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s n o i t p O

July 2013 | 2nd Edition

A Guide to your Discharge from Hospital

How am I referred to the social work team?

The assessment process

Home Enablement Services

24 hour Care homes



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Contents A Guide to your Discharge from Hospital July 2013 Contents Our hospital team


How am I referred to the social work team?


The assessment process


Continuing NHS Care


Getting the most out of your assessment


More about the assessment


Assessments and carers


Intermediate care


Home Enablement Services


24 hour Care homes


What happens next?


Discharge from Hospital


Problems or queries


Assistive Technology


Other sources of help for when you have left hospital


Rehabilitation into the community Contact Details


Alzheimer’s Society Services in Rotherham


Age UK


Whilst every care has been taken to make sure the information in this publication is up to date it is not intended to be a complete and authoritative statement of the Law on the issues covered. The publishers and the promoters cannot accept responsibility for any loss arising from the use of information contained in this publication. No reproduction by any method whatsoever of any part of this publication is permitted without written consent of the copyright owners. Designed and published by Octagon Design and Marketing Ltd. Š2013. Tel: 01909 478822

Whilst we have taken every care in compiling this booklet, the publishers and promoters cannot accept responsibility for any inaccuracies. The inclusion of any advertisement in no way endorses the services or products sold.


Introduction For most patients, being discharged from hospital to their home is straightforward. Most are unlikely to need the support of Social Services, though some may need some information or advice about social care. However some people have new or ongoing health and social care needs which require a detailed assessment. Staff from Health and Social Services

will usually work together to plan and deliver services to support such people after discharge. This guide explains some of these processes, and explains the role of Adult Social Services in the hospital discharge process.

Our hospital team Adult Social Services in Rotherham have a social work team based in Rotherham General Hospital.

How am I referred to the social work team? Planning for discharge normally begins at the point, or even before, you are admitted to hospital. The discharge process will be coordinated by a member of the nursing team on the ward. Following an initial assessment by nursing and medical staff, you will be referred, with your consent, to the hospital social work team if you appear to have social care needs that require assessment prior to your discharge. 4

This is done by the ward sending a section 2 Notification. (Delayed Discharge Act 2003). You can also give your consent to your carer who can ask for you to be referred to the social work team. If you have any queries or want any general advice you can contact the Adult Services Health and Social Care Information Facilitator on 01709 424650

The assessment process A member of the social work team allocated to your particular ward will contact you. The assessment is not a test, but 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 the ward staff, with you and your family/ carers. This process of information gathering and clarification of the situation will enable the social worker/social services officer to work alongside you to: • identify your needs • establish your eligibility for services (our eligibility criteria is set so we are only able to support people who meet Fair Access to Care level at ‘critical’ or ‘substantial’ level. (For more information please visit )

In Neighbourhood and Adult Services, we aim to do what we can to help people to live independently and safely. We work within resources available to us, and therefore ensure that we prioritise the people who are in greatest need of help. This guide tells you more about assessments and eligibility criteria. It also tells you about what will happen after you have an assessment. This may be relevant to you if you are an older person (65+), have a physical or sensory disability, have mental health problems, or have a learning disability.

• give you information about services that could immediately support you to be discharged from hospital or support you in the longer term. Depending on how complex your care needs are, other specialist assessments may also be required. The referral process and time scales for assessments are outlined in the Delayed Discharge Act 2003. The length of time required to complete the process can vary depending on how complex your needs are. 5

Questions I would like answering:

Whilst we have taken every care in compiling this booklet, the publishers and promoters cannot accept responsibility for any inaccuracies. The inclusion of any advertisement in no way endorses the services or products sold.



To advertise in this publication please call the sales team on 01909 478822 Whilst every care has been taken to make sure the information in this publication is up to date it is not intended to be a complete and authoritative statement of the Law on the issues covered. The publishers and the promoters cannot accept responsibility for any loss arising from the use of information contained in this publication. No reproduction by any method whatsoever of any part of this publication is permitted without written consent of the copyright owners. Designed and published by Octagon Design and Marketing Ltd. Š2013 Britannic Chambers, 8A Carlton Road, Worksop, Nottinghamshire S80 1PH 01909 478822 | |

Continuing NHS Care If you have complex, ongoing health care needs the team involved in your care, must first consider whether you meet the eligibility criteria for Continuing NHS Care. If you are entitled to NHS continuing healthcare the health authority staff will discuss with you how your needs and care will be managed. This can be provided in any setting e.g. your own home, a nursing home or in hospital. If you have met the criteria a comprehensive assessment of all your needs will have been completed by the multi disciplinary team (MDT). This is

the collective name for the different professionals involved in your care i.e. doctor social worker, nurse etc). If you are not eligible to receive NHS continuing health care but still have health needs, then the NHS may pay for part of the package for support, this is called a joint funded package. (For more information please visit Carers may also be entitled to support that would help them in their caring role. If you have an identified carer, this would also be an appropriate time for them to receive a carer's assessment from Social Services.


Getting the most out of your assessment You might want to prepare for your assessment by jotting down anything you want to talk through with us. What is difficult for you? What kind of help are you having at the moment? Are some days much easier than others? If so, why do you think this is?


We know that there are some things which can be difficult or stressful to talk about, but please don't be embarrassed. We will understand your feelings and respect them. If your first language is not English, or if you use sign language, we can arrange for an interpreter. Please let us know what you need.

More about the assessment Once the ward has asked for an assessment, one of our staff will come and visit you on the ward. You can have a friend or relative with you at the assessment, if you wish.

might share some of the information you give us with other people, but only when it is necessary to help to plan your care, on a 'need to know' basis with your consent.

The assessment is free and will involve discussions about;

On the assessment form we write down everything we discussed and agreed with you during the assessment, and also anything we might have disagreed about. You will get a copy of the completed assessment form to keep.

• What difficulties you are having at the moment; • What type of help you feel is needed; • How stressful and urgent you feel your situation is. We look at four main areas of life:

Following the assessment, we will give you information about support that may be available, and any charges involved.

1) How much control you have over your own life, and how easy or difficult you find it to make decisions about the way you live 2) Your health and safety, including any risks to your mental health or wellbeing 3) Your daily routines, such as personal care and domestic chores, and how well you are able to manage them 4) How well you are able to involve yourself in family responsibilities, community life, and work or study. We may want to get information from other people, such as the Ward, Doctor, Therapists and family etc. We 9

Assessments and carers If you have a carer - a relative or friend who provides you with unpaid help - we may want to talk to them about what help they are able and willing to give. Carers may also be entitled to support which helps them in their caring role. If

you have an identified carer, this would also be an appropriate time for them to receive a carer's assessment from Adult Services. Please ask us for more information on this.

Intermediate care Intermediate Care is the name for support to help you build back your skills and enable you to live at home as independently as possible. In some cases hospital staff may recommend a period of rehabilitation in order


to maximise your independence. A member of the Therapy Team would assess you for this. An intermediate care service may be provided by community health and social care services to support you during this period.

Home Enablement Services You may be assessed as benefitting from Home Enablement Services for your return home. The Home Enablement Service provides re-enablement for adults aged 18 years and over within their own homes.

If you require continued support after this period you will be assessed under Fair Access to Care Services criteria and a financial assessment would be undertaken as there may be a charge for any ongoing services.

The service is for people who require support at home so that they are able to achieve optimum levels of independence and therefore remain safely at home. It will help you regain your confidence and your ability to do things for yourself after your spell of illness or your recent accident. The service is available for people for up to six weeks and can be extended to up to 8 weeks in exceptional circumstances. The service is free of charge for a period of up to six weeks. The Home Enablement Service is designed to encourage and support you over the weeks to enable you to gradually carry out your personal care needs and tasks around the home on your own without any or little help.


24 hour Care homes If it is felt that you can no longer manage at home even with support, the decision may be for you to move to a care home. You and your family will be involved in this decision. The assessment will identify your care needs. This will help you and your family to select a registered care home which will be able to meet your needs. There are 3 categories of care homes. • Residential care – provides accommodation meals care and support throughout the day and night. • Nursing care – offers the same as residential care with the addition of 24 hour care by a qualified nurse.


• Dementia care or EMI (Elderly Mentally Ill) care – which provide specialist extra care for people often due to dementia or other mental health diagnosis. You and your family have the right to choose the care home you will move to. During the care planning process you should be supported to identify a suitable care home which is registered to meet your needs and has a vacancy. Your social worker/social services officer can help you with this process. However if the home of your choice has no vacancy, you may have to accept a place in an alternative care home until a place in your home of choice is available.

What happens next? Once you are declared medically fit for discharge by the medical team and all the appropriate assessments have been completed, Adult Services will be

formally notified by the ward by sending a Section 5 Notification (Delayed Discharge Act 2003) to the hospital social work team.

Discharge from Hospital Once all assessments are completed the social work staff will discuss with you what help may be available and decide with you how your care needs can best be met. Your discharge should take place in a timely fashion. We will endeavour to

give you a copy of your individual social care assessment and support plan before leaving hospital. If this is not possible we will give you a discharge letter giving you an overview of your planned care and your individual social care assessment will follow in the post.

Problems or queries If you have queries or are experiencing difficulties relating to your discharge you can either contact your social worker/ social services officer or speak to the nurse caring for you on the ward. If a social worker has not been allocated to you, you can contact the hospital social work team to speak to a Health and Social Care Information Facilitator who will assist to resolve any problems or issues which are the responsibility of Social Services.

The hospital social work team have a member of staff whose role involves supporting the black minority ethnic communities with their social care needs during the hospital discharge process. Contact number 01709 424650

They can also give further information and contact details you may find helpful. Tel 01709 304650 13

Assistive Technology

Helping you to connect to the support you need Connect to your support online – People needing help and support in Rotherham are now just a click away from finding out what services are available. Connect to Support is a website where the general public, service users, carers and social work staff can view and purchase goods, products and care/ support services from providers; seek information, guidance or advice and be signposted to appropriate services including community groups. The website is in addition to the usual guidance and access to services that people have through other work such as assessments and care planning. Care and service providers have the chance to have their services on the website and accreditation of providers will be included through ratings such as CQC inspection ratings, specialist businesses sector quality marks for organisations and customer feedback. Local groups providing services that are free of charge, can also use the site to promote themselves. As with the information currently supplied to people, the Council cannot recommend specific providers but does offer information and guidance on the services available. For more information visit or email


Assistive technology is equipment or sensors which are specifically designed to help reduce the risks associated with independent living for vulnerable people. Some of these sensors are placed around the home and can detect environmental issues e.g. fires, floods others are used to detect a fall or when someone has left the property at an in-appropriate time of the day e.g. during the night. Some of the equipment works with the Rothercare community alarm system. Rothercare is the Council's community alarm service which provides an emergency call handling service and mobile response service 24 hours a day 365 days per year. Environmental package These four sensors generate an alert to Rothercare when the following are detected: • Smoke • Carbon Monoxide • High temperature or low temperatures • Water (floods)

Falls Package This package consists of a fall detector which is worn on the waist, this generates an alert when the person falls anywhere in the home or garden during the daytime. A bed sensor can be provided, which is used during the night time. If the person gets out of bed during the night and does not return within a predetermined time it generates an alert which may indicate the person has had a fall.

– What is it ? Purposeful walking package A voice announcer plays a message to try to deter the person from leaving the property at inappropriate times of the day e.g. during the night time. If the person does exit the property an alert is generated to either Rothercare or a carer’s pager. This does require a family/carer responder. It is very useful for people with Dementia. Carers package This package consists of a portable pager and possibly a vibrating pillow alerter, it informs an on site carer when a telecare alert is generated e.g. fall detector. Can also be used to alert a person with a hearing impairment of a telecare alert e.g. smoke alarm.

emergency services to gain entry to the property in response to an alert or emergency. Automated medication dispenser Once the medication dispenser is programmed it will automatically dispense medication at the correct time of day, it provides an audible and visual alert to encourage the user to take their medication which is dispensed into the open compartment. The alert will continue intermittently until the medication is taken. Orientation clock The orientation clock assists the user to orientate the day of the week and whether it is day or night. It can greatly reduce anxiety for user and family/carers and is particularly effective for users suffering the effects of Dementia or memory loss.

Gas detector This plug in gas detector will generate an alert to Rothercare if natural gas is detected. It can also be linked to a complete gas shut off solution Heat detector The heat detector is specifically for use in the kitchen as an extra fire safety detection device. It is ideal for people that are at extra risk in the kitchen e.g. leaving gas ring switched on. We can offer five items without the need for a social care assessment. Magi plug – this is a simple devise to prevent bath/sink from overflowing using a pressure activated valve. It also indicates when the water is at a safe temperature to use Keysafe – this can be provided for an individual who has formal or informal carers needing to access the property or if the user has Rothercare alarm system to enable Rothercare assistants or

Big Picture telephone This telephone has compartments where users can insert photographs of key people e.g. family members; once the telephone is programmed, the user would then press the picture of the person they wish to contact. This enables the user to make contact without worrying about remembering telephone numbers, thus reducing anxiety and risk by ensuring they can make contact with key people. This telephone is also amplified. How can I get this equipment? If you have a social work assessment as part of your discharge the allocated social worker or social services officer will be happy to discuss and consider any appropriate assistive technology as part of the assessment. Once you have left the hospital please contact Assessment direct on Tel: 822330 or e-mail who are able to discuss and action your request.


Other sources of help for when you have left hospital Assessment Direct 01709 822330 – search for Help at home If you think that you may need help from the Council you can ask for advice or a care assessment by contacting Assessment Direct. To make things easier for you we have set up a first point of contact for all our services called Assessment Direct. You can speak to an Officer who will listen to your enquiry, advise and assist you, and make sure you receive an assessment if required. We can help you with: • Social care assessments • Carer's assessments • Safeguarding vulnerable adults • Disabled person parking permits (Blue Badge) • Adaptations within your home • Community alarm scheme - Rothercare • Occupational therapy assessments • Any other aspect of your social care • Assistive technology Age UK – Rotherham 01709 835214 or 01709 786958 Age UK are an independent charity whose objectives are to make the lives of older people in Rotherham as fulfilling and rewarding as possible. Age UK can help you with a variety of 16

day opportunities that are fun and offer companionship when used as part of a care plan can help older people remain healthy and well. Access to community information about housing, benefits, products and services (home insurance, motor insurance etc) Carers Centre – 01709 254809 Caring for someone is not always easy which is why the Council and its partners have all come together at 'Carers Corner' to provide you with all the support you need under one roof. At Carers Corner you can get face to face advice - such as how to access benefits or legal advice, along with how to access the Carers Emergency Scheme and Carers Assessments. Advice and guidance is also available through the Ask My Community Website. Community Occupational Therapist Service – 01709 822330 The Community Occupational Therapy Team helps anyone who is elderly or disabled and is having problems with activities of daily living. You can refer yourself for help, or someone else can contact us on your behalf. All contacts to the Community Occupational Therapy Service are taken by Rothercare Direct. They may be able to respond to your problem at the point of contact or

they may pass your request to another agency, such as the Home Improvement Agency. If they are unable to do this, your request will be passed to the Community Occupational Therapy Team. Physiotherapist Service – Badsley Moor Lane – 01709 422323 We offer a range of treatments including manual therapy, electrotherapy, acupuncture, hydrotherapy, education and self-help programmes, active rehabilitation and chronic pain management. department.aspx?id=198

Rehabilitation into the community Contact Details: Rotherham Intermediate Care Centre (RICC) – 01709 514003 The Rotherham Intermediate Care Centre, located on Badsley Moor Lane, is a joint partnership between Rotherham Council and Rotherham Foundation Trust. The centre is set to provide new rehabilitation facilities within a day setting for the people of Rotherham. The new centre will work as an intermediate care hub, bringing together therapists, specialist mental health

workers and support workers who are providing services to promote and maximise independence following a patient's recent episode in hospital, change in functional abilities or a worsening of their long-term condition. The new service will provide activities which are tailor-made to a patient's own interests and abilities. You can also view this booklet on the RMBC internet site www.rotherham. where updates may be added. This booklet was written by Rachael Crehan


Alzheimer’s Society Services in Rotherham If you think you may have a form of dementia, or are caring for a person who has dementia, there are many ways that Alzheimer’s Society in Rotherham can help. Someone to talk to You can phone at any time during our opening hours to talk in confidence with a member of our Dementia Support Team. Our team are here to listen when you just feel the need to talk, or to offer advice on specific issues. Support from Dementia Support Workers Our Dementia Support Workers can offer advice on accessing professional help. We are in touch with a wide range of services and other advice centres throughout Rotherham, so we can put you in touch with specialists who can help you if your concerns are outside of our expertise. We can also refer you, or the person you care for, to services provided for people with dementia


in Rotherham, particularly if you are having trouble accessing these yourself. Home Visits We can also arrange for a Dementia Support Worker to visit you at home and provide information, advice and support. Information We also have a wide range of information and advice sheets which include specific information on different types of dementia, care issues and understanding the needs of the person with dementia. Singing for the Brain An innovative project providing structured musical stimulation for people with dementia and their carers. Singing is an enjoyable activity and provides a way for people with dementia to express themselves and socialise with others in a fun, supportive group. Groups run once a month. Memory Café Anyone who has dementia or is caring for a person with dementia is welcome to attend the monthly Cafés. Each Café is staffed by Alzheimer’s Society workers and volunteers. Staff from partnership agencies including Social Workers, Community Psychiatric Nurses and Occupational Therapists are invited to attend the groups. Please contact us for more information including dates and times. Carer’s Education Group Our Carer’s Education Group is a series of four workshops for carers of people with dementia. This programme is for anyone caring for a person with a diagnosis of dementia and aims to offer structured information to inform and support the caring role. Carers do not necessarily have to live with the person with dementia. Fundraising As a charity we rely heavily on donations to maintain our levels of service. If you would like to help and are able to make a donation of any amount please contact us at the Mexborough office. All donations will be gratefully received. What should I do now? For information, advice and support, please call us on 01709 580543. We are open from 9am to 5pm, Monday to Friday Alternatively you could visit us at: Alzheimer’s Society Doncaster and Rotherham, Room F9, Mexborough Business Centre, College Road, Mexborough S64 9JP Membership All members of Alzheimer’s Society receive a monthly national magazine. The more members we have, the greater our lobbying power. Membership is free to carers and people with dementia. Email: doncaster@alzheimers.

DEMENTIA FRIENDS PROGRAMME Dementia Friends is a national initiative that is being run by the Alzheimer’s Society. It's funded by the government, and aims to improve people's understanding of dementia and its effects. Through the Dementia Friends programme, we aim to change the way the nation thinks, talks and acts. By 2015, we want a million Dementia Friends who have knowledge and confidence to help people with dementia feel understood and included in their community. Because, together, we can create dementia friendly communities. How will it work? We will train and develop a group of volunteers to spread the word about what dementia is and what action individuals can take in their community. We will then ask them to recruit Dementia Friends who will then receive a basic information session on dementia and be encouraged to take action. What is a Dementia Friend? A Dementia Friend learns a little bit more about what it is like to live with dementia during a Dementia Friends Information Session and then turns that understanding into action. What is a Dementia Friends Champion? Dementia Friends Champions are volunteers who run information sessions where they talk to people about being a Dementia Friend in their communities. It's easy to get involved. Dementia Friends Champions will attend a training course, receive support as and when they need it and be part of a growing network of people creating dementia friendly communities together. How can I get involved? It's easy to get involved. Just visit and book onto a Dementia Friends Information session. Alternatively, you can contact your local Alzheimer’s Society office for more information. 19

Age UK Rotherham Services Age UK Rotherham became the new name for Age Concern Rotherham in April 2011. We have been working with and campaigning for older people since 1974. We are an independent charity, whose objectives are to help older people who live in Rotherham to maintain their independence, health and well being by providing services that meet individual needs. We recognise that you want a choice in how you are supported, to continue to remain independent in your own home. The following services are designed to offer you support when and where needed to keep your independence. Services to support independence We currently offer a range of health and wellbeing services, which include: St Anns Social Centre The centre aims to help you feel less socially isolated and to keep you active by providing you with an opportunity to meet friends and participate in various activities like: Crafts, gentle exercise, guest speakers, outings, toe nail cutting, massage There is a choice of lunchtime menu that will be cooked fresh on site. Independence At Home Our services offer a comprehensive range of support so that you can be happier in your own home, stay safe and remain independent. We have over 20 years experience of providing a trusted service to older people in Rotherham. The team are trained, caring and fully vetted for your safety. Our services include: 20

Domestic help – Cleaning, laundry, shopping, prescription collecting etc Handypersons – Minor household repairs, home safety and security, plumbing repairs Gardening – All year round garden maintenance, fence/gate repairs and general garden tidying Independent Living Support – Support packages can include : Assisted bathing, meal preparation, hair washing The above services are chargeable Advice & Information Services – This is a free service We can offer drop in sessions or home visits to provide you with advice on a range of issues including: Benefits, housing, community care and general health and welfare. We can also provide: • Help to complete forms and make applications • Advocacy support to help you with complex issues Trading – This is a free service A wide range of products and services have been designed for people in later life these include: Home insurance, car insurance, motor breakdown, travel insurance, gas and electricity, funeral plan, will writing. Age UK Rotherham is an appointed representative of Age UK Enterprises Ltd which is authorised and regulated by the Financial Services Authority for insurance mediation. For any further information on these services please contact 01709 835214


Helping and supporting you at difficult times Hospital Aftercare Service – This is a free service

to get home quicker.

Age UK Rotherham has been running a support service for older people being discharged from hospital since 1996. The team will support you on discharge from hospital by offering you:

If you feel you are lonely and isolated we can provide you with a fully trained and police checked volunteer to visit you at home. The service will provide companionship, or give you confidence to join back in local activities.

Non clinical assessment – This is an holistic assessment of your own individual needs supporting you to regain your independence and confidence following your hospital stay Provide a short term package – We have trained enablers that can visit you for up to 30 days to assist you to remain independent and offer reassurance and support with your daily living activities including: assistance with meal preparation, shopping, cleaning, mobility issues etc

Befriending Services

We can also provide you with a link line telephone support call, which provides a reassuring call to you each morning or when requested. This can be on a permanent or temporary basis if your carer is away. For any further information on these service please contact 01709 786958

Signposting – We will give you information or refer to other services that may help and support you now that you are back home, and ensure you are getting the correct benefits you are entitled to Transport – We can take you home from hospital providing you are mobile and able to get into a car and need help to settle back home after your hospital stay which would mean you would get home sooner and not be waiting for other forms of transport Hospital medication – We can return to the hospital to collect your medication from the pharmacy, this will enable you 21


• Home care • Support services • Support planning • 0114 281 2946

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Have you considered care at home as a cost effective alternative to a nursing or residential home? Our care at home service has many benefits: •Allows you to remain living in your own home •Allows you to continue living your chosen lifestyle •Comparable cost to care homes •One-to-one support,provides greater flexibility and personalised care •Available on a short or long term basis and at short notice

We are here to support the life you want to lead. Please call our friendly team on 01132 180 119 to discuss your specific details.

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• Warm & friendly welcome • En-suite rooms available • Comprehensive social and activity programme We aim to provide a home from home environment that gives peace of mind, security, support and stimulation.

Tel: 01709 367337 Whiston Hall, Chaff Lane, Whiston, Rotherham

Dr Anderson Lodge Dr Anderson Lodge is:

A Care Home with Nursing (Nursing Home) with 60 registered places.

• Older People (Over 65) - 29 Residential & Nursing places Care for elderly frail people who need help with day to day living and also have medical problems which require the attention of trained nursing staff.

• Dementia (Over 65) - 11 Residential places - 20 Nursing places

Care for older people with dementia, including Alzheimer’s disease, who need a secure environment and also have medical problems which require the attention of trained nursing staff. Care for the Elderly Mentally Ill (EMI).

East Lane, Stainforth, Doncaster, South Yorkshire DN7 5DY

Telephone: 01302 350003

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Options Rotherham - A guide to your discharge from hospital