MODULE B – PERFORMANCE REQUIREMENTS – …
MODULE B – PERFORMANCE REQUIREMENTS – SPECIFICATION, QUALITY AND PRODUCTIVITY
SECTION 1 – SPECIFICATION
|Care Pathway/Service |SFHT Fernwood Community Unit Service |
|Commissioner Lead |NHS Newark & Sherwood CCG |
|Provider Lead |Sherwood Forest Hospitals NHS Foundation Trust |
|Period |1st April 2015 - |
|Applicability of Module E (Acute Services | |
|Requirements) | |
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|Purpose |
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|Introduction |
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|This document sets out the service specification for the SFHT Fernwood Community Unit (FCU). It outlines the services the identified provider organisation will be |
|required to deliver. The specification is designed to ensure the rehabilitation needs of service users are effectively met and monitored. It describes the services|
|required of the Service Provider [Sherwood Forest Hospitals NHS Foundation Trust] and makes reference to the role of other parties likely to be involved in the |
|operation of the Service, including: |
|Therapists |
|Referrers e.g. Integrated Care Teams |
|Social workers |
|Voluntary Services |
|CNCS |
|OOH Services |
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|FCU is a 12 bedded rehabilitation ward located at Newark Hospital. It opened on the 4th February 2013. The unit provides single sex bays (2 x 3 beds) and private |
|rooms (6) for anyone aged 18 or above who requires a short period of rehabilitation (up to 3 weeks - in exceptional circumstances this can be extended by the duty |
|admissions coordinator or the MDT). It provides both step up from home and step down from hospital rehabilitation. |
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|The acronym “FCU” will be used to describe beds commissioned by the Newark & Sherwood CCG in SFHT that is supported with therapy inputs, aimed at maximising the |
|person’s independence / capacity to undertake activities of daily living. |
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|Aims |
|Deliver rehabilitation services to people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute inpatient care, long |
|term residential care, or continuing NHS inpatient care |
|Assist and enable the person to achieve and maintain an optimum level of health and independence at home or in another community setting. |
|Enable a full assessment of the person's needs and future care requirements to be carried out in a non-acute environment where the focus is on promoting |
|independence and a return home. |
|Deliver time-limited rehabilitation packages |
|Incorporate cross-professional working, with a single assessment framework, single professional records and shared protocols. |
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|Evidence Base |
|Sherwood Forest Hospitals NHS Foundation Trust Newark Hospital Fernwood Community Unit Review, March 2014, Elizabeth Cowley |
|NHS Mandate, April 2013 – March 2015 |
|The NHS Outcomes Framework. DH London |
|Health and Social Care Act 2012 |
|Carer (Equal Opportunity) Act 2004 |
|Nottinghamshire End of Life Care Pathway for all diagnosis |
|King's Fund's Guidance, Enhancing the Healing Environment for People with Dementia |
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|Scope & Service Delivery |
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|Service Description |
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|The FCU provides inpatient intermediate healthcare. |
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|The FCU is required to: |
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|Deliver a service that: |
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|Actively promotes the independence of all those referred and enables individuals to achieve and maintain an optimum level of health and independence |
|Ensures that service users are cared for in an appropriate setting, with respect to personal privacy, dignity, choice and independence, and are provided with |
|opportunities for rehabilitation and recovery wherever possible |
|Provides an holistic care experience which addresses the physical, psychological, cultural and social needs of service users, their family and informal carers |
|Facilitates the prompt step down from acute care and step up admissions from the community |
|Provides the opportunity for service users to become medically and psychologically stable following an acute episode |
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|Provide a rehabilitation environment with nursing and therapy support available 24 hours per day, 7 days per week. Qualified occupational therapist and |
|physiotherapist will both be available Monday to Friday; 52 weeks a year with therapy cover available Saturday and Sunday. |
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|Provide/identify 1 bed for people who are dependent upon hoisting and have rehabilitation goals. |
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|Start upon the person’s admission and complete within 24 hours of their admission an effective, person-centred multi-disciplinary care plan(s) that provides |
|enabling care and support to assist people who are recovering from an acute episode or period of ill health to regain their confidence, motivation and ability to |
|undertake activities of daily living, and deliver this plan. This can be provided by a therapy on-call service at the weekend 9am – 5pm. |
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|Following the completion of the multi-disciplinary care plan(s) for the person, deliver this plan in accordance with its requirements on a 7 day a week basis. |
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|To support the person to independently manage their own medication. |
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|The multi-disciplinary care plan(s) are evaluated at a daily (Monday to Friday) MDT and progress towards discharge evaluated. |
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|Provide a physical environment that allows for the assessment of the person’s needs for on-going care and therapy and also supports other Community Teams’ |
|involvement, including: |
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|Suitable space in which to hold multi-disciplinary team meetings |
|Adequate and suitable therapy space for the Therapist(s) to deliver the service |
|Provision of WIFI or a hard-wired 3m network compatible internet connection and telephone line |
|and secure space for the operation of a printer and/or fax machine |
|Provision of adequate and suitable space in which to store therapy equipment |
|Adequate and suitable space in which to use equipment, including access to stairs and a |
|kitchen environment with microwave and other kitchen equipment, and suitable bathroom facilities e.g. domestic bath, shower. |
|Ability to arrange the environment to replicate the layout of the person’s home e.g. bed at same |
|height, bed access from the same side, not using bed rails, etc. |
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|Provide a physical environment that is supportive of people with dementia in line with the King's Fund's Guidance on Enhancing the Healing Environment for People |
|with Dementia, and which is designed to: |
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|Ease decision making |
|Reduce agitation and distress |
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|Encourage independence and social interaction |
|Promote safety |
|Enable activities of daily living. |
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|Be accountable for and must ensure that all stored equipment including therapy equipment |
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|Is risk assessed as being appropriate for its agreed purpose |
|Continuously meets health and safety requirements as it is removed from and returned to storage |
|Is regularly maintained and cleaned |
|Is returned to the store when it is no longer needed by a person, e.g. on discharge |
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|Communicate with other members of the MDT and other stakeholders as required, including providing all necessary information to other care providers e.g. social |
|services, PRISM & Integrated Care Teams, Intermediate Care at home, voluntary services, CNCS, person’s GP on the person’s needs and condition to assist in |
|facilitating discharges. |
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|Contact the Social Services immediately if there is any significant change in the person’s condition where a care package is on hold. |
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|Notify the Community Care Teams & person’s GP as soon as possible if a person’s circumstances change, such as their medical condition, social issues or other |
|changes that may impact on their discharge date or destination. |
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|Decision to discharge will be with agreement of the GP/Community Care Team. |
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|Upon discharge provide a discharge summary to include any changes to medication and the person’s current medical & functional status to the relevant Community Care|
|Teams and a discharge summary on SystmOne where possible. |
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|Provide a service that is compliant with the Essential Standards of Quality and Safety. |
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|Referral, Access and Acceptance Criteria |
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|Geographic coverage/boundaries: |
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|The service will be delivered within the boundaries of the NHS Newark and Sherwood Clinical Commissioning Group, to the adult population, registered with a Newark |
|and Sherwood GP practice. |
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|The service will operate within Newark and Sherwood locality with population of 129,558. |
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|Location(s) of Service Delivery: |
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|The Fernwood Community Unit is situated at Newark Hospital and can be accessed through the Main Entrance located to the front of the building. The Fernwood |
|Community Unit is clearly sign posted from the Hospital main corridor. There are 6 single occupancy bedrooms and two 3 bedded bays. |
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|Days/Hours of operation |
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|Sherwood Forest Hospitals step down persons can be discharged to Fernwood 7 days a week with a TTO supply and newly written drug card. |
|Non SFH step down persons can be repatriated 7 days a week 08:00 – 16:00 and will arrive with a TTO supply of medication. The Pharmacy Technician will then |
|transcribe on to a drugs card. |
|Step up persons can be admitted 24 hours a day with a FP10 to accompany persons so that current medications can be transcribed by Pharmacy staff or Out of Hours |
|G.P. |
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|Referral criteria & sources |
|Medically stable for primary care management with no further intended acute secondary care requirements for this episode of care |
|Diagnosis and an outline care plan with parameters for discharge (referring clinician to stipulate the indicative discharge date) |
|18 years and over |
|Person is aware of and in agreement with admission / transfer having understood the reason |
|Ability to engage with a rehabilitation programme or appropriate management plan |
|Dementia persons with management/care plan. |
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|Referral route |
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|Step Down: |
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|Repatriation from acute or sub-acute bed via discussion with designated duty admissions coordinator. |
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|Step Up: |
|MIU- via discussion with GP or delegate |
|Ambulatory clinic following discussion with designated duty admissions coordinator and GP informed |
|GP - on discussion with designated duty admissions coordinator |
|Band 6 Senior Clinicians with appropriate clinical assessment skills with the acknowledgement of the GP/OOH on discussion with designated duty admissions |
|coordinator |
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|Exclusion criteria |
|The service will not be appropriate for the following groups: |
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|People who are not resident within Newark & Sherwood CCG boundaries |
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|People with acute medical needs requiring secondary care |
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|If planned date of discharge is within 48 hours, person cannot be stepped down to the FCU |
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|Step down to the FCU cannot take place if it does not demonstrate a measurable benefit to the person |
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|Step down to the FCU cannot take place if the person does not have clear therapy or management goals |
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|People who do not have the capacity to return home |
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|People whose need for rehabilitation and re-enablement can be managed in their own home |
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|People with capacity that refuse the Service. However, for people for whom there is an on-going concern, e.g. relating to safeguarding, capacity or risk, the |
|Service must follow the Nottinghamshire Safeguarding Adults Procedure. |
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|People who cannot be safely managed within a rehabilitation environment |
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|People who are at latter stages of end of life pathway where there is no rehabilitation / re-enablement potential. |
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|People whose informal carers are unable to manage them being back at home even with a comprehensive package of support because of their own health needs. |
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|People who require a temporary care home placement as a result of carer breakdown e.g. carer being admitted to hospital, or a period of respite to avert carer |
|breakdown. |
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|Response time & detail and prioritisation |
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|For urgent step up admissions, a decision for accepting or declining admission should be made in line with the admission criteria during the referral phone call to|
|the duty admissions coordinator. |
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|Urgent step up admissions should take priority for bed allocation. |
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|For non-urgent step up/step down admissions, a decision for accepting or declining admission should be made within an hour of the referral phone call to the duty |
|admissions coordinator. |
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|Documentation |
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|Fully implement SystmOne across the FCU to ensure integration with the GPs and Community Services to reduce duplication of documentation and assessments and enable|
|sharing of clinical documentation. |
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|Staffing |
|The Service Provider shall ensure: |
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|The provision of regular supervision of, and on-going training for, all staff as required under the |
|National Minimum Training Standards for Healthcare Support Workers and Adult Social Care Workers in England, Nursing & Midwifery Council and the Health & Care |
|Professions Council. |
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|All staff are undertaking mandatory training. |
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|That all staff are working in line with policies and procedures. |
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|The Service Provider shall provide as a minimum: |
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|A designated duty admissions coordinator is identified to coordinate admissions into the FCU and ensure that admissions can occur 24 hours per day, 7 days per |
|week. |
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|There is appropriate skill mix available on every shift, 52 weeks a year. This includes therapy input 7 days per week. |
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|Medical Cover |
|Readmission |
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|Readmissions to the FCU as per admission criteria |
|Readmissions/admission to secondary care - any person requiring secondary care acute intervention. |
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|Medical Cover |
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|Robust GP cover is provided in hours by the five following surgeries: |
|Barnbygate |
|Lombard Street |
|Balderton |
|Sutton on Trent |
|Fountain |
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|Out of hours the staff contact the out of hours (OOH) GP service and any emergency medical requirements trigger a 999 call to EMAS. |
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|Temporary Registration |
|Any person not already registered with one of the listed 5 practices is temporarily registered with one for the duration of their stay. |
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|Discharge Criteria and Planning |
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|Decision to discharge will be with agreement of the GP/Community Care Team. |
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|Notify the Community Care Teams & person’s GP as soon as possible if a person’s circumstances change, such as their medical condition, social issues or other |
|changes that may impact on their discharge date or destination. |
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|Upon discharge provide a discharge summary to include any changes to medication and the person’s current medical & functional status to the relevant Community Care|
|Teams and a discharge summary on SystmOne. |
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|Medicines Management |
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|The safe receipt, storage and custody of medicines on the ward are the responsibility of every Registered Nurse. |
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|All medicines received on the ward must be immediately placed within the appropriate locked cupboard. |
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|All persons should be assessed as to their ability to self-administer medication and if deemed competent should be supported to self-administer medication. |
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|Each bedside locker is provided with an integral lockable drawer for the storage of persons’ medicines. The drawer must be kept locked at all times. Persons who |
|have been assessed as suitable for Self Administration of Medicines may hold a key to the drawer, in accordance with the appropriate policies. |
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|Prevention, Self-Care and Patient and Carer Information |
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|Provide an information leaflet for persons and relatives, ensuring it emphasises the re-enablement focus and is consistently provided prior to transfer/admission |
|to the FCU. |
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|Promotes self-management including referring onto appropriate services e.g. PRISM Plus, FLO Telehealth services. |
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|Acts as a resource for signposting to self-help/patient support groups. |
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|Transport |
|The referrer / referral handling team will be responsible for arranging the person’s transport to the FCU. |
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|The FCU will be responsible for arranging transport for people discharged from these beds. |
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|The FCU will be responsible for making arrangements for people to attend hospital and other essential appointments with an escort as required. |
|Baseline Performance Targets – Quality, Performance & Productivity |
|See Appendix 1 |
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|Currency and Prices |
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|11.1 Currency and Price |
|Issued separately as part of the Sherwood Forest Hospitals NHS Foundation Trust main Contract. |
Appendices
Appendix 1
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