Your Hospital Team

A member of the Multi – disciplinary team including your Hospital Case Manager, Consultant team, Matron and ward nurses, Occupational Therapists, Physiotherapists and Social Workers will begin to process your transfer from hospital as soon as you are admitted. This team of clinical experts will explain their key roles to you if they are involved in your hospital care.

The assessment process

Your assessment begins as you are admitted to the ward area and is a way of working out what your needs are and which ones might be putting you at risk.

The assessment process will start with discussions with your Hospital Case Manager, with you and your family / carers. This process of information gathering and clarification of the situation will indicate which members of the multi disciplinary team need to be involved in your assessment. Your Hospital Case Manager will work alongside you to:

• Identify your needs

During your hospital stay we have a dementia practitioner who is available to provide support for patient’s relatives and carers.

• Establish which members of the Multi disciplinary team may need to be involved in your care and assessment

• Provide you with information about services that could support you as you are discharged from hospital

Therapies

You may be referred to a therapist to assist in planning for your discharge from hospital.

This could be someone from a number of different professions; a dietician, occupational therapist , physiotherapist or a speech and language therapist. They will discuss with you and assess what you are able to do; and what you might need more help with. They will then discuss with you what treatment, help or support is available to improve your independence. The therapists will discuss with the other members of the hospital team their findings and together with you and your family make a plan for your discharge from hospital.

Dementia practitioner

During your hospital stay we have a dementia practitioner who is available to provide support for patient’s relatives and carers.

Dementia patients will receive a ‘This Is Me’ document in order to deliver specific care needs along with the opportunity to take part in bedside activities. Every dementia patient admitted to the hospitals or their carers will also receive information as to relevant advice in order to support them following their hospital stay.

Shaun Lever – Dementia Practitioner, Royal Liverpool and Broadgreen University Hospitals 0151 7062000 bleep 5111; 0151 7064727

Intermediate Care

Here in Liverpool, intermediate care can support people as they are discharged from the acute hospital who are not quite ready, and if they meet the criteria, to return home.

This period of intermediate care can provide rehabilitation from therapy staff or a period of reablement prior to returning home. Your hospital team will work with you to assess your level of need and which intermediate care service which would suit your needs should you require it.

The aim is to help you to relearn daily living skills so you do not need long-term support or go back into hospital.

All patients who no longer need acute care but cannot return home and do not require specialist care are eligible for intermediate care if they meet the following criteria:

• Over the age of 18

• Resident of Liverpool or

• Registered with a Liverpool GP Intermediate care is provided under Health and Social Care joint Commissioning arrangements and is free of charge whilst you are on the intermediate care pathway.

People may be eligible for intermediate care following an episode of acute care for a further short period of recovery and or reablement. This can benefit patients and enables a more accurate assessment of your ongoing care needs prior to returning home or before long term care is considered.

Aiming to get you home

The aim is to help you to relearn daily living skills so you do not need long-term support or go back into hospital.

You need to know what you want to achieve and how this will be done in hospital to establish your reasons for going into Intermediate Care through your multi disciplinary team assessment. First route out of hospital should always be your own home. If this is not possible, then the Intermediate Care aims to get you home and to eliminate dependency on long term support.

Liverpool City Council provides a model of health and social care support through community bed based centres. The model creates a circle of health and social care support for adults.

The Model of care:

Each facility supports intensive short-term community bed based services under the umbrella of re-ablement services.

Re-ablement services help to ensure people receive the right level of support at the right time.

We aim to support patients as they are discharged from hospital to reduce the length of time you stay in hospital and can offer a more realistic assessment of your future support needs.

The Multi-disciplinary team consists of temporary registered ICRAS GP, Advanced Clinical Practitioners, Nurses, Social Worker, Therapists, General Practitioner, Access coordinator (social care) and appropriate attendees related to your care programme.

Sedgemoor (30 beds)

41 Sedgemoor Road, Norris Green, Liverpool L11 3BR. Tel: 0151 256 1810

During your stay, you may move from one part of our service to another depending upon your assessed needs.

• Provides a service to support hospital discharges, admissions and respite specialising in care and support for people with dementia. A new purpose built integral day facility has been attached to the main building and is fully operational. The new build provides carer support, drop-in facilities, café, day support, community outreach work, advocacy, crisis intervention, health and well being advice and support.

Townsend (25 beds)

106 Townsend Lane, Liverpool L6 0AY Tel: 0151 263 2888

• Provides a service to support hospital discharges and admissions for people who have had a stroke. Service delivery is supported by the acute trust through Physiotherapist, Occupational Therapists, Speech and Language specialists and a range of social and health support services for individuals and their carers. An integral day facility has been commissioned and this will provide a unique opportunity to support people who have poor or limited mobility, are prone to falls.

Granby (30 beds)

50 Selbourne Street, Liverpool L8 1YQ Tel: 0151 233 8631

• Is a specialist intermediate care unit, designed specifically to help you regain mobility and confidence, in order to live independently again. Once admitted to Granby, you will be assessed by a qualified team of a Physiotherapist, Occupational Therapist and Social Worker, who will develop an individual therapy programme specifically to meet your needs. This may involve staff working with you on a daily basis to complete exercises to improve your mobility and to ensure that all support you may need is in place.

Intermediate Care bed based services provide assessment, care and treatment for you and discuss with you and your family or carer what care and support you need. During your stay, you may move from one part of our service to another depending upon your assessed needs. This may include transfer to a stepdown bed in a care home, there is no charge unless family can support until POC can be arranged.

During your admission you will be assessed by our therapy team who will discuss any treatment plans, goals and frequency of interventions with you. Therapy treatment may be delivered on the ward or in the gym and will consist of chair based exercises, walking practice and functional activities, treatments will be carried out by a member of the multi disciplinary team where it is deemed appropriate to do so. It may be necessary to carry out a home assessment prior to your discharge and if so we will ask you to provide access to your home and ensure that you have appropriate outdoor clothing for the assessment.

If the Multi disciplinary team deems that you are medically fit for discharge but you are not ready for discharge home, you may move to another part of the service dependent upon your assessed needs. This may include transfer to a stepdown bed in a care home. If required you will be assessed by a Social Worker or community care assessor to find out if you require ongoing support at home.

Intermediate care at home: ICRAS

ICRAS is a multidisciplinary team of Health and Social Care professionals including Nurses, Occupational Therapists, Physiotherapists, Podiatrists, Social Workers, Support Workers, GP, ACP and Pharmacists.

ICRAS support in health and social care crisis and have skills where they can often support you at home instead of a hospital admission when you are unwell. The rehab and reablement elements of the service aim to enable people to recover from recent loss of function, due to an illness, or fall, for example. Therapists work in partnership with the local authority to develop a plan of care and rehab to enable people to regain their independence.

ICRAS tends to provide lots of support in the beginning and gradually reduces this support as people become more independent, but identifies that some people will need that care and support for the long term, and arranges that for them.

If you are assessed as requiring support from ICRAS you will be referred by a health or social care professional in the hospital.

Contact details

For more information please contact ICRAS. Tel: 0300 323 0240

“I had to make the hardest decision to look for a care home for my mother, after an extensive and exhaustive search and visits, I chose Damfield Gardens and boywhat a home! The staff and manager are lovely, they can’t do enough for my mum and me. They’ve made me feel happy and that my mum is safe and verywell looked after. I thoroughly recommend this home.” Rachel (daughter of resident) March 2020

Set in 10 acres of picturesque parkland, Damfield Gardens is a 67 bed residential care home which provides both residential and dementia care over three floors, offering luxury living and incorporating the highest standards of care with exceptional design and the latest innovations.

Being a family business, Highpoint Care whole-heartedly understands and empathises with the difficult decisions families have to make when considering care for their loved ones and we make it our absolute priority to ensure each of our residents receive quality care tailored to you.

It is because of this priority that Highpoint Care offers all our residents purpose built homes, which boast luxurious and homely settings, as well as offer a fresh environment with high-quality furnishings throughout, all of which are surrounded by stunning landscape scenery which residents can explore.

Everything we do is centred around providing the very best and highest standards of care tailored to each resident’s individual needs. Where needed we also offer additional support via our fully integrated primary care partners for those suffering with a range of mental, physical and degenerative illnesses such as Dementia and Alzheimer’s.