanda.rexxxxxx@xxxx.xxx.uk Resource Centres Roshni Resource Centre 173

88 Speech & Language Therapy - Overview of Service The Speech and Language Therapy (S&LT) Service () works across the whole county providing help in both hospital and community settings to adults (16 years and over) who have a difficulty with communication or swallowing. The service is provided in a number of ways, depending on need. e.g. individual or group treatment. The service also undertakes a role in providing training and specialist support to carers and to those working with adults in residential care and other settings. This enables carers and professionals involved with the adult to provide an appropriate level of support and input. Where service is based Treatment is usually provided wherever is most appropriate for the patient. The S&LT Service works in Bedfordshire and Luton in the following locations: acute and community hospitals; patients homes; social care establishments e.g. day centres; hospices; care homes; mental health assessment units; Bedford prison. Hours of Operation Monday - Friday Appointments may be offered outside these times in some settings. How to contact service How to refer into the service South Bedfordshire S&LT Team Luton and Dunstable Hospital Lewsey Road Luton LU4 0DZ Tel: Bedford S&LT Team Bedford Hospital Kempston Road Bedford MK42 9DJ Tel: Referrals are accepted from: GPs; consultants; allied health professionals; speech and language therapists; carers; self-referral. NB: For adults requiring an assessment of their swallowing the referral must be made either by a doctor, nurse or other health care professional who has received specific training from the service. Patients referred with voice disorders must have an examination by an ear nose throat (ENT) consultant or GP with a special interest in ENT prior to referral. Speech & Language Therapy - Please contact the service directly to refer. 175

89 Referral criteria The S&LT service provides an individual approach to patients (16 years and over), who have a disorder of communication or swallowing and have a Bedfordshire or Luton GP. Further information The service will provide a single assessment and advice to young mental health patients and learning disability patients who are in the acute setting and require urgent swallowing assessments. Additional information to support referral criteria Exclusions from service What response times to expect (16 years and over) referred to the service may have: an acquired speech, language or communication disorder (either understanding and/or expressive difficulties) as a result of stroke, progressive neurological condition, dementia, head injury or head and neck cancer; eating, drinking and/or swallowing difficulties as a result of stroke, progressive neurological condition, dementia, head injury or head and neck cancer; a disorder of voice (for example vocal nodules); a stammer; unresolved speech, language or communication disorders caused by physical factors, e.g. adults with cleft palate. The service does not accept referrals for adults with either a: primary learning disability; primary mental health diagnosis (other than dementia); dyslexia. Initial appointments are made based on clinical priority. SEPT management responsible for service Clinical Service Manager: Marion Watts Tel: marxxx.xxxxx@xxx.xxx.uk Associate Director Allied Jill Stephen Health Professions: Tel: jill.stxxxxx@xxxx.xxx.uk Deputy Director Children s & Chris Myers Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Speech & Language Therapy - Treatment within 18 weeks from referral. 177

90 Services For People With Learning Disabilities (SPLD) Community Overview of Service The Services for People with Learning Disabilities (SPLD) Community provide specialist healthcare services for people who have a learning disability and are 18 years and over, living within Bedfordshire and Luton. The service is provided for people who have: challenging or disturbed behaviour; degenerative neurological disorders which occurred during their developmental period and led to learning disabilities; epilepsy, which cannot be managed by general neurology services; mental illness and other mental disorders, such as autism; sensory deficits which cannot be managed by general services. The community services are multi-disciplinary and include: Arts Psychotherapies: Provides a facility that creatively enables patients who have difficulty articulating and expressing themselves through verbal and non- verbal expression to improve emotional communication through art, music and drama. Dietetics: Provides support for patients to make informed decisions where possible regarding diet and health and highlights the health gains associated with good nutritional care. Health Facilitation Service: Nurse-led service, working with adults who have a learning disability to enable them to access and receive equitable healthcare from services. Occupational Therapy: Helps patients identify the occupational elements that contribute to the difficulties they have carrying out meaningful activities and provides advice, support and patient-centred intervention to achieve identified occupational goals, with the ultimate aim being the improvement of physical and/or mental health and sense of wellbeing. Physiotherapy: Provides access for patients to generic physiotherapy services or to provide specialist intervention as required or indicated from the initial assessment, as well as promoting activities which complement the patients overall physical management programme and their health. Psychology: Provides assessment and evidence-based interventions and support for individuals with emotional, behavioural and social interaction difficulties, including behaviour that challenges, anger problems, anxiety, depression, psychosis and difficulties surrounding relationships and interaction with others. Sensory Impairment Service: Supports patients to gain access to appropriate sight and hearing assessments, and develop the use of their senses, as well as providing Primary Ear Care and health promotion. Specialist Medical Department: Provides a consultant-led service to patients through specialist psychiatrists working within the three pathways of the Service, mental health with challenging behaviour, complex physical needs and forensic services. Speech and Language Therapy: Supports patients through assessing the level of language and communicative functioning and determines the potential to maximise these skills through a variety of communication. They also act as interpreters for service users with communication difficulties. The services provided by those listed above can be accessed by both inpatients and outpatients depending on individual need. (SPLD)- Community 179

91 Where service is based Clinical Resource Centre Twinwoods Health Resource Centre Milton Road Clapham Beds MK41 6AT Tel: Beech Close Resource Centre Beech Close Dunstable Beds LU6 3SD Tel: Referral criteria Exclusions from service individual must be 18 years or older; must be registered with a Bedfordshire GP for at least three months; presumed to have a learning disability; if this is not known, but felt to be likely, an assessment will be carried out to clarify this; have needs which require a specialised learning disability service - i.e. their needs are not best met by mainstream provision e.g. mainstream mental health and mental health services for older people. If person does not have a learning disability. Hours of operation Monday - Friday However, the services are flexible and will be available for the individual patients depending on their needs. How to contact service Twinwoods (Bedford): Tel: Beech Close (Dunstable): Tel: How to refer into the service & who can refer Referrals are accepted from: GPs; health professionals; related professionals such as social services; families; individuals. What response times to expect SEPT management responsible for service Associate Director: Director: Confirmation within seven days of referral and arrangements made for an appointment as soon as possible. Elspeth Clayton Tel: elspeth.claytxx@xxxx.xxx.uk Declan Jacob Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk (SPLD)- Community 181

92 Services for People with Learning Disabilities (SPLD) - Intensive Support How to refer into the Referrals are accepted from: Overview of Service The Service for People with Learning Disabilities (SPLD) Intensive Support Team (IST) provides a 24-hour crisis service as well as community based services to people who have a learning disability and are 18 years and over, living within Bedfordshire and Luton, who are experiencing a mental health or challenging behaviour crisis requiring urgent assessment and treatment. Where possible the service is provided in the individual s own home, with the intention of minimising the need for admission.where the level of risk is such that hospital admission is required, the IST can assist in minimising inpatient stays by facilitating early discharge and supporting people back into the community. Support is given through: advice assessment practical support short-term treatment staff training to the current care provider The team offers a range of services in partnership with patients, carers and staff. The aim is to bring about positive changes, reduction of challenging behaviour and enable the patient to resume their daily life. Where service is based Hours of operation Inpatient Crisis Unit The Coppice 2 The Glade Bromham Bedford Beds MK43 8HJ Tel: hrs, 365 days How to contact service Via 24hr crisis number: service & who can refer Referral criteria Exclusions from service What response times to expect GPs; health professionals; related professionals such as social services; families; self-referrals. Referrals via the single point of referral at Twinwoods Clinical Resource Centre Tel: Emergencies: the person is over 18 years of age and is resident in Bedfordshire; must be registered with a Bedfordshire GP; presumed to have a learning disability; if this is not known, but felt to be likely, an assessment will be carried out to clarify this; experiencing a mental health or challenging behaviour crisis requiring urgent assessment and treatment; have needs which require a specialised learning disability service - i.e. their needs are not best met by mainstream provision e.g. Mainstream Mental Health and Mental Health Services for Older People. If person does not have a learning disability. Urgent: Assessment within four hours of referral Non-urgent: Confirmation within 24hrs of referral Assessment within five days of referral 183 (SPLD) - Intensive Support

93 (SPLD) - Intensive Support SEPT management responsible for service Clinical Team Manager: Associate Director: Sandra Hukin Tel: sandra.hukxx@xxxx.xxx.uk Elspeth Clayton Tel: elspeth.claytxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 185

94 Service for People with Learning Disabilities (SPLD) - Low Secure Services Overview of Service Forensic low secure services provide a specialised service for people who have a learning disability who offend. The units are secure units which means all patients are detained under the Mental Health Act. The Forensic Low Secure Team is made up of nurses and specialist clinicians, supported by a consultant psychiatrist who acts as the responsible medical officer. Patients who are admitted are expected to fully participate in their comprehensive and detailed treatment programme with a goal of planned rehabilitation and resettlement in the community. How to refer into the service & who can refer Referrals are accepted from: GPs; community teams; magistrate and crown court referrals; occupational therapists; offender therapy leads; police (including custody sergeants); private sector transfers; probation officers; psychiatric and learning disability nurses; responsible clinicians; social workers. Treatments and therapies include: access to psychology and occupational therapy upon referral; arts psychotherapy; cognitive behaviour therapy; daily living skills; socialisation and rehabilitation into the community; treatment of offending behaviour. Where service is based Hours of operation Wood Lea Clinic 5 The Glade Bromham Bedford Beds MK43 8HJ Tel: hours, 365 days How to contact service On call manager : Tel: Referral criteria Referrals to Wood Lea Clinic. Tel: Or referral forms can be forwarded directly to the Responsible Clinician Dr M Iqbal, Twinwoods Resource Centre, Milton Road, Bedford. Tel: All patients must: have a Wechsler Adult Intelligence Scale (WAIS) assessment which indicates a score of 70 or below; require a low secure environment. Wood Lea Clinic can arrange for the WAIS to be conducted, should the referrer not have this information, although this would only be actioned following a screening assessment by the multi-disciplinary team. (SPLD) - Low Secure Services 187

95 Additional information to support referral criteria The team would require extensive information through reports from the following to enable a thorough and robust assessment: responsible clinician; social work reports / care co-ordinator; care programme approach (CPA) minutes; psychology; nursing; occupational therapy. Exclusions from service Wechsler Adult Intelligence Scale (WAIS) over 70, unless agreed by the medical director or responsible clinician on an individual basis. What response times to expect SEPT management responsible for service Team Leader (Acting): Executive Director: Assessment within seven days of referral. Emergency assessment within four hours from on-call manager. Lorraine Tottman Tel: lorraine.txxxxxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk (SPLD) - Low Secure Services 189

96 TB Nursing Service Overview of Service The aims are to prevent, contain and manage the treatment of Tuberculosis. Providing individual care at the point of need to support people with TB and their families. By rapid intervention and assessment of those suspected of active Tuberculosis, the TB nursing service expects to prevent the spread of Tuberculosis within the community by arranging treatment at the earliest opportunity and by identifying and screening those who have been in contact with and are at risk of developing Tuberculosis. BCG vaccination is offered to high risk groups as per NICE Guidance to help protect those most at risk of developing TB. Where service is based Chest Clinic Ombersley House Bedford Hospital South Wing Kempston Road Bedford MK42 9DJ The majority of patients are seen in TB nurse led clinics at Chest Clinic Bedford Hospital. Community domiciliary visits as required. Satellite clinics are arranged as appropriate at health centres or other suitable venues. Workplace, school, university or other setting if a mass TB contact screening needs to take place. Hours of operation Monday - Friday How to contact service Tel: How to refer into the service Referral criteria Referrals are accepted from: GPs; health professionals; self-referral. For all patients registered with a GP within North and Mid Bedfordshire. Patients outside of the area who are under the care of a Bedford consultant, also people who live outside the area who are part of whole group screening, their GPs outside of the area are then notified. Patients within the south locality have service provision delivered by Luton and Dunstable hospital. Additional information to Referrals for active or latent TB patients: support referral criteria 1. Port of Entry Health Unit; 2. CCDC at Health Protection Agency 3. Bedford Hospital respiratory physicians or paediatricians; 4. any other medical consultant in Bedford Hospital or specialist service; 5. any health care professional; 6. GPs; 7. prison service; 8. Yarlswood IDC; 9. social services 10. voluntary associations; 11. self-referral; 12. TB services out of area. TB Nursing Service 191

97 Exclusions from service What response times to expect Referrals for BCG vaccination: 1. maternity service at Bedford Hospital; 2. paediatricians from Bedford Hospital; 3. health visitors; 4. GPs; 5. practice nurses; 6. school nursing service; 7. new entrants identified at port of entry for TB Screening; 8. self-referral as appropriate. Requests for BCG vaccinations will only be accepted if they fulfil Bedfordshire BCG policy and NICE CG117. Urgent referrals are contacted within 48 hours. Patients requiring routine screening are offered an appointment at the next available clinic. SEPT Management responsible for service Lead TB Specialist Nurse: Lead Clinician: Mary Everitt Tel: Michael Dimov Tel: Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: Executive Director of Richard Winter Integrated Services: Tel: Patients requiring contact screening are offered an appointment, between one and six weeks appropriate to the risk of infection and contact with the infected person. TB Nursing Service 193

98 Tissue Viability (Wound Care) Service Overview of Service The Tissue Viability (Wound Care) Service provides holistic assessment delivered in the community and other care establishments. The team provides specialist assessment, advice, care planning and treatment for patients with active wounds and for those requiring follow up/prevention of further episodes after treatment. The service also provides specialist support and advice to other professionals for complex wound management e.g. Pressure Ulcers, Diabetic Foot Ulcers, wounds needing sharp debridement, topical negative pressure therapy or larvae therapy. Where service is based Bedford Enhanced Service Centre Bedford Health Village 3 Kimbolton Road Bedford Beds MK40 2NT Mid / South Bedfordshire Ampthill Health Centre Oliver Street Ampthill Beds MK45 2SB Hours of operation Monday Friday In addition there are three leg ulcer clinics operating across the county which are covered by the service. How to contact service How to refer into the service Chronic Wound Care Service Administrator Tel: Pressure Ulcer Education Tel: Tissue Viability Nurse North Tel: Tissue Viability Nurse South/Mid Tel: / Referrals are accepted from: GPs; community allied services i.e. occupational therapy, physiotherapy, podiatry; community nurses (if community nurse referring housebound patient with leg ulcer, it is assumed a full assessment and doppler has been carried out and ulcer has failed to respond to standard management or there is concern with the results); community mental health services; emergency care practitioners; hospital consultants; practice nurses; prison service; school nursing; tissue viability nurses; community in-patient units; community paediatric nurses. Tissue Viability (Wound Care) Service 195

99 Referral criteria Exclusions from service What response times to expect Patients will be seen with any of the following: any post-operative wound complicationspoor healing; any wounds not responding to standard treatments; burn wounds; diabetic foot ulcers; non healing leg wounds of six weeks; palliative wound care for malignant fungating tumours; pressure ulcers no exclusions; wounds for larvae therapy; wounds needing sharp debridement; wounds requiring topical negative pressure therapy. biopsy; prevention only work; self referrals; varicose veins. Patients are triaged and prioritised on a weekly basis Urgent referrals assessment within five days from referral Routine referrals assessment within three weeks from referral Leg Ulcer appointments - within four weeks from referral SEPT management responsible for service Team Leaders: Lead Clinician: Patricia Comerford Tel: patricia.comerforx@xxxx.xxx.uk Clare Lazelle Tel: clare.lazxxxx@xxxx.xxx.uk Carol Ferdinandez Tel: carol.ferxxxxxxxx@xxxx.xxx.uk Michael Dimov Tel: michael.dimox@xxxx.xxx.uk Director of Adult Integrated Helen Smart Services and Lead Nurse: Tel: helen.smarx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Tissue Viability (Wound Care) Service 197

100 Wheelchair Services Overview of Service The Wheelchair Service provides the framework to clinically assess and then provide appropriate wheelchairs with associated equipment to patients with a long-term need, (long term defined as six months plus) who require a wheelchair for all their mobility both indoors and outdoors and who may also have postural and pressure care issues. Once provision is established, the Wheelchair Service will support the equipment provided and will offer reassessment as required. The service works with children over 36 months and adults who have a long term condition. The service undertakes individual assessments to identify mobility needs and supply the appropriate equipment. Assessments are completed in our clinic. In addition the service: provides bespoke adaptations to wheelchairs either in house or through a rehabilitation engineer; utilises specialist technicians to assist therapists, check stock in and out, and respond to urgent domiciliary specialist seating. For occasional users or those who need a manual wheelchair for outdoor mobility (please contact OneCall or Community Assessment & Rehabilitation Team [ CART] details below) Where service is based Steppingley Hospital Steppingley Beds MK45 1AB Tel: We are also able to offer clinic appointments at the Disability Resource Centre, Dunstable for clients with a Luton GP and at the Child Development Centre, Kempston for Bedfordshire Children. Hours of operation Monday - Friday Telephone line open How to contact service Tel: Fax: wheelchairs.xxxxx@xxxx.xxx.uk How to refer into the service Referral criteria Additional information to support referral criteria Referrals are accepted from: GPs; education staff; health professionals; social services. Patients known to the service can make contact directly for re-assessment. the individual must be registered with a GP in Bedfordshire for at least six months; the individual requires the use of a wheelchair for a period in excess of six months; minimum age of the individual is usually 36 months. Referral via: OneCall: (Bedfordshire) CART Community Assessment & Rehabilitation Team: (Luton) It is helpful for the service to have a history of mobility equipment tried, postural, functional and environmental assessments and information on planned surgery or specialist care. 199 Wheelchair Services

101 Exclusions from Service patients newly registered with Bedfordshire GP - under six months; requests for buggies for children; terminally ill patients, with a prognosis less than six months (please contact OneCall or CART); people who want outdoor only powered wheelchairs. SEPT management responsible for service Clinical Service Manager: Sarah Sherwood Tel: sarah.sherwxxx@xxxx.xxx.uk Associate Director Allied Jill Stephen Health Professions: Tel: jill.stxxxxx@xxxx.xxx.uk This service is not responsible for wheelchairs other than those supplied by the wheelchair service to named individuals. Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk What response times to expect The service will make contact with the client within one week of referral to arrange an assessment date at one of our clinics. Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Treatment is expected to be completed within 18 weeks. Further information Patients who are not wheelchair dependent indoors, but who require assistance with outdoor mobility, can be assessed by the Community or Social Services Therapy teams. Referral via: OneCall: (Bedfordshire) CART Community Assessment & Rehabilitation Team: (Luton) Terminally ill patients, with a prognosis less than 6 months (please contact OneCall or CART) Wheelchair Services 201

102 0 19 Children s Service Overview of Service The 0-19 service consists of 5 skill mixed teams including Specialist Community Public Health Nurses who are Health Visitors and School Nurses. They are supported by Community Staff Nurses, Community Nursery Nurses, Health Care Assistants and administrators. Together they provide a programme of prevention and early intervention services for children, young people and their families in Bedfordshire. This service is delivered through the Healthy Child Programme and offers a comprehensive programme of screening, immunisations, developmental reviews, information and guidance to support parenting and healthy choices and interventions which enhance a child or young person s life chances. The Healthy Child Programme will also provide individual and tailored support to ensure that children receive appropriate referrals to specialist services where indicated and that families are signposted to wider support systems. The programme will ensure that each family receives support that is appropriate for their needs with the most vulnerable families receiving additional interventions in partnership with education and other agencies. Where Service is based The 0-19 Service covers all children registered with Bedfordshire GP Practices and those who are not registered with a GP but live in Bedfordshire. The teams are organised into five localities : Bedford 2 Central Bedfordshire 3 Hours of Operation Monday - Friday (this may be extended in some teams) How to Contact Service In person, telephone, letter or referral form. Please see Manager s contact details below or speak to a 0-19 team member. How to refer into Referrals for children aged 0-19 (if in full the service time education) are accepted from : GPs Paediatrics Midwives Children s Centre staff Education staff and schools Acute Hospital Services Social Care and housing Other health professionals Self-Referral Referral Criteria Additional Information to support referral criteria Exclusions from Service All children aged 0-19 years old receive a universal service. For specific interventions related to: social, emotional wellbeing, development, parenting support, neurological development, public health priorities and vulnerable families with additional needs referral can be made using a 0-19 referral form. Please complete referral form or speak to a member of the 0-19 team. Ages 0-5: If a child is not registered with NHS Bedfordshire GP or is a non Bedfordshire resident. Ages 5-19: If a child is not registered with NHS Bedfordshire GP and is a non Bedfordshire resident and not in education services in Bedfordshire. Children 0-19 Children s Service 203

103 What Response Times to expect All families with children under five years newly registered with a GP or moved into the area are contacted within five working days of the Health Visitor being notified. Families seeking telephone advice and support from a health professional will receive a response within 48 hours. School aged children/parents or guardians are contacted following referral (as appropriate) between during the working week. Children SEPT Management responsible for service 0-19 Service Locality Manager: Deirdre Wisdom Tel: deirdre.xxxxxx@xxxx.xxx.uk Deputy Director Children s Services & Specialist Services: Chris Myers Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Integrated Service: Richard Winter Tel: richard.wintxx@xxxx.xxx.uk 0-19 Children s Service 205

104 Child & Adolescent Mental Health Service - Learning Disability Overview of Service The Child and Adolescent Mental Health Learning Disability Service provides community based help for children with a learning disability and their families. This includes children living in foster care and adoptive families. The team work with children and their families with the learning disabilities as well as helping families with issues including: aggressive behaviour; eating problems; mental health needs; self injury; severe / profound learning disability; sleep problems; those in special education. Additionally, the team also assess and offer treatments for other mental health problems including anxiety, depression, attention deficit hyperactivity disorder (ADHD) and psychosis. The service works with everyone within the child s network to improve communication, best practice and consistency. The team includes: Psychologist Assistant Psychologist Child and Adolescent Psychiatrist Clinical Nurse Specialist Where Service is based Family Consultation Clinic 24 Grove Place Bedford Beds MK40 3JT Hours of Operation Monday - Friday How to Contact Service Tel: How to refer into the service & Who can refer Referral Criteria Additional Information to support referral criteria Exclusions from Service What Response Times to expect Referrals are accepted from: GPs Health Professionals Social Workers Teachers Youth Workers SEPT Management responsible for service Clinical Service Manager: Associate Director: Age 18 years old and under Must be registered with NHS Bedfordshire GP Have or be suspected of having Learning Disabilities & Mental Health Issues Families can contact the team if they wish to discuss a referral Those without Learning Disabilities Admission within 11 weeks from referral Matthew Sparks Tel: matthew.sparxx@xxxx.xxx.uk Sharon Hall Tel: sharxx.xxxx@xxxx.xxx.uk Children Child & Adolescent Mental Health Service - Learning Disability Executive Director: Sally Morris Tel: sally.morrxx@xxxx.xxx.uk 207

105 Child and Adolescent Mental Health Service Overview of Service The Child and Adolescent Mental Health Service (CAMH) provides outpatient assessments, support and treatment for children experiencing moderate to severe mental health problems in young people up to the age of 18. The service works to provide patients with a greater knowledge of their condition and improve coping techniques. The service provides help to children and to the wider family, including children living with foster parents, children who have been adopted and young people living in children s homes. The service may see children and adolescents on their own, with their parents or with their family, and may also see parents on their own. Children, adolescents and their families referred to the service may be experiencing different kinds of problems. These may include: Eating difficulties Emotional feelings such as those of unhappiness, loneliness Fears and anxieties Parents may have problems managing their children or may feel that their own difficulties are affecting their children Relationship problems Traumatic experiences The service is also available to help children, adolescents and their families with mental health issues related to physical or learning disabilities. The service consists of a multi-disciplinary team which offers a range of expertise including: Art Psychotherapists Child & Adolescent Psychiatrists Clinical & Educational Psychologists Nurse Specialists Psychotherapists Social Workers Other Child & Adolescent Clinicians Specialist Teams within the service: Community Learning Disability Team: Provides assessment and intervention for children up to the age of 18 who have a learning disability and associated severe challenging behaviour or mental health problems. Home Treatment Team: Provides high intensive community based treatment using a care pathway approach and regular visits to patient s home or preferred location. In a few cases, where home treatment is not an appropriate option, then the team may need to consider an inpatient admission. Looked After Children s Team: Offers support to young people who may be accommodated or under Care Orders with the local authorities. Where Service is based Dunstable CAMH Team Beech Close Resource Centre Beech Close Dunstable Beds LU6 3SD North Bedford CAMH Team 5-7 Rush Court Bedford Beds MK40 3JT Hours of Operation Monday - Friday How to Contact Service Dunstable CAMH Team Mid Bedfordshire CAMH Team North Bedford CAMH Team Luton CAMH Team Mid Bedfordshire CAMH Team 24 Grove Place Bedford Beds MK40 3JJ Luton CAMH Team Charter House Alma Street Luton Beds LU1 2PL Children Child and Adolescent Health Service

106 How to refer into the service & Who can refer Referrals are accepted from: GPs Health Professionals Social Workers Teachers Youth Workers SEPT Management responsible for service Dunstable & Mid Beds Locality Clinical Group Manager: Matthew Sparks Tel: Children Referral Criteria 18 years old and under Must be registered with NHS Bedfordshire GP Experiencing moderate to severe mental health issues North Bedford Locality Clinical Group Manager: Jo Meehan (Looked After Children s Tel: Team, Home Treatment) jo.xxxxxx@xxxx.xxx.uk Luton Locality Exclusions from Service What Response Times to expect Over 18 years old Assessment within 11 weeks from referral Clinical Group Manager: CAMH Associate Director: Executive Director: Briege Gates Tel: briege.gatxx@xxxx.xxx.uk Sharon Hall Tel: sharxx.xxxx@xxxx.xxx.uk Sally Morris Tel: sally.morrxx@xxxx.xxx.uk Child and Adolescent Health Service 211

107 Children s Community Medical Service Overview of Service The service provides Paediatric Medical and Nursing Services to children and young people with the following conditions: suspected developmental delays or disorders; neuro-developmental problems such as Autism Spectrum Disorders, Cerebral Palsy; ADHD and associated behavioural problems (excluding anxiety disorders, depression, mood disorders, Obsessive Compulsive Disorders, suicidal tendency); Developmental Co-ordination Disorder / Dyspraxia; Enuresis, encopresis and constipation; Special Educational Needs ( we do not accept referrals to confirm/rule out dyslexia); safeguarding concerns, alleged neglect, physical, emotional, sexual abuse; adoption, Looked After Child medicals; children with additional needs/disability and having sleep/ behaviour/ toileting/feeding problems (in Nurse led clinics at CDC). It also investigates, assesses and diagnoses other underlying medical problems. Referrals to other professionals/agencies made where appropriate. In addition, it provides specific role related functions like: Named Doctor for safeguarding children Designated Doctor for Education Lead Doctor for NHSP & LAC Medical Advisor to Adoption Panel Lead Paediatrician to CDOP The service complies with statutory requirements and has extended its role to develop health activities in line with Every Child Matters. Where Service is based Union Street Clinic Union Street Bedford MK40 2SF Hours of Operation Monday - Friday How to Contact Service How to refer into the service Union Street Clinic Union Street Bedford MK40 2SF Tel: Tel Dr s Office: Fax: Referrals are accepted from: GPs School Nurses Health Visitors SENCOs Therapists CAMH Hospital Paediatricians Re: urgent referrals must be faxed (Fax: ) + telephoned ( ) if necessary to speak to the doctor Referral Criteria Additional Information to support referral criteria Patients must be registered with NHS Bedfordshire GP Patients 18 years old and under This service is offered to any child or young person with additional needs. Specialist service is available to any child or young person with complex clinical needs be it chronic, physical, palliative care or a technology dependent need. Children Children s Community Medical Service 213

108 Exclusions from Service What Response Times to expect SEPT Management responsible for service Admin Manager: Associate Specialists: Exclusion criteria for the service: patients over 18 years old; not registered with NHS Bedfordshire GP. (The exception being for temporary residents and vulnerable groups). All referrals are considered when received and prioritised accordingly. All urgent referrals are acted on within 24 hours. All children are seen within six weeks. Key Worker / Lead Professional are identified as appropriate. Di Buchanan Tel: diane.xxxxxxxx@xxxx.xxx.uk Dr Ratneswary Veeravahu Tel: ratneswaryy.veeraxxxx@xxxx.xxx.uk Consultants: Clinical Lead: Dr Samira Ajmal Tel: samira.ajmal@yahoo.com Dr Rishi Arora Tel: rishi.arxxx@xxxx.xxx.uk Dr Salma Rehman Tel: salma.rxxxxx@xxxx.xxx.uk Dr Varthamanan Chandra Tel: dr.xxxxxxx@xxxx.xxx.uk Dr Chinnaiah Yemula Tel: dr.yxxxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Children Children s Community Medical Service 215

109 Children s Community Nursing Team Overview of Service The Children s Community Nursing Team (CCN) provides a range of services to support children aged 0 16 years old (0 19 years old with Special Needs) who live within Bedfordshire and require skilled nursing support in their home environment. The service is provided by a team of specialist trained children s nurses with the appropriate knowledge, skills and expertise. The team support and provide specialist training for families to enable them to care for their sick child within their own home and promote high quality family centred care. The team can also support children and young people in attending school or nursery by training carers, where appropriate. The service provides: 1. Skilled Care if a child or young person requires a specific identified procedure, for example intravenous, subcutaneous, intramuscular medication. Other examples include wound care, post-surgery and orthopaedic care. 2. Symptom Control Management if the child or young person requires a period of regular assessment and monitoring of symptoms, for example pain control in children requiring palliative care, exacerbation of chronic conditions such as eczema and constipation. The team also support oxygen dependant babies and children with complex healthcare needs. 3. Education if the family or carer requires training to enable them to continue providing support and on-going care, for example enteral feeding, suctioning, oxygen therapy, tracheostomy care and administration of medication. 4. Nursing Procedures - that can be safely undertaken at home. 5. Acting as advocate - for child and family, identifying Lead Professional in conjunction with family and other health care professionals. 6. Acting as resource - for other health care professionals. Where Service is based Union Street Clinic Union Street Bedford MK40 2SF Hours of Operation Monday - Friday How to Contact Service How to refer into the service Referral Criteria Additional Information to support referral criteria Exclusions from Service For further information or to make a referral please contact: Children s Intermediate Care Team: Tel: Fax: Referrals are accepted from: GPs Health Visitors School Nurses Child Development Centre Acute Sector - Children s Ward, Neonatal Unit, Outpatients at Bedford Hospital Specialist Centres Professional working with the child or young person. GP to be located within north and mid Bedfordshire and the child or young person must have a nursing need. Services for children and young people residing in south Bedfordshire receive services from Luton Community Children s Nurses Tel: Initial telephone contact to discuss the referral. A referral form must be completed following this discussion. Over 16 years old (or over 18 years old with special needs) Children Children s Community Nursing Team 217

110 What Response Times to expect All referrals are prioritised on receipt. The CCN team aim to respond to urgent referrals within 24 hours. Non urgent referrals within 2 weeks. Children Further information Union Street Clinic Union Street Bedford MK40 2SF SEPT Management responsible for service Specialist Children s Services Hazel Dean Manager / Lead Nurse: Tel: hazel.xxxx@xxxx.xxx.uk Deputy Director Children s & Chris Myers Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Children s Community Nursing Team 219

111 Children s Continence Service Overview of Service The Children s Continence Service promotes continence for children and young people in Bedfordshire and Luton. The service is primarily for special needs children who require help and support with toilet training including daytime wetting, constipation and soiling. At the initial assessment, information and advice is given on helping the child acquire toileting skills including routines and recommended fluid intake. Families will be informed how to access a provision of nappies, if appropriate to the child s needs. Other help we can give includes workshops on toilet training; advice on intermittent self-catheterisation; visual symbols, reward charts and care plans; telephone advice; liaison with education and social services staff and follow up assessments. Where Service is based Disability Resource Centre Poynters House Poynters Road Dunstable Bedfordshire LU5 4TP Tel: Patients are assessed for their continence needs at clinics held at The Child Development Centre in Kempston, Bedford; at the Edwin Lobo Centre in Luton and at Special Needs Schools throughout the county. Occasionally, assessments are done in the patient s home when they have severe health and mobility issues. Hours of Operation Monday - Friday How to Contact Service How to refer into the service Referral Criteria Exclusions from Service Referral forms can be sent by post or fax. Occasionally, urgent referrals are taken over the phone for severely ill children or those receiving palliative treatment. Tel: (line is open Monday to Friday and Safe Haven Fax: Referrals are accepted from: GPs Paediatricians Health Visitors Social Workers Special Needs School Nurses Patients should be registered with a Bedfordshire or Luton GP. Children aged 4 18 years old (mainly special needs) Aged under 4 years old Aged over 18 years old Not registered with Bedfordshire or Luton GP Night time wetting only (these patients should be referred to the Enuretic Service at Union Street Clinic in Bedford or Liverpool Road Health Centre in Luton) Constipation and soiling experienced by children in mainstream education these children should initially be seen by the School Nurse and if the problem persists, they should be referred to the Bowel Clinic at the Child Development Centre, Kempston, Bedford or Edwin Lobo Centre in Luton. 221 Children Children s Continence Service

112 What Response Times to expect All appropriate referrals are added to the waiting list on the day they are received. All children are seen within 18 weeks from referral. Children SEPT Management responsible for service Specialist Children s Services Hazel Dean Manager / Lead Nurse: Tel: hazel.xxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Children s Continence Service 223

113 Children s Continuing Care Team Overview of Service The Children s Continuing Care Team supports families in the community who have children with life limiting or life threatening conditions and complex medical needs. The team aims to enable these children to reach their full potential. Without the support of the team many families would find it impossible to continue to care for their child at home. The Children s Continuing Care Team is a team of Qualified Nurses and Specialist Community Nursery Nurses. They work under the guidance of a team leader to ensure they are trained and competent to undertake the delivery of specific packages of care. The Nursery Nurses provide the majority of the care to the children, with emphasis on development and stimulation through play and are clinically trained to meet the identified medical needs of the individual children. The Children s Continuing Care Team delivers care to children as set out in the individual care plan, which is written by a Registered Nurse in agreement with parents and multi-agency team. Care provided by the team has an emphasis on normalisation for the children at all times. Staff will be trained to deliver appropriate care, be updated through regular training opportunities and encouraged to develop new skills as appropriate to children supported by the team. Play plans are implemented to ensure that children are stimulated appropriately according to their age and stage of development. These plans aim to support each child to fulfil their full potential, and are reviewed as required. Where Service is based Hours of Operation Union Street Clinic Union Street Bedford MK40 2SF Tel: The Children s Continuing Care Team deliver packages of care 24 hours, 365 days. The Specialist Community Nursery Nurses and families have the additional support of a Qualified Nurse via a telephone on-call service. How to Contact Service Tel: How to refer into the service Referral Criteria Additional Information to support referral criteria Referrals are accepted from: GPs Children s Community Nurses Social Care Must be registered with NHS Bedfordshire GP Under 18 years old Referrals to the Children s Continuing Care Team are usually made soon after birth, diagnosis or when complex medical needs arise. Following discussions with the family and professionals, a discharge planning meeting will be held. This will involve the parents and all professionals involved in providing care to the child. The purpose of this meeting is to discuss how the needs of the child can best be met at home and a package of care established that meets the needs of the family within the resources available. Following the professionals meeting, an application will be made to the Joint Allocation Panel (JAP) to decide an appropriate package of care for each child. Some families benefit from night support where others prefer day support. Identified needs may also be met by health care professionals, social services or the voluntary agencies as part of an agreed package of care. 225 Children Children s Continuing Care Team

114 Referrals are made primarily from secondary care providers locally and from tertiary centres. Children s Community Nurses, Social Care colleagues and GPs can also refer if a package of Children s Continuing Care is deemed appropriate. A Health Needs Assessment using the National Service Framework for Children and Young People s Continuing Care decision tool is completed prior to being considered and agreed by the Joint Allocation Panel. Children Exclusions from Service Over 18 years of age not eligible for Children and Young People s Continuing Care What Response Times to expect SEPT Management responsible for service All referrals are acknowledged within 48 hours and a plan agreed for assessment as part of a planned discharge planning process. Specialist Children s Services Hazel Dean Manager / Lead Nurse: Tel: hazel.xxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Service: Tel: richard.wintxx@xxxx.xxx.uk Children s Continuing Care Team 227

115 Children s Eye Service Overview of Service The Children s Eye Service is provided by Ophthalmologists and Orthoptists who specialise in the diagnosis and treatment of eye conditions by medical and surgical means. Orthoptists are allied health professionals who use non-surgical methods to diagnose and treat abnormalities of vision and co-ordination of eye movements in people of all ages. Main services provided to residents of Bedfordshire and Luton in community clinics: Specialist Ophthalmic and Orthoptic services for children and young adults in community clinics across Bedfordshire and Luton including Looked After Children Specialist clinics for children with special needs at Child Development Centre and Special Schools across Bedfordshire and Luton Pre-school vision screening at aged 4-5 years old in Bedfordshire How to refer into the service Referral Criteria Referrals are accepted from: GPs; Orthoptists (as per agreed protocol with GPs) after pre-school vision screening; 0-19 Team; Community Paediatricians; Multi-disciplinary teams at CDC and Edwin Lobo Centre; parents/carers of children who meet the criteria. Patients must be registered with a Bedfordshire or Luton GP Referrals accepted for children aged 0-19 years in the following groups (criteria): Children Where Service is based Enhanced Services Centre (Bedford) Child Development Centre (CDC Bedford) Liverpool Road Health Centre (Luton) Wigmore Lane Health Centre (Luton) Edwin Lobo Centre (ELC Luton) Flitwick Health Clinic Biggleswade Health Centre Shefford Health Centre The following special schools: Ridgeway; St Johns; Ivel Valley; Chiltern School and Lady Zia Wernher) Hours of Operation Monday - Friday How to Contact Service Bedford Tel: Luton Tel: children with defects of binocular vision, squint and amblyopia; children with symptoms of headaches and blurred vision associated with close work, diplopia (double vision) or eye movement problems; children who fail to meet agreed standards of vision at School vision test (5+ years); children whose parents/carers are concerned about their visual development or possible eye movement problems or where there is a strong family history of eye disorders; children who fail to meet local and national pre-school (4-5 years old) orthoptic screening standards. 229 Children s Eye Service

116 Additional Information to support referral criteria On receipt of the referral the Orthoptist prioritises urgency and nearest clinic venue if not specified in referral letter. Children Exclusions from Service What Response Times to expect Patients over 18 years old Patients not registered with a Bedfordshire or Luton GP Urgent cases will be contacted by telephone where possible. All other new cases will be sent a letter advising them to contact the clinic by phone or send in the tear off slip to request an appointment Urgent referrals seen within 1-2 weeks Non urgent referrals seen within 18 weeks of referral Further Information Leaflets available from Angela Coleman - Enhanced Service Centre, Bedford Tel: SEPT Management responsible for service Associate Director Allied Jill Stephen Health Professions Tel: jill.stxxxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Children s Eye Service 231

117 Children s Intermediate Care Service Overview of Service The Children s Intermediate Care Service consists of a multi-disciplinary team comprising of a number of specialists working together to provide a coordinated approach to meeting the needs of children and young people with complex health needs in the community. The team include the following: Children s Community Nurses; Children s Continuing Care; Children s Respiratory Nurse; Paediatric Continence Adviser; Special Needs Nurses and Nursery Nurses; Child Development Centre Nursing Team; Early Support Manager. The team also works in partnership with the Local Authorities to ensure a holistic approach to meeting the health and social care needs of children and young people by focussing on the individual rather than specific needs. This service operates a case management approach to care, co-ordinating service provision and resource allocation based on clinical assessment of health need. The service aims to reduce hospital attendance and admission by doing short term acute assessment and treatment at the child s home and by offering advice to other professionals, allocation to support robust community packages of care, in partnership with wider Children s services to ensure that specialist health needs are met wherever the placement. Where Service is based Union Street Clinic Bedford MK40 2SF Tel: The service also works in a variety of settings across Bedfordshire. This includes honorary contracts with Bedford Hospital and Luton and Dunstable Hospital, to promote early discharge of children and young people with complex needs. Hours of Operation How to Contact Service Community Children s nurses deliver care to children and young people in a variety of community settings across North and Mid Bedfordshire. Special School Nursing Team reports daily to one of three special schools in North and Mid Bedfordshire. Child Development Team provides part time cover and support to families attending the Child Development Centre. Children s Continuing Care team provides a service 24 hours, 365 days working in a variety of settings across Bedfordshire. Non registered nurses are supported by a Nurse On Call out of hours. Community Children s Nurses work primarily Monday - Friday , however CCNs will work at any time between the hours of to meet the needs of the service to support IV therapy and end of life care where appropriate. Special School Nursing Team reports daily to one of 3 special schools in North and Mid Bedfordshire Monday - Friday (term time only). Child Development Team provides part time cover Monday - Friday Respiratory Nurse provides a part time service. Union Street Clinic, Bedford Tel: CICx@xxxx.xxx.uk 233 Children Children s Intermediate Care Service

118 How to refer into the service Referrals are accepted from: GPs; Paediatricians; Health Visitors; Social Workers; Education Officer; Specialist Nursing Teams at local and tertiary hospitals. SEPT Management responsible for service Specialist Children s Services Hazel Dean Manager / Lead Nurse: Tel: hazel.xxxx@xxxx.xxx.uk Deputy Director Children s & Chris Myers Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Children Referral Criteria Exclusions from Service What Response Times to expect Further Information Patients should be registered with Bedfordshire GP. This service is offered to any child or young person with additional needs, Specialist service is available to any child or young person with complex clinical needs be it chronic, physical, palliative care or a technology dependent need. Aged over 18 years old Not registered with Bedfordshire GP. (The exception being for temporary residents and vulnerable groups) All urgent referrals are acted on within 24 hours All children are seen within six weeks from referral Service leaflets available from the team base Union Street Clinic Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Children s Intermediate Care Service 235

119 Children s Nursing Team at the Child Development Centre Overview of Service The Children s Nursing Team at the Child Development Centre (CDC) coordinates and supports paediatric clinics for children and their families. Working in partnership with paediatricians and families while waiting for, or following, diagnosis, supporting families at this often difficult time working to support transition into education and universal services. We provide nursing advice and health promotion and safeguard and promote the welfare of children accessing the service. The Nursing Team also oversee the Information Room which provides resources regarding specific conditions, support groups and a number of other topics related to special needs for children, young people and their families. Where Service is based Child Development Centre Hill Rise Kempston MK42 7EB Tel: Hours of Operation Monday - Friday How to Contact Service The Children s Nursing Team Child Development Centre (CDC) Hill Rise Kempston MK42 7EB Tel: Fax: How to refer into the service Referral Criteria Additional Information to support referral criteria Referrals are accepted from: GPs; Paediatricians; Health Visitors; Social Workers; Education Officer; Specialist Nursing Teams at local and tertiary hospitals. Families that access any service at the CDC can also access our service. The Information Room is available to all who would like to access information regarding disability. Any child with an additional need that can be managed in the community setting, age under 18 years old (or under 19 years old with special needs). Referrals to the CDC are assessed as part of the Single Point of Referral process where all referrals are assessed and an appointment offered at the most appropriate venue according to identified need. This allows Children and Young People to be seen by professionals in a timely manner by ensuring any physiotherapy or occupational therapy assessments are completed prior to seeing the Paediatrician to inform decision making. Children Children s Nursing Team at the Child Development Centre 237

120 Exclusions from Service Over 18 years old (or over 19 years old with special needs). Children What Response Times to expect SEPT Management responsible for service The nursing team will respond to enquiries within 48 hours. Specialist Children s Services Hazel Dean Manager / Lead Nurse: Tel: hazel.xxxx@xxxx.xxx.uk Deputy Director Children s & Chris Myers Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Children s Nursing Team at the Child Development Centre 239

121 Children s Occupational Therapy Overview of Service The Children s Occupational Therapists (OTs) work with children and young people who have physical disabilities and co-ordination difficulties. They treat the specific problems of children with poor gross and fine motor coordination and visual perceptual difficulties where they have significant impact on activities of daily living skills e.g. washing, dressing, eating, toileting; play and leisure activities and accessing the school curriculum i.e. ability to participate in school lessons or move around the school building. Where Service is based Child Development Centre Hill Rise Kempston Bedford MK42 7EB Tel: Redgrave Children & Young People s Centre Redgrave Gardens Luton LU3 3QN Tel: The Service provides input to a large range of settings across the county. Wherever possible, patient s preference and clinical suitability influence location of treatment. This includes: Child Development Centre (CDC); Redgrave Children & Young People s Centre; patient s own home; mainstream education settings; special schools (Ridgeway, St Johns, Ivel Valley, Chiltern Primary, Chiltern Secondary, Lady Zia Wernher and Woodlands). Hours of Operation Child Development Centre : Monday - Friday Redgrave Children & Young People s Centre: Monday - Friday How to Contact Service How to refer into the service: Bedford and Central Beds Paediatric OT Tel: Luton and South Beds Paediatric OT Tel: Referrals are accepted from GPs; Health Professionals; Early Years Support Team; Sensory and Communication Team. A Choose and Book initiative is in place to ensure that all patients receive a choice in appointment time. Please contact the service directly to refer. Children Children s Occupational Therapy 241

122 Referral Criteria Additional Information to support referral criteria Exclusions from Service Patients must be registered with a Bedfordshire or Luton GP. Patients can self-refer back into the service within six months of discharge regarding the same functional area of difficulty that they were originally referred for. Patients with a deteriorating condition can self-refer back into the service at any time:- up to the age of 18 years old if in mainstream educational setting or; up to the age of 19 years old if in special educational setting. Care packages have been developed for children with the following conditions, where the child s activities of daily living skills are significantly affected: Cerebral Palsy & Other Neurological Difficulties Developmental Co-ordination Disorder (DCD) Degenerative Physical Disabilities including degenerative syndromes Syndromes (excluding degenerative syndromes) Musculo-Skeletal / orthopaedic conditions including amputees, spinal, brittle bones Burns and other acquired injuries Patients not registered with a Bedfordshire or Luton GP What Response Referrals are prioritised as either Priority 1 Times to expect (Urgent: acute or deteriorating neurology and trauma) or Priority 2 (all other referrals) Ref: National Association of Paediatric Occupational Therapists (2000) Guidelines for Good Practice NAPOT: Cheshire Routine initial appointments (priority 2) are offered within 18 weeks of receipt of referral. Urgent initial appointments (priority 1) are offered an appointment within 10 working days of receipt of referral. Children subject to an Assessment Review Meeting will be seen within 16 weeks Referrals are considered using a common countywide Paediatric Occupational Therapy Service Criteria. SEPT Management responsible for service Patients will be seen within 18 weeks from referral. Associate Director Allied Jill Stephen Health Professions Tel: jill.stxxxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Children Children s Occupational Therapy 243

123 Children s Special Needs School Nursing Service Overview of Service The Special Needs Nursing team support children and young people aged 3-19 years old, with learning disabilities and associated additional health care needs within the special school setting. The service is provided by a multi-skilled team of registered nurses and specialist nursery nurses. The team work in partnership with parents and carers, education teams, children s community nurses, continuing care, social care and the wider multi-professional team to enable children and young people to access the curriculum. The service provides: Care Planning The team develop individual care plans to meet the health care needs of children and young people through a process of assessment, planning, implementing care and evaluation of outcomes. The team co-ordinate pre and post-operative planning in order to ensure all services are in place to promote a timely return to school following surgery. The team take an active role in transition planning to promote effective transition from children s to adult services. Education The team provides training to parents, carers, education staff, respite provision and voluntary agencies in a variety of clinical interventions specific to individual care plans, to include, administration of medicines, enteral feeding, rescue medication (buccal midazolam/rectal diazepam), epilepsy awareness, oxygen therapy, suction, and the management of anaphylaxis (Anapen/ Epipen). Clinics The team work in partnership with the multi-professional team to co-ordinate health care clinics held within the special school setting in order to ensure that children and young people spend as little time as possible attending appointments outside the school setting. Clinics provided are: Medical reviews (led by Community Consultant Paediatrician) Continence Dental Dietitian Vision Audiology Immunisations (planned and provided by the special needs nursing team) Health Promotion The nursing team work in partnership with the education staff in the planning and delivery of health promotion to include healthy eating, sexual health, drug awareness and other government initiatives. Family Support The special needs nursing team act as an advocate and provide advice and support to families meeting their children s health care needs. The team are responsible for sign-posting to and referring to specialist services as necessary, sourcing relevant information, liaising with and when appropriate taking the Lead Professional role in conjunction with the family and other health care professionals. Children Children s Special Needs School Nursing Service 245

124 Where Service is based Hours of Operation St. John s School Austin Canons Bedford Road Kempston Beds MK42 8AA Tel: (direct line to nurses office) Ridgeway School Hill Rise Kempston Beds MK42 7AB Tel: Ext. 216 Ivel Valley School (Primary Site) The Baulk Biggleswade Beds SG18 0PT Tel: Ivel Valley (Secondary site) Hitchmead Road Biggleswade Beds SG18 0NL Tel: Flexible to meet the needs of the service. Core Hours: Monday - Friday (term time only) How to Contact Service How to refer into the service Referral Criteria Additional Information to support referral criteria Exclusions from Service What Response Times to expect Contact Special Needs Nursing team directly at the special school child/young person attends. Alternatively contact : Andrea Roberts Special Needs Nurse Coordinator Union Street Clinic Union Street Bedford Beds MK40 2SF Tel: andrea.roberts3@nhs.net Contact directly to Special Needs Nursing team based at child s/young person s special school. On admission to special school. All children and young people attending a special school will have access to the Special Needs Nursing service. Children and young people who live out of county will continue to be seen by their named Community Consultant Paediatrician for medical review. However all other services are inclusive. The Special Needs Nursing team are available every day at the special schools (term time only). Children Children s Special Needs School Nursing Service 247

125 Further information The Special Needs Nursing team are part of the wider Intermediate Care Team, thereby providing a co-ordinated specialist service. Children SEPT Management responsible for service Specialist Children s Services Hazel Dean Manager / Lead Nurse: Tel: hazel.xxxx@xxxx.xxx.uk Deputy Director Children s & Chris Myers Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Children s Special Needs School Nursing Service 249

126 Children s Speech & Language Therapy Overview of Service The Speech and Language (S&LT) Service works across the whole county providing help in both community and hospital settings. We treat children up to the age of 16 years (up to 19 years in special education), who have a difficulty with communication or swallowing. The Service is provided in a number of ways, depending on need. This may be; for example: individual or group treatment, parent/carer workshops and drop -in information clinics. The service also undertakes a role in providing training and specialist support to parents/carers and staff working with children and young people in schools, residential units and other settings. This enables parents/carers and professionals involved with the child, to provide an appropriate level of support and input. Where Service is based The S&LT Service works in Bedfordshire and Luton in the following locations:- Health Centres and Clinics Patients homes (where GP Practices appropriate). Child Development Centre/ Language Provisions Redgrave Gardens Children & Special Schools Young People s Centre Social Care Nurseries Mainstream Schools and Nurseries Hours of Operation Monday Friday Appointments may be offered outside these times in some settings. How to Contact Service Treatment is usually provided wherever is most appropriate for the patient. Referrals should be sent to the Single Point of Access administrator at: Union Street Clinic Union Street Bedford MK40 2SF Tel: How to refer into the service Referral Criteria Referrals are accepted from: GPs; Health Visitors; School Nurses; Consultants; Allied Health Professionals; Speech and Language Therapists from other trusts; Education; Parents, Carers; Self-Referrals. Medical consent (i.e. a doctor s signature) is required for all children requiring an assessment of their swallowing. Patients referred for voice therapy must have an examination by an Ear Nose &Throat Consultant prior to referral into the service. Please contact the Single Point of Access administrator directly to refer. Children requiring a multi-disciplinary assessment i.e. where speech and language difficulties are accompanied by other concerns, should be referred direct to: Child Development Centre (North and Mid Bedfordshire) Tel: or Children & Young People s Centre (South Bedfordshire) Tel: The S&LT service provides assessment, diagnosis and management for children under 16 years old (or up to 19 years old in special education) with a Bedfordshire or Luton GP, who have a disorder of communication or swallowing. 251 Children Children s Speech & Language Therapy

127 Additional Information to support referral criteria Exclusions from Service Children referred to the service may have: difficulty with producing and using speech sounds; difficulty in understanding and/or using language; difficulties with eating, drinking or swallowing; a stammer; problems with voice production; hearing impairment; any of the above problems associated with a learning and /or physical disability, autistic spectrum disorder or a hearing impairment. Referrals of children where speech and/or language described appears age appropriate and/or in line with other skills. Referrals of selective mutism where there is evidence that speech and language development is age appropriate and/or in line with other skills. Lisps in children younger than 4½ years Referrals of children with a tongue-tie where there is no concern about speech and language difficulties. Referrals of children with general learning difficulties where there is evidence that speech and language skills are in line with general development. Referrals of children with specific literacy problems where there is evidence that verbal communication is normal. Referrals for dribbling where there is no concern about speech and language skills. Re-referral of children within six months of being discharged due to no therapy Expected Response Times: SEPT Management responsible for service required, and presenting with no new/ additional difficulties. Referrals for children whose speech, language and communication needs are being met by other appropriate means for example Independent Speech and Language Therapist. Prioritisation (triage) for intervention is based on the initial referral assessment using a common framework Routine initial appointments are offered within 18 weeks of receipt of referral. Urgent initial assessments (patients with swallowing difficulties) are offered an appointment within 10 working days of receipt of referral. Children subject to an Early Support family plan will be seen within 12 weeks Patients will be seen within 18 weeks from referral. Associate Director Allied Jill Stephen Health Professions Tel: jill.stxxxxx@xxxx.xxx.uk Deputy Director Children s Chris Myers & Specialist Services: Tel: chris.myxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk 253 Children Children s Speech & Language Therapy

128 Early Intervention in Psychosis Service Overview of Service This specialist service works with people aged years old who are experiencing their first episode of psychosis, no matter what the cause of symptoms, whether it is drug induced or related to a bipolar disorder or a primary psychotic illness. This intensive service is available to people with psychosis and their carers for a maximum of three years. Psychosis is a term used to describe conditions that affect the mind, where there has been some loss of contact with reality. Hallucinations, such as hearing voices, delusions (false beliefs), paranoia and disorganised thoughts and speech are some of the symptoms that may be experienced. These symptoms can seem so real that often the person does not realise that they are experiencing psychosis. Psychosis also affects feelings and behaviour. The service also works with people with low level psychotic symptoms such as, odd beliefs, altered sensations particularly in their hearing and vision, a family history of psychosis, fleeting psychotic symptoms and/or changes in their mental state. The Service The service is comprised of a community based multi-disciplinary team which provides assistance and interventions at a time and location that are convenient to the person with psychosis. The team aims to reduce both the duration and severity of acute psychosis and to improve a person s social functioning and assist them in staying or getting back into employment or education. The service offers: advice, information and assessment; an assessment period of up to 3 months; assertive outreach approach youth friendly services, emphasising social recovery; comprehensive package of care for a duration of 2-3 years; cognitive behavioural therapy for hallucinations and delusions; family intervention; help with returning to work or education; hospital admission arranged when necessary; low dose neuroleptic medication; relapse prevention strategies; seeing people in their homes or other non stigmatising settings; support/advice for family, carers and friends. Where Service is based Early Intervention in Psychosis Team Admin Block Twinwoods Health Resource Centre Milton Road Clapham Beds MK41 6AT Tel: Hours of Operation Monday - Friday How to Contact Service Tel: Fax: ei.txxx@xxxx.xxx.uk How to refer into the service & who can refer Referral Criteria Referrals are accepted from: GPs; Health Professionals; Related Professionals such as Social Services, Youth Workers; Self-Referrals; Families & Friends. All our patients must be: aged 14 to 35 years old (inclusive); registered with NHS Bedfordshire GP; suspected of having experienced a first episode of psychosis. 255 Children Early Intervention in Psychosis Service

129 Additional Information to Please contact the service on support referral criteria Tel: where someone can discuss any additional information that would be useful; for example: when and what has raised your concerns. Children For other agencies/professionals a brief referral form is available by contacting the team. Exclusions from Service What Response Times to expect SEPT Management responsible for service Team Manager: Associate Director: There has been treatment for psychotic symptoms greater than 12 months ago. Confirmation of referral within 24 hours Assessment within 14 days from confirmation Mike King Tel: mike.kxxx@xxxx.xxx.uk Paul Rix Tel: paul.rxx@xxxx.xxx.uk Director of Mental Health Declan Jacob Services: Tel: xxxxxx.xxxxx@xxxx.xxx.uk Executive Director of Richard Winter Integrated Services: Tel: richard.wintxx@xxxx.xxx.uk Early Intervention in Psychosis Service 257

130 Looked After Children Service Overview of Service The Looked After Children (LAC) Service aims to ensure the health of looked after children by providing holistic health care from birth to 17 (inclusive) years of age. Providing statutory health assessments, information and a link to health for looked after children and young people, parents, carers and other professionals working with LAC. To co-ordinate and monitor health assessment reviews for children placed in Bedfordshire by Central Bedfordshire and Bedford Borough Councils. To arrange and co-ordinate health assessment reviews for co-shared care children placed out of Bedfordshire. To ensure that looked after children have equality of access to health care. To undertake assessments of non-school children in care homes, or those who have complex needs and or previous history within the service. How to refer into the service Referral Criteria Additional Information to support referral criteria Referrals are accepted from: Central Bedfordshire Council & Bedford Borough Council Social Worker; Looked After Children Nurses for children placed in Bedfordshire by outside Local Authorities. Child or young person is looked after by Bedford Borough and Central Bedfordshire. Child or young person is looked after by another local authority but placed within Bedfordshire. Service only applies to statutory health assessments for children & young people in the care system. Children Where Service is based The LAC Nurse and Team Administrator/ Co-ordinator are based at: Unit 2 - Doolittle Mill Froghall Road Ampthill Bedfordshire MK45 2ND Tel: Hours of Operation Monday - Friday How to Contact Service Tel: There is some flexibility to these hours to suit the needs of the children/young people. Exclusions from Service Pathway for access to statutory health assessments for children and young people in care, to facilitate access to health services provision to meet the individual health needs. Request for statutory health assessments for children in placements in Bedfordshire but placed by outside Local Authorities incur a fee. Service only available to children/young people (0-19) who are looked after. Looked After Children Service 259

131 What Response Times to expect Child/young person within the local authority s area will be seen within four weeks of receiving initial referral Child/young person under an out of area arrangement will be seen within a negotiated/agreed timeframe Telephone requests will be responded to within two working days There may be some prioritisation where requests for immediate health advice or information are required by local authority for reviews or court proceedings Children SEPT Management responsible for service Head of Service Safeguarding Dawn Andrews Safeguarding Children & Tel: Vulnerable dawn.andrexx@xxxx.xxx.uk Looked After Children Service 261

132 Patient Experience Team If you have any concerns or need advice about accessing NHS services, you can speak in confidence to the Patient Experience Team on or you can This leaflet can be produced in large print, audio cassette, Braille and other languages on request. SEPT regards equality and diversity as integral to the way it works. Our staff will ensure that everyone is treated fairly and no one is discriminated against on the basis of their ethnicity, gender, disability, age, sexual orientation and religion or belief. Follow us on Published date: May 2013 Review Date: April 2014