Supporting the NHS

Bexley’s Adult Social Care team works in partnership with local hospitals and other health and community partners to provide practical support to minimise the number of people who have to be readmitted to hospital.

One man who lives in Bexley was discharged home with carers who came in daily to ensure he was looked after. Before his discharge the hospital team, made up of nurses, doctors and adult social care staff from the Council, established that the man’s son was staying with him and would be able to help carers. However, he was diagnosed with Covid just before his father was discharged and had to move out. Adult Social Care arranged for an occupational therapist to urgently visit the man to reassess his needs. The equipment that he needed, including a hoist, pressure relieving mattress, hospital bed and sliding sheets, were delivered within two hours to his home, with the result that he didn’t have to be readmitted to hospital.

One young woman aged 44, who has multiple sclerosis (MS), declined offers of care despite repeatedly being admitted to hospital due to injuries caused by falls. Bexley’s Neuro Rehab team got involved and discussed the needs of the young woman within their team, with the GP, an MS nurse and Adult Social Care. Arrangements were made for Adult Social Care and the GP to visit her to discuss everyone’s concerns and to address any issues that she had. This meant that she received one home visit, rather than several from different teams. The woman’s physical and mental health were considered and a robust care plan was put in place with her agreement, that enabled her to remain safely at home.

“Across the borough, teams in both health services and Adult Social Care are working together to understand people’s needs and then bringing together services to help them live the lives they want to lead. In doing this they are supporting our under-pressure NHS by preventing unnecessary readmissions to local hospitals.”