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Discharge Policy / Version 12 / October 2017

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Burton Hospitals

NHS Foundation Trust

DISCHARGE POLICY

Approved by: Trust Executive Committee

On: 24 October 2017

Review Date: October 2020

Corporate / Directorate Corporate

Clinical / Non Clinical Clinical

Department Responsible for Review:

Capacity Management Team in conjunction with Senior nursing teams and partner organisations

Distribution:

Essential Reading for:

Information for:

All staff Burton Hospitals NHS Foundation Trust

All wards and Departments, Discharge teams, SSOTP and relevant partners

All staff involved in the process of patient discharge/transfer On Call Managers and Executives

Policy Number: Version Number:

36 13

Signature: Date:

Chief Executive 24 October 2017


Burton Hospitals NHS Foundation Trust

POLICY INDEX SHEET

Title:

Discharge Policy

Original Issue Date:

November 2010

Date of Last Review:

May 2015

Reason for amendment:

Internal Audit review of Discharge Policy

Responsibility:

Head of Capacity

Stored:

Intranet

Linked Trust Policies:

Major Incident Policy Adult Protection Policy Policy framework for Safeguarding Children Medicines Management Policy Frailty Policy Escalation Policy Transfer Policy

E & D Impact assessed:

EIA 149

Responsible Committee / Group

None

Consulted:

Divisional Directors Matrons Divisional Nurse Directors Trust Executive Committee Head of Therapy Chief Pharmacist Head of Capacity Discharge Team


REVIEW AND AMENDMENT LOG

Version

Type of change

Date

Description of Change

6

15/09/11 To reflect changes to the Governance structure

7

Internal Audit review of Discharge Policy

18/10/12 To reflect the findings of the Internal Audit review of the policy

8

Internal Audit review 12/07/13 To reflect the changes in the monitoring structure and discharge process

9 Transfer of care policy added

28/11/13 To reflect the changes to the updated transfer of care protocol

10 Planned review of Discharge Policy

12/12/14 Reflection in changes in structure and process related to complex discharges

11 Review of policy to reflect legislative changes

15/05/15 To reflect the implementation of the Care Act from 1st April 2015

12

Review and update 12/10/17 Review and update


DISCHARGE POLICY

CONTENTS PAGE

Paragraph Number

Subject Page

Number

1 Statement of Intent 1

2 The Scope of The Policy 1

3 Underpinning Principles 2 - 3

4 Responsibilities of Key Staff 4 - 11

5 Nurse Initiated Discharge 12 - 14

6 Discharge of Vulnerable Adults From Wards 14

7 Transfer To Other Care Providers 15

8 Maternity Discharge/Transfer 15

9 Neonatal Unit Discharge/Transfer Protocol 19 - 22

10 Paediatric Unit Discharge/Transfer Protocol 22 - 28

11 Self-Discharge 29

12 Implementation of the Policy 30

13 Monitoring Effectiveness 30

Appendix 1 Confirmation of assessment for transfer of care 32

Appendix 2 Discharge Flow Chart 33

Appendix 3 Checklist for Patients Discharged from Hospital with a Medical Device 34

Appendix 4 Self-discharge documentation 35

Appendix 5 Risk assessments 36

Appendix 6 Monitoring matrix 37

Appendix 7 Transfer of Care Protocol 38


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BURTON HOSPITALS NHS FOUNDATION TRUST

DISCHARGE POLICY

1. STATEMENT OF INTENT

To provide a framework for Trust staff to facilitate appropriate and safe discharge of

patients from hospital to home or alternative care facilities to achieve the following: Objectives:

Avoidance of delays in discharge or transfer of medically stable patients not requiring acute care

Reduce length of stay for patients across the Trust

To reduce the risk of re-admission following inappropriate discharge

To reduce delays in discharge and support optimal bed management

To ensure timely access for elective and emergency admissions

To ensure pro-active discharge planning at the earliest opportunity resulting in safe and appropriate discharge of patients

To involve the patient and family on the planning and implementation of discharge plans, taking into account the specific needs of the patient

Establish and maintain effective communication with patients, relatives and partner organisations

To work within the Safeguarding Children and Vulnerable Adult Policies and Guidance

To ensure patients with a known diagnosis of dementia do not spend longer in hospital and ensure carers’ needs are addressed during the discharge planning process. Information regarding support and discharge (written in plain English or other appropriate language) should be made available to patients and their relatives on admission. To work within the Dementia Strategy guidelines.

Monitor the effectiveness of the discharge process, taking action to address shortfalls as required

To transfer patients into Community Hospital beds once deemed medically fit if ongoing rehabilitation care is needed

To work in partnership with outside agencies i.e. Social Services/Virgin healthcare to ensure timely and effective discharge

2. THE SCOPE OF THE POLICY

For all staff employed by the Trust involved in the process of discharging / transferring patients. This Policy builds on the existing collaborations and joint protocols between all partner agencies such as Social Services and local Clinical Commissioning Groups (CCGs).


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3. UNDERPINNING PRINCIPLES 3.1 Principles in this Policy are underpinned by the Discharge From Hospital Pathway

Process and Practice DOH 2003, The NHS Continuing Healthcare (Responsibilities), Directions 2012, NHS-funded Nursing Care Practice Guide (revised) 2012, The National Health Service (Nursing Care in Residential Accommodation) Directions (England) 2009 and The National Dementia Audit (2009) Standard 3.1 Discharge policy. Ready to go – Ten steps to discharge DOH 2010, Care Act 2014

3.2 Avoidance of delays in discharge must be a priority for all staff. As soon as the

acute phase of care is completed, medically stable and functionally optimised patients, including those whose period of rehabilitation is completed, or can be provided elsewhere, should be discharged from acute hospital beds in a timely and safe manner to their interim/other or final destination. Discharges take place across a 24 period and the same principles and processes apply at all times. (see appendix 1)

3.3 If a transfer of care cannot be achieved for whatever reason the patient will be

offered a placement in an interim setting which the Multi-Disciplinary Team deem appropriate to meet the needs of the patient from the time of discharge until the permanent destination is ready. Consideration however must be given to vulnerable adults including patients with dementia as an interim setting may be detrimental to their recovery and safety.

3.4 The patient, family and carers will be made aware of the Discharge Plan from

admission. The Multi-Disciplinary Team will ensure that good communication and involvement is maintained throughout the process with all stakeholders and a discharge plan agreed. In the interests of patients with dementia, they should only be moved for reasons pertaining to their care and treatment. Any move should take place during the day and relatives and carers should be kept informed of any move and given adequate notice.

3.5 Involving appropriate agencies, for example interpreting and advocacy services, is

an integral part of the discharge process and will be facilitated through the nurse responsible for the discharge.

3.6 Registered nurses are responsible for the assessing, planning and implementation

of the uncomplicated discharge of patients not requiring the involvement of multi-agency services. The nurse will also be responsible for initiating referral to other professionals.

3.6.1 All patients will be assessed for potential discharge needs prior to elective

surgery either at pre-admission clinics or on admission.

3.6.2 All emergency admissions will have an assessment started within 24 hours.

3.6.3 All assessments will be reviewed daily and updated as deemed necessary.


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3.7 The Trust Discharge Liaison Nurses will co-ordinate with the Community Liaison Nurses to facilitate the timely transfer of care for patients with complex nursing care, such as those that have high level needs and warrant an Emergency care plan for the community, this is done with input gained from the MDT. The Discharge Liaison Nurses are able to support and advise all hospital staff involved in the discharge of patients on all aspects of the discharge process.

3.8 Procedures relating to Safeguarding children or the protection of vulnerable

adults will be followed. If a patient has been referred for assessment within the terms of these policies, procedures for the protection of the patient will take precedence over the Policy Framework for Safeguarding Children. All staff should refer to the Adult Protection Policy and the Policy Framework for Safeguarding Children for detailed information. Further support and advice is available from the Matrons for Adult and Child Safeguarding or Social Services upon request.

3.9 Local multidisciplinary speciality guidelines for Gynaecology, Obstetrics, Day

Case Surgery, Palliative Care Discharge Pathway and Emergency Department (ED) will be adhered to in conjunction with this Discharge Policy.

3.10 Staff caring for patients who request to self-discharge against advice, and are not

required to be detained under the Mental Health Act and are deemed as having capacity, should refer to the relevant guidance and inform the appropriate Matron/Duty Sister for further support if required. A discharge letter must be sent to the patients GP. Please refer to section 11 of this policy

3.11 Major incidents may escalate the Discharge Policy to facilitate the movement of

patients out of the hospital. The Discharge Liaison Nurses and Social Worker will identify patients who are known to be fit to transfer to interim care settings or discharge.

3.12 Patients who have been deemed fit to transfer and are waiting the start of social

care will be tracked in accordance with the reimbursement protocols (Sitrep). 3.13 Final discharge arrangements will be co-ordinated to enable the patient to leave

the ward before 10.00 am unless clinical reasons prevent this. 3.14 All patients that fit the criteria for the Discharge Lounge will be discharged via this

facility.


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4. RESPONSIBILITIES OF KEY STAFF 4.1 Medical Staff will:

4.1.1 Wherever possible, discuss and agree a patient management plan and an expected date of discharge (EDD) with the MDT on admission to the ward. The EDD will be recorded on the ward board and the Medworxx system.

4.1.2 Inform both the patient and ward nursing staff when the patient is

medically fit or stable with adequate support, for discharge and will record this information clearly in the patient record.

4.1.3 Identify patients who are undergoing assessment for discharge and record

a ‘medically safe to transfer 4.1.4 Liaise directly with the GP to facilitate the discharge of vulnerable patients

or those with complex medical needs.

4.1.5 Record details of the inpatient episode and ongoing treatment in the discharge slip, which must be processed on the day of discharge and forwarded to the General Practitioner (GP). A full discharge letter will be completed on the day of discharge

4.1.6 The discharge letter must also provide the GP with information relating to

the patients admission covering changes to medication (and the reason for changes), Investigations and Findings plus any complications and treatment/procedure

4.1.7 Ensure that the patient’s medication is updated and ordered through the

electronic prescribing system. Take home medication (TTOs) should not be prescribed until the patient is medically stable.-. All TTOs should be available 24 hours prior to discharge. Planned discharges medication should be ordered where possible 24 hours prior to discharge

4.1.8 Ensure that TTOs include a supply of drugs for a minimum of 14 days (normally 28 days’ supply will be issued). Surgical Dressings and dietetic supplies will be supplied for 7 days. Patients own medication will be returned if still prescribed along with any newly started medication(s).

4.1.9 Ensure that when prescribing Controlled Drugs, consideration should be given to the risk of accumulation of these drugs in the patient’s home. A supply for 14 days is considered suitable.

4.1.10 If a patient is to be discharged to another hospital it is preferable, but not

essential, that TTOs are supplied. Please check with Pharmacy if in doubt.


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4.1.11 If a patient is being transferred to a Community Hospital, do NOT supply Enoxaparin, laxatives and analgesics as TTOs as the Community Hospital wards keep these as stock. For other TTO items a whole or a part pack should be supplied with details of name and expiry date. The Pharmacy at each Community Hospital will review and supply the next working day.

4.1.12 If a patient has an adequate supply of their medicine (with no dose

changes) at home a TTO is not required. 4.1.13 Review patients on the day of discharge unless a discharge plan has been

agreed and the Consultant has delegated the responsibility of discharge to nursing / therapy staff (See section 5: Nurse Initiated Discharge).

4.1.14 Document Infection control risks and precautions on the discharge slip by

the discharging medical staff. The Infection Control and Prevention Team will be actively involved with the discharge of these patients. Further advice is available from the Infection Control and Prevention Team.

4.2 Ward Nurse Responsibilities

4.2.1 To commence a discharge plan and activate the social discharge assessment with target date of discharge on admission, co-ordinating the referral to and assessment by the multidisciplinary team. Ensure that all risks are assessed for discharge of the patient and documented in the patient’s notes and assessment documentation (Discharge flow Chart, Appendix 2).

4.2.2 It is the responsibility of the Senior Sister or designated ward nurse to

inform the Capacity Team of all definite and potential discharges in a timely manner throughout the day. During the night they should ensure the Clinical Site Practitioners are informed promptly. Where possible a time of discharge should be provided with consideration of utilising the discharge lounge.

4.2.3 Registered nurses will facilitate the ongoing involvement of the patient,

carer and family in the discharge planning process. In particular, it is important to discuss with the family / carers at the point of admission the patient’s home social conditions.

4.2.4 If a patient is admitted with an established care package, it is the

responsibility of the ward nurse to inform Discharge liaison of the anticipated date of discharge and when the reinstatement services will be required. . It is usual for wards to refer to District Liaison Nurses (DLN) to reinstate care in for Staffordshire patients for up to 7 days post admission.

4.2.5 To ensure suitable provision is made to transport the patient to their

discharge destination, taking into account the patient’s assessed mobility needs. Transport arrangements will be made as soon as the discharge date is agreed ensuring relative / carers are informed. Ambulance transport will only be provided when other options are deemed


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inappropriate or unavailable. The patient requires assessing as fit for chair or stretcher

4.2.6 Discharge of vulnerable patients including patients with dementia will be

discussed and plans agreed with community nursing and/or mental health services and Social Services prior to discharge.

4.2.7 The ward nurse will ensure that relatives have provided the patient with

suitable clothing for discharge and that blankets are provided to maintain comfort and dignity during the journey from hospital, if necessary. Arrangements will be made, if required, for a suitable person to meet patients at their discharge destination.

4.2.8 The ward nurse will ensure that any valuables, which have been stored in

the hospital safe, are returned prior to discharge. 4.2.9 The ward nurse will, prior to discharge, assess whether the patient can

self-medicate and if a medication compliance aid is required. 4.2.10 TTOs will be checked against the discharge prescription in accordance

with Pharmacy policies by either the ward nurse or Discharge Lounge nurse. Information about these medications including dosage and storage instructions will be discussed with the patient and a printed TTO list explained. This will include the name of medication, dose and frequency and will accompany the patient on discharge

4.2.11 If the ward keeps TTO packs (appropriate quantities should be issued to

the patient at the point of discharge appropriate to the patient’s needs (refer to Medicines Management Policy).

4.2.12 Nurses should complete a pharmacy assessment form whenever they

consider a patient to require a Medication Compliance Aid (MCA, “Venalink”). The ward nurse must ensure that the Pharmacy is informed of the proposed discharge of a patient requiring an MCA as soon as the discharge date is agreed. This will be discussed with the patient and relatives if required to ensure safety of the patient. Normally Pharmacy will need 24 hours’ notice to prepare discharge medication in a compliance aid. For weekends and bank holidays this must be pre-planned to be available ready for discharge

4.2.13 It is the responsibility of the nurse to ensure that provision for continence

and catheter care has been organised prior to discharge and this will be documented in the discharge plan and given to the patient. Consideration must be given to what the needs of the patient were prior to admission and any changes to their management on discharge.

4.2.14 The ward nurse is responsible for informing the medical staff if the

patient’s condition deteriorates in the interval between the discharge decision and the patient leaving the ward.


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4.2.15 The ward nurse will highlight and arrange to transfer suitable patients to the Discharge Lounge.

4.2.16 The ward nurse will be responsible for checking that patients and/or

carers discharged with medical devices state they have the skills and information to safely use them in the care setting (Appendix 3).

4.3 Therapy Services Each service will work according to professional standards and within their own

scope of professional code of conduct. A referral system operates when the nursing or medical staff request Therapy Services as appropriate. On receipt of referral, assessment should take place on the same day if possible, or at the latest within 24 hours, to ensure no delays to discharge. 4.3.1 Therapists are responsible for assessing referred patients, documenting in

the patient record and liaising with other professionals, patients and carers as appropriate.

4.3.2 Therapists will communicate with other members of the multi-disciplinary

team about the progress and status of the patient in relation to discharge planning.

4.3.3 Therapists will arrange for delivery and fitting of equipment to the patient’s

home or interim setting prior to or following discharge as appropriate to the patient’s need and safety.

4.3.4 Therapists will be responsible for recommending and ordering equipment

required for discharge 4.3.5 Therapists will ensure that follow up appointments are arranged as

required, liaising with patient, carers, relatives and ward staff and documented in the discharge plan.

4.3.6 When carrying out Discharge Home Visits, the Occupational Therapist will

work in accordance with the Home Visit Protocol. They will liaise with ward staff to facilitate the preparation of TTOs and documentation to support discharge.

4.3.7 Therapists should complete a Pharmacy Assessment form whenever they

consider a patient to require a Medication Compliance Aid (MCA). 4.3.8 Therapists will follow the principles of home first

4.4 Pharmacy

4.4.1 A Pharmacist will, (wherever possible during office hours), provide advice on discharge medication for individual patients and may be available to carry out pre-discharge counselling.


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4.4.2 NHS patients will be provided with 28 days treatment as required (a minimum of 14 days). Surgical dressings and dietetic supplies will be supplied for 7 days.

4.4.3 Prescriptions for Controlled Drugs should consider the risk of

accumulation of these drugs in the home. A supply for 14 days is considered suitable.

4.4.4 If a patient has an adequate supply of their medicine (with no dose

changes) at home, a TTO will not be required. 4.4.5 Pharmacy will monitor any patient with an MCA to facilitate appropriate

dispensing at discharge. When informed of a new patient requiring an MCA, review of the assessment form will be undertaken. The named pharmacist will liaise with the ward nurse to agree requirements for the patient and liaise with the named community pharmacy to ensure continued supply of the medicines post discharge.

4.5 Social Care and Health The CCG will be responsible for arranging and funding continuing health care

services where, following an assessment of the individual’s needs, they have a clinical condition that is so complex or intense that the general eligibility criteria applies. Refer to National Health Service Act 2006, Local Authority Social Service Act 1970, the NHS Continuing Healthcare (Responsibilities) Directions 2009 and NHS Funded Nursing Care Practice Guide (revised 2012).

The assessment for, and delivery of NHS Continuing Care and NHS-Funded

Nursing Care should be organised so that individuals and carers understand the process, and receive advice and information to enable them to participate in informed decisions about their future care.

4.5.1 When a patient is deemed medically stable and further nursing care is

required (either at home or in a 24 hour placement) the ward nursing staff should carry out a NHS Continuing Healthcare checklist at the earliest opportunity so that they are considered for Continuing Health Care or NHS funded nursing care. This is done with all patients now due to new referral on version 6, however based on the patients clinical need it may be beneficial to screen using the checklist due to everyone being entitled for assessment

4.5.2 Immediately following this, where appropriate, a Notification for

assessment referral to the social work department is then required indicating the outcome of the Continuing Healthcare checklist, if a checklist has not been used the nursing staff can override the score boxes on the referral by typing in 0 in all boxes.

4.5.3 If the outcome of the checklist is positive a Decision Support Tool (DST)

DoH Screening Assessment for funding meeting is required. A professional, who is familiar with the needs of the patient and the CHC


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process should lead the meeting. Family should be advised of the date and time of the meeting.

4.5.4 Co-ordination of the DST is done by the DST co-ordinator. This role may

also be fulfilled by a senior ward nurse the ward nurse familiar with the patient’s needs.

4.5.5 A minimum of two professionals from different specialities should be

present at the meeting to enable facilitation. Any persons absent from the meeting will be seen as being in agreement with the decisions made. Further advice and support can be obtained from the Discharge Co-ordinators or the Community Discharge Liaison Nurses.

4.5.6 The Acute Trust, Social Services and the CCG must ensure that the

process, including completion of paperwork and funding decisions, does not delay treatment or appropriate care being put in place. Any actual or potential delays must be highlighted to the Matron for the area immediately. Any delays in CHC funding process are highlighted to head of discharge who escalates to head of CHC.

4.5.7 Acute Trusts have a duty under the Care Act, Transforming Social Care

(2014) to notify local authorities of patients who have been deemed medically stable and are likely to need social care services on discharge from hospital. The legislation allows Social Care (SC&H) 2 days following receipt of the notification for assessment (previously a Section 2) to carry out their assessment. The notification (previously section 2) should include a planned discharge date to assist Social care in managing their response and encourage discharge planning at the earliest opportunity .

4.5.8 Trust and Social Care staff must consider alternatives to remaining in an

acute bed for the purposes of assessment. These ‘step down’ alternatives should be in the least dependent setting and include the patient’s own home, NHS Rehabilitation, Intermediate Care or SC&H Enablement. Social care will access the beds within given facilities as required as well as considering other alternatives for patient enablement.

4.5.9 The Notification for Assessment should be accompanied by the Single

Assessment Process (SAP/CCA ) document when required. The Contact Assessment and the initial Overview assessment is completed by the social worker and should always be following the consent of the patient or their representative.

4.5.10 Ward staff are required to identify the responsible local authority for the

patient and direct non-Staffordshire residents to the Discharge Co-ordinators for Derbyshire & Leicestershire

4.5.11 Social care welcome requests for assistance and general enquiries direct

from patients and their representatives as well as from Trust staff. They will provide support and advice and act as a ‘signpost’ to support services outside their area of responsibility, where this will assist the discharge planning process and reduce anxieties for patients/representatives. If a


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community care assessment is indicated at this point Social care staff will advise Trust staff to issue the Notification for Assessment.

4.5.12 Social care staff will base the level of assessment required on the

information included on the Notification for Assessment (previously section 2) referral and, where necessary, from discussions with health professionals caring for the patient. The Single Assessment Process defines the following levels of assessment: -

Contact and Overview

All initial requests for assessment should include these documents and, for some patients with very limited changes in their circumstances, will be sufficient to determine the Social care response

Specialist Assessments

These will be required where opinions from at least one professional other than Social care are essential to determine the discharge needs

Comprehensive Assessments (formerly CCA)

Patients with very complex needs will require a comprehensive assessment with Specialist Contributions from the range of interested parties including Social care and the multi-disciplinary team. It will be co-ordinated by an appropriately trained and skilled professional

4.6 Eligibility for services

Social care staff will determine eligibility for services following assessment under the Fair Access to Services (FACs) framework. Staffordshire County Council provides services only where there is a critical or substantial risk to the service user if services were not provided. Social Care services may be subject to charges following a financial assessment under ‘Fairer Charging’ procedures but this should not delay discharge for the patient

Derbyshire County Council Assessment staff will also determine eligibility under the Fair Access to Care Services; however services would be provided when a moderate risk has been identified. Currently Domiciliary Care provided or commissioned by Derbyshire County Council is at nil cost to Service Users

It is essential that Trust staff do not offer services to patients / representatives but should indicate that a request for an assessment for services will be made on their behalf.

In addition, patients in need of services from Social care , including home care, residential or nursing home care should not be discharged without the agreement of Social care. Any such discharge could incur charges for the hospital Trust.

Further information can be obtained by accessing:


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www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252.

4.7 Discharge Notification

Following the completion of the assessment, Trust staff are required to notify Social services of the proposed discharge date using Discharge notification.( formally Sect 5 ) This should follow the guidance of the Department of Health’s ‘safe to transfer’ protocol and should be issued when the following three criteria are met: -

A clinical decision that the patient is ready for transfer

The multi-disciplinary team agree that the patient is ready for transfer

The patient is safe to transfer / discharge

(See Appendix 7)

4.7.1 Social Services have 24 hours following the Discharge Notification to ensure discharge services are in place. Reimbursement liability will occur if delays are the sole responsibility of Social services

4.7.2 Communication between all parties is essential to good discharge planning

and reduces stress to patients / representatives. The Single Assessment process requires robust inter-agency communication and avoidance of the duplication of assessments. Trust staff will keep Social care informed of any changes in the patient’s condition or circumstances at all stages of the assessment. Similarly Social care must keep the multi-disciplinary team informed of any factors that affect the patient and their discharge planning, informing ward staff of the outcomes of discussions with patients / relatives and recording in the ward notes and / or on HISS any discussions and proposed action.

4.7.3 Once the MDT has agreed the discharge plan and issued a Discharge

notification via order entry notification, any funding issues should not delay provision of care for the patient being put in place.

4.8 Supporting Services

4.8.1 There are a number of Voluntary and Care Services that can be utilised to support and facilitate the discharge process. Further information regarding community based support services and criteria for referral is available through the Trust’s Discharge Co-ordinators or Social Workers.

4.9 Hospital Discharge Liaison Team

4.9.1 A Discharge Liaison Nurse (DLN) will attend the daily Ward boards at least 3 times a week to identify complex discharge planning with a focus on expediting discharges identified for that week. They can also be referred to via order entry on Version 6 system for early recognition of complex cases, and manage a case load. There will be ongoing communication between the DLN and ward staff between planned meetings to update discharge plans

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003252


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4.9.2 The Lead Discharge Nurse (or representative) will attend the daily 12 pm Operational meetings on the main site, and will act as the point of referral for all complex/problem discharges for that day that require an urgent response.

4.9.3 The Discharge Co-ordinators will provide advice, support and education to Trust staff relating to the discharge process. They also provide advice regarding support services available in the community.

5. NURSE INITIATED DISCHARGE SURGERY 5.1 Introduction

5.1.1 This protocol provides a framework for nursing staff to discharge patients from the hospital following assessment against condition based protocol or by specific criteria detailed in the patient record by the Consultant or his/her designated deputy.

5.2 Accountability

5.2.1 The overall legal responsibility for care from admission until discharge is that of the named consultant/named GP. The consultant/named GP may delegate responsibility for discharge to a nurse with appropriate knowledge and skills.

5.2.2 The nurse taking responsibility of discharging the patient is professionally accountable for their actions and must always work in accordance with Trust policy and the Nursing and Midwifery Code of Conduct.

5.2.3 The Senior Sister is responsible for implementing the protocol within their area of responsibility.

5.3 The Benefits of Nurse Initiated Discharge

Improvements to the quality and timeliness of the patient’s journey for both elective and emergency admission

Medical staff / MDT can determine individual criteria for discharge in collaboration with the nurse in charge / nursing team leader

The nurse is empowered to facilitate early decision-making to promote the safe discharge of the patient

The Trust will benefit from the timely discharge of patients to enable elective and emergency targets to be achieved

Delays in starting Theatre lists will be avoided

Bed Management will be able to predict bed availability more accurately

Reduction in complaints relating to delays in treatment and waiting time

Hot clinics

To support increased weekend discharges


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5.4 Definition of Nurse Initiated Discharge

The nurse’s responsibility to facilitate discharge in accordance with the Discharge Policy is unaffected by this protocol. This aim of this protocol is to reduce delays in discharge by avoiding the need for a doctor to see the patient immediately prior to discharge.

5.4.1 Protocol based discharge

Specialities may develop protocols for discharge for specific conditions. This process is most likely to apply to surgical or investigative procedures.

5.4.2 Criteria based discharge

Senior medical staff or their designated deputy may write specific criteria for

discharge, against which the nurse can assess the patient and make the final decision for discharge. It is expected that 40% of patients will be discharged by this process.

5.5 Education and Training

Nurses will undertake a core discharge skills analysis with their Senior Sister, undertaking training to address shortfalls in knowledge and skills. Nurses will be deemed competent to follow discharge protocols / criteria appropriate to their usual area of work. Review of competency will take place at appraisal.

5.6 Accountability

5.6.1 Medical Staff

Continue to have overall responsibility for the clinical care from admission to discharge.

The criteria for Nurse discharge must be clearly documented in the patient record and signed by the Consultant or a designated deputy such as a Registrar

The doctor completing the criteria for Nurse Discharge must ensure that TTOs are prescribed and follow up arrangements are clearly

5.6.2 Senior Sisters Responsibilities

To identify which nurses can facilitate discharge

To ensure staff are familiar with the process and paperwork

To assist in the evaluation process and incorporate that learning into practice skills on the ward

To take overall responsibility for the patient’s safe discharge


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5.6.3 The Responsibilities of the Nurse Initiating Discharge The competent delegated nurse will be accountable for selecting the

patient for nurse-initiated discharge and completion of the process in accordance with Trust Protocol and Policy and the NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics 2015). The responsibilities are summarised below:

6. DISCHARGE OF VULNERABLE ADULTS FROM WARDS

6.1.1 Prior to discharge the discharge plan will be agreed with the Consultant and the multi-disciplinary team. The discharge of an adult recognised as vulnerable must be planned for a smooth, safe transfer into the community. Good communication and documentation is essential.

6.1.2 Adults recognised as vulnerable may have been subject to Adult Protection

Investigations or planning meetings. Where Social Care are working with the family or care providers, staff must liaise with social worker as part of discharge planning.

6.1.3 Prior to discharge, a plan will be agreed with the relevant people.

6.1.4 Should a vulnerable adult, under adult protection investigation be removed

from Burton Hospitals NHS FT without the consent of the relevant agencies then Social Services and the police will be informed, where an Emergency Protection Order may be sought.

6.2 People who are homeless or living in temporary or insecure

accommodation includes:

Rough sleepers

Individuals or families living in temporary accommodation (under the homelessness legislation, local authorities must ensure that suitable accommodation is available for applicants who are eligible for assistance, unintentionally homeless and who fall within a priority need group (e.g. families with children).

6.2.1 Staff should signpost the patient to the local housing office to register as

homeless where they should be offered temporary accommodation; the responsible Council authority is the last place where the patient was resident

. 6.2.2 The Discharge Liaison nurses must work in partnership with the local, the

voluntary sector and the local authority to ensure safe and effective discharge.

6.2.3 Close liaison with the local housing authority and involvement with the

homeless strategy is vital.


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6.2.4 If the patient is medically fit for discharge and requires ongoing Social care support ensure they have been referred to them and they will be transferred to interim accommodation until suitable accommodation is found and the costs met by the provider of the ongoing care.

7 TRANSFER OF CARE

7.1 The Trust’s ‘Transfer of care’ Protocol has been implemented to assist clinicians and managers to improve the discharge process for those patients who are expressing their right to choose regarding discharge plans, which have been agreed by the Multi-Disciplinary Team (see Appendix 7.

8 MATERNITY DISCHARGE

8.1 This section provides guidance for the women being transferred from the maternity setting in hospital to continuing care within the community or other healthcare provider. Maternity care aims to be seamless across the boundaries and good communication is essential.

8.2 Discharge / transfer of the women will fall into the following categories:

Antenatal

In-utero

Post Natal

8.3 Antenatal Discharge

8.3.1 Antenatal women will have an agreed discharge plan made in conjunction with the patient and the Consultant or Registrar.

8.3.2 The plan is agreed with the woman and is entered into the woman’s

hospital and hand held notes. 8.3.3 Appropriate appointments are made and documented on the hand held

notes. 8.3.4 Investigation results to be entered in the hand held notes including copies

of ultrasound scans that have been performed. 8.3.5 The midwife discharging the woman completes 2 discharge letters. One

copy is filed in the woman’s hand held notes and the other filed in the hospital case notes.

8.3.6 Where the plan requires a community midwife to visit at home the midwife

will inform the maternity office giving details of the woman’s name, address, GP, gestation and special instructions or information for the community midwife. The administrative staff in the maternity office will inform the community midwife.


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8.3.7 Where information required by the community midwife is urgent or sensitive

the midwife discharging the woman will contact the community midwife directly herself and convey the information verbally making a record of the conversation in the notes.

8.3.8 TTOs will be ordered and checked by the midwife in accordance with Trust

policy.

8.4 In-Utero Transfers

8.4.1 In-utero transfers may be due to: -

Specialist Neonatal care requirements

Pregnancy related condition requiring specialist care

Neonatal cot unavailable at Queen’s Hospital

There are agreed lines of communication between the obstetric and neonatal teams. When the need for in-utero transfer has been confirmed the following action will be taken: Read in conjunction with the Guideline for Transfer of the Obstetric patient.

8.4.2 The Obstetric Registrar will:

Inform the mother and relatives of need to transfer and keep informed

Inform the patient’s Consultant / Service Consultant or on-call Consultant Obstetrician

The Consultant Paediatrician will be informed by the Paediatric Registrar

Identify neonatal facilities that have availability

Confirm neonatal cot and document name of hospital accepting transfer

Contact Obstetric department of Unit with Neonatal Cot availability and confirm that obstetric facilities are also available

The notes will be completed to indicate:

Reason for transfer

Receiving hospital

Destination ward of the mother

Name of designated doctor accepting transfer

A transfer letter will be written

When the Neonatal Cot and Obstetric services have been confirmed by the receiving hospital the midwife in charge of the ward area will co-ordinate transfer


17

Ambulance control will be contacted to book ambulance and level of urgency will be given. The time of call will be documented with the estimated time of arrival of the ambulance

Identify a midwife to accompany the mother

Arrange for all relevant notes to be photocopied to accompany the patient

Inform Matron or senior midwife of transfer

Confirm stability of patient prior to transfer, check any equipment to be used is functioning correctly

Confirm relatives are aware of the transfer / confirm destination / give directions

Ensure notes and documentation accompany patient

The accompanying midwife will give verbal handover of care at the receiving unit

8.5 Post Natal

8.5.1 The professional making the decision for discharge / transfer to community care will be determined by the history of the woman.

8.5.2 For low risk patients having had a normal delivery with no complications the

midwife will agree discharge with the woman.

8.5.3 For women where medical intervention or complications had arisen a medical review is made for fitness to discharge / transfer to care of community midwife/GP.

8.5.4 A postnatal discharge letter for both mother and baby will be completed by

the midwife on HISS - 4 copies of each will be printed. The mother will be given 1 copy addressed to the Community Midwife, 1 copy will be posted to the GP, I copy will be sent to the maternity office and 1 copy filed in the Patient’s medical record.

8.5.5 The baby NHS number will be given to the mother for registration of the

birth and for reference for relevant healthcare professionals e.g. Health Visitor.

8.5.6 The mother will be made aware of contact numbers for midwives in the

community.

8.5.7 The Maternity office will inform the appropriate community midwife of the discharge from hospital.

8.5.8 For discharges / transfers outside of normal office hours (0830-1700) it is

the responsibility of the midwife discharging the woman to ensure the appropriate community midwife is informed. Outside of normal hours this


18

will usually be the on-call community midwife for the patient’s area of residence.

8.5.9 TTOs will be arranged as appropriate, checked in accordance with Trust

policy. 8.6 Transfers to the Samuel Johnson Community Hospital See guideline for Transfer of Obstetric Patients. 8.7 Discharge of Vulnerable Children from Maternity Wards 8.7.1 Prior to discharge the discharge plan will be agreed with the Consultant. The

discharge of a child recognised as vulnerable must be planned for a smooth, safe transfer into the community. Good communication and documentation is essential. The discharge will either be into the care of parents / carer or Children’s Social Care.

8.7.2 Babies recognised as vulnerable pre-birth may have been subject to strategy or

planning meetings. Where Children’s Social Care are working with the family under service plans staff will liaise with Children’s Social Care. Where children are monitored under a CAF the midwife will liaise with the Lead for the CAF.

8.7.3 Where a baby is subject to a Child Protection Plan a pre discharge meeting will

be held and discharge plans agreed between all agencies involved. 8.7.4 Prior to discharge the discharge plan will be agreed with the relevant people. 8.7.5 Follow up appointments will be in place prior to discharge where possible. 8.7.6 Where possible babies will not be discharged at weekends unless agreed by

other involved agencies. 8.7.7 The baby will have a registered GP prior to discharge; this may need to be

facilitated by hospital staff. For Staffordshire addresses contact Staffordshire Patient Registration 01785 252233, Derbyshire Primary Care Support 01332 86897.

8.7.8 Hospital notes will be created for the baby and relevant documentation from case

conference will be filed within them. 8.7.9 Should a child deemed vulnerable be removed from Queen’s Hospital without

the consent of the relevant agencies then Children’s Social Care and the police will be informed where an Emergency Protection Order may be sought.

9 NEONATAL UNIT DISCHARGE AND TRANSFER PROTOCOL 9.1 This section includes guidance for the discharge of the neonate back to the

postnatal ward, to the community, either to the care of the parents or identified carers, or transfer to another health care provider.


19

9.2 The maintenance of good communication is essential in providing a seamless

transition into the care setting required. 9.3 Discharge of the Baby into the Community

9.3.1 Parent craft forms are completed by nursing staff in co-operation with the parent as an ongoing process from the time of the infant’s admission.

9.3.2 Concerns re the home situation, parenting skills or safeguarding issues

identified during the time of admission should be addressed in advance of making plans for discharge.

9.3.3 Where a child is subjected to a Child Protection Plan the senior nurse

and doctor checks with all agencies that the Child Protection Plan is followed.

9.3.4 If a discharge-planning meeting is required, this will be agreed by the MDT

and the most relevant agency concerned will arrange all meetings with relevant agencies. If a provisional discharge date has been set, agencies should be made aware of this prior to the meeting. The senior nurse and medical staff should ensure that, following the meeting, all processes are put into place ready for discharge.

9.3.5 Parents are invited to be resident with their baby in a parent’s flat for a

minimum of 24 hours prior to discharge to establish breast or bottle-feeding and parent craft. Baby should be gaining weight and feeding well and maintaining their temperature, before a provisional discharge date is given.

9.3.6 Parents receive teaching on basic resuscitation on an individual basis as

requested by the Consultant or as indicated by their condition. 9.3.7 For babies who require home oxygen, parents must be competent in all

aspects of caring for baby and in the use of home oxygen equipment. See guideline for Chronic Lung Disease of Prematurity (May 2005). A pre-discharge planning meeting is arranged with multi-agencies involved in order to support the family in the community. Appointments will be required for administration of Synagis and the baby usually requires overnight admission to Children’s Ward for routine immunisations.

9.3.8 TTOs are ordered. These are checked by the nurse in accordance with

Trust policy. The nurse ensures that the parent or carer has previously demonstrated they are competent to measure and administer the medicines to the baby.

9.3.9 Follow-up appointments are made as required and recorded on the

baby’s discharge letter. Babies who have had retinopathy screening are reviewed in Ophthalmology at 18 months of age. Babies <31 weeks gestation or <1500 grammes require developmental assessment at 6 months corrected age.


20

9.3.10 The ward clerk informs the health visitor of discharge and any special

instructions discussed. If sensitive issues need to be relayed, this should be done by the Nurse in charge.

9.3.11 The neonatal nurse ensures that all appropriate agencies are involved

and aware of the discharge plan and good communication has been maintained throughout the discharge process.

9.3.12 The SHO performs a full discharge examination and records the findings

on the discharge sheet of the medical notes. 9.3.13 A hearing screen is performed by the Audiology Department. Results

are recorded in the patient’s notes, HISS, and also entered in to the baby’s red book.

9.3.14 If the baby has received any vaccinations, these should be recorded on

the discharge letter, medical notes and red book. Batch numbers should be documented.

9.3.15 The doctor completes the discharge letter and prints 5 copies. The

Health visitor / community midwife, family doctor, parent/carer each receive a copy. The neonatal nurse gives the parent or carer the letter for the midwife or health visitor and sends the letter to the GP through the post. One copy is retained in the notes and the fifth letter is sent to the Maternity office.

9.3.16 The nurse completes the discharge plan and the Badger Summary is

completed by the SHO, who prints 3 copies: 1 copy for notes / 1 copy for the GP / 1 copy for the Parents.

9.3.17 The nurse completes the care plan and discharges the baby on HISS.

9.4 Discharge to the Postnatal Ward

9.4.1 Some babies may be well enough to be discharged back to the care of their mother on the postnatal ward.

9.4.2 The Paediatric SHO performs a discharge examination of the baby and

completes one copy of the discharge letter. 9.4.3 The neonatal nurse informs the parent that the baby will be discharged to

the ward and discusses any concerns with them. 9.4.4 The doctor or neonatal nurse informs the midwife on the postnatal ward

of transfer and any special instructions. 9.4.5 The neonatal nurse completes the nursing care plan prior to transfer. 9.4.6 The baby is transferred on HISS to the postnatal ward, ensuring that the

service is changed from “Special Baby Care” to “Neo.”


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9.5 Transfer of the Neonate to another Provider

9.5.1 Transfers may be urgent or non-urgent. Most transfers are carried out by the Central Newborn Network Transfer Team. Contact numbers and further information is available in the Transfer folder on the Neonatal Unit. This includes a list of information required by the Transport Team.

9.5.2 Read in conjunction with the following policies:

Admission and Transfer of Preterm’s

Central Newborn Network Emergency Transport

Procedure for Transfer of Babies From the Neonatal Unit These can be found under; Doctors – Specialities – Paediatrics –

Neonatal.

9.6 Admission and/or transfer of newborn babies

This guideline relates to the baby’s gestation. 9.7 Central Newborn Network Emergency Transport This gives a brief outline of the network Transport Service. Please see Transport

folder for the full information. 9.8 Transfer of babies from the Neonatal Unit

9.8.1 This guideline outlines the categories for transfer, mode of transport and procedure for emergency inter hospital transfer.

9.8.2 Transfer arrangements are discussed with the parents by the

Paediatrician. Directions and information about the receiving unit are given to the parents.

9.8.3 If the mother is to be transferred to accompany her sick baby (see

section 10).

9.9 Guideline for transfer of obstetric patients 9.9.1 The midwife caring for the mother is requested to take 10mls clotted

blood to accompany baby for cross-matching purposes. 9.9.2 The ward clerk ensures that photocopies are taken of all notes and

charts, including laboratory results and X-Rays are copied to a CD. A copy of medications history and present regime is printed from HISS.

9.9.3 The Obstetric Registrar writes an accompanying letter.


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9.9.4 The SHO completes the discharge transfer letter. 9.9.5 The midwife completes a transfer letter – one copy to receiving unit and

one copy for medical notes. 9.9.6 Verbal handover is given to the receiving Unit. 9.9.7 The Care Plan is completed by the midwife and the baby is discharged

on HISS. 9.9.8 The midwife enters the discharge into the admission / discharge book.

10. PAEDIATRIC UNIT DISCHARGE/TRANSFER

10.1 This protocol provides guidance for the Paediatric Unit. It concerns Paediatric patients being discharged or transferred from Queen’s Hospital Paediatric Unit to either home, with or without continuing care within the community, or to other health care providers. With effective two-way communication Paediatric care aims to provide a seamless and smooth transition from the acute setting to their discharge destination.

10.2 If required, follow-up will be maintained by community staff and/or other

health care providers and/or via our Trust’s robust Outpatient Department.

10.3 Discharge Categories 10.3.1 Paediatric discharges fall into different categories

Discharged on Medical advice – including transfers and retrievals to other health care providers

Parent or Child - Taking Own Discharge

Discharged by Nurse – Nurse Led Discharge

Discharge on Medical Advice when certain criteria have been fulfilled

10.3.2 Most patients fall into the Discharged on Medical Advice Category – discharge home or to another provider (transfer) is dealt with in the main body of this protocol, other methods of discharges are: -

10.3.3 The Self-Discharge Category See Appendix 4 for self-discharge documentation. The parent / carer

who has parental responsibility can take self-discharge of the child but some children / young people under the age of 16 years who have the capacity and understanding to give consent themselves, i.e. they fully understand what is involved in the proposed procedure, can be deemed to be competent following the Fraser Guidelines, ("Gillick" competency),


23

and can therefore take their own self-discharge. The parent can overrule this but other consent issues need to be taken into account and the Trust’s policy on Consent referred to.

Self-discharge is not an option in relation to Safeguarding issues when there is a Care Order in place.

10.3.4 The Nurse Led Discharge (NLD) Category NLD in Paediatrics is at present only concerned with: - ENT post-operative patients following guidelines set out by the ENT

department. Community dental post-operative patients following the guideline set

down in the Nursing/Community Dental Protocol. General Paediatric Surgery day case post-operative patient following

instruction in the patient’s notes. A qualified Children’s Nurse working on the Paediatric Unit carries this

out following the Nurse Led Discharge instructions in the medical notes. Paediatric Diabetes patients under the care of Dr Samuel can be

discharged by the Paediatric Diabetes Specialist Nurse (PDSN.)

10.3.5 Discharge on Medical Advice once certain criteria have been fulfilled

Still discharged on medical advice but the Nurse can discharge the

patient once the discharge criteria are fulfilled – i.e. urines obtained or feeding well.

10.4 Discharge Destination

10.4.1 The discharge destination can be varied; differing plans may be required to be set up for different destinations:

Discharged Home – to their usual place of residence

Discharged to a place of temporary residence – i.e. foster care, residential school / home, from where they were admitted. (With parental responsibility or Legal Representatives)

Discharged to a place of temporary residence – i.e. foster care, residential school / home, from where they were NOT admitted. (With parental responsibility or Legal Representatives)

Transfer to other Tertiary Services for further care, or retrieval by another Health Care Provider Unit – i.e. PICU, Stoke, Leicester, Nottingham or Birmingham for continuing care. If transfer is required the Consultant / Registrar will identify facilities available for the child


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and liaise with the new Health Provider in aspect of care required and mode of transfer required. All other care required for transfer is as below.

10.5 Discharge Plans 10.5.1 Discharge Plans on V6 must be commenced from admission. The child /

young person and their parents / carers will be involved in all stages of the discharge planning, ensuring they are constantly kept up to date and are in agreement with all plans.

10.5.2 All discharge planning should be noted in the child’s medical notes by

Doctors. 10.5.3 Children with complex health needs often require input from a number of

different specialities so multi-agency discharge-planning meetings will be held. The aim of these meetings is to establish detailed plans ensuring services and equipment are arranged to meet the physical, social, emotional and spiritual needs of the child and family thus allowing smooth transition from hospital. Agreed plans can be made and agreed by all the carers and the child / young person and their parent / carer.

10.6 Communication/Liaison Preparation Plans

10.6.1 For a non-complex discharge - if relevant, the necessary liaison with

outside agencies / services involved in the care of the child / family and the discharge package should be contacted pre discharge. Otherwise the agencies involved should be fully informed of planned and actual discharge dates.

Midwife – for babies less than 10 days of age, inform maternity office 4361 with full details – Mon-Friday 9-5, outside these hours ring midwife on call on bleep 310 or ring delivery suite who will document the discharge

Health Visitor – if it is necessary a phone call is made but all discharges of children under the age of 5 will be notified to HV by sending a copy of Doctor’s discharge slip

School Nurse – if it is necessary a phone call is made but all discharges of children over the age of 5 will be notified to School Nurse by sending a copy of doctors discharge slip

Social Worker – either direct to child’s own SW or area social care offices

Community Physio – via internal department here at Queen’s

Community Dietician via internal department here at Queen’s

Community Speech Therapist – via internal department at Queen’s


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Children’s Community Nurse Team – for areas covered by the CCNT contact is made from the ward and a prior visit to the child / family while still in hospital undertaken if possible. For all other areas contact to that Team needs to be established

District Nurse – via the GP practice attached and relevant forms completed

Paediatric Diabetes Nurse Specialist – internal contact and will refer others to their own PDSN if out of area

CAMHS – via referral and appointment system from the relevant area

Family Doctor – via discharge slips / summaries post discharge. If a child is not registered with a GP the parents/guardians should be advised to register the child immediately. Information regarding GP’s accepting patients can be found in www.nhs.uk

10.6.2 When in the discharge planning stage it is essential that referrals/orders

for all equipment and community services that will be required at home are made as early as possible, by the appropriate person/Trust.

10.7 Safeguarding Children

10.7.1 If child protection concerns have been raised, the child must not be

discharged from the ward or Emergency Department without the permission of the Consultant Paediatrician, or middle grade Paediatrician out of hours.

10.7.2 If child protection concerns have been raised, the child must not be discharged from the ward or Emergency Department without a documented plan for future care of the child. This must include follow-up arrangements, the child’s address on discharge and the name(s) of the parent(s)/carer(s).

10.7.3 If concerns about deliberate harm have been raised the child must not be

discharged until Social Care have conducted an assessment of the environment to which the child will be discharged. The child may only be discharged if the environment is deemed to be safe.

10.7.4 If non-organic failure to thrive has been diagnosed the child must not be

discharged until a multi-agency discharge planning meeting has taken place and a plan devised for future care.

10.7.5 A Child in Need planning meeting must be held where concerns have

been raised about a child’s welfare or where parental drug misuse has been identified.

10.7.6 A written discharge summary detailing concerns and follow-up

arrangements must be forwarded to the child’s GP on the day of discharge and the health visitor / school nurse must be informed by telephone.

http://www.nhs.uk/


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10.7.7 Where a child is not registered with a GP they must not be discharged

from hospital until a GP has been allocated to the child. 10.7.8 If a child is being discharged into foster care the following information

must be collated and documented prior to discharge as part of the discharge planning process:-

The name and address of the placement, unless in circumstances where the child is being placed at a secure address

Who has parental responsibility? i.e. parents, one or other parent, Children’s Social Care or both

Where follow-up appointments are to be sent

How birth parents are to be informed of the discharge and the follow-up arrangements

The child’s GP/Health Visitor/School Nurse/Social Worker/Midwife or Community Children’s Nurse must be involved in the discharge planning arrangements

10.8 Discharged on Medical Advice to Home or to a Temporary Place of

Residence

10.8.1 A child can only be removed from the Unit on discharge by the parent/carer who has “Parental Responsibility”, or by self-discharge by parent or Fraser competent young person as discussed previously, or if a plan has been made by the person or persons with parental responsibility, or by the legal representative (LR) – i.e. Social Worker or Foster Parent. The unit must have such plans in writing.

10.8.2 If there is a Care Order on the child then they cannot be removed from the place of safety named in the order until a new order is given naming a new place of safety or the old order is cancelled or expires.

10.8.3 All Child Protection issues will have had multi-agency action plans

agreed upon and recorded before discharge. 10.8.4 on discharge from the Hospital the child / young person / parents /

carer / legal representative should have: -

A written Discharge Plan with verbal confirmation agreed by the child/young person and their parents/carers will be given

Red hand held Information Booklet completed by a nurse for all pre school age children / babies with information re the admission and discharge plans

All medications required as TTOs – one calendar month’s supply is necessary if ongoing. These are checked as per policy and all explanations re medications must be given to young person and


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parent/carer and patient information for the prescription should be printed off HISS

Dressings and/or equipment as required at home – sufficient for 1 month (or less as required) and explanation of where further supplies are obtainable from

Full understanding of all equipment to be used at home with the required training by all who would be using it. Written instructions and competency forms to be completed by the trainer whether ward nurse or Homeward nurse

Names and contact numbers for all carers involved for parents to make contact

GP Discharge Slip letter given to parent/carer and 1 sent on to their GP. (If a full discharge summary is required this will be noted by the Doctors and completed by a Registrar or designated person post discharge)

Advice sheets – Patient information for condition / future plans etc., verbal and written advice given along with relevant contact numbers

Voluntary / support groups contact numbers if appropriate

Explanation of follow up, via GP or OPA with dates if appropriate and full explanation of purpose

Safe transport arranged by parents / carers from the hospital if appropriate

10.9 Transfer or Retrieval of a Child to Another Healthcare Provider

10.9.1 On transfer or retrieval: - to another care provider the new providers OR child/parents/carer/legal representative should also have: - (these should be read along with the Critical Care Guidelines for transfer/retrieval of a sick child)

Transfer plan – agreed transfer plan made with Consultant / Registrar and parents/carers so they have full knowledge of the intended plan. Written and verbal confirmation given to carers

Information re new health care providers to be given to parents/carers along with travel directions

Doctor’s transfer letter

Nurse transfer letter with patient notes and assessment printed off HISS

All medical notes (photocopies) to accompany child/young person

Copies of all observation charts and current drug status to be sent

X-Rays on CD, MRI and CT scans also to be available for transfer – reports of above if available


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All relevant laboratory reports printed from HISS to accompany child

Any special drugs or feeds that may be needed by the new care providers

Safe transport to be ordered via Ambulance control with level of urgency required, appropriate secure and safe mode of transfer (i.e. chair, car seat, incubator etc.) arranged by either Queen’s Hospital (if transferral) or the retrieving hospital (if retrieval). Estimated time of arrival to be obtained to ensure this will not compromise the patient’s condition as time can be critical in some conditions i.e. it may be preferential to transfer as a priority rather than wait for retrieval with some conditions

Condition of child to be continually reassessed pre transfer to confirm stability for safety reasons in case of deterioration etc. i.e. may need upgrading to retrieval if not safe for transfer or deteriorating quickly

Senior nurse and/or Doctor, if required, will accompany the child if transferred – retrieval team care for child and family if retrieved

Drugs and all equipment used on transfer also to be assessed for safety and ensure fully functioning and checked in accordance with local policy before leaving

10.10 On Discharge

10.10.1 For patients under the care of Paediatricians:

See the “Patient Discharge Summary Protocol” flow chart for correct procedure for recording and informing of discharge by Paediatric Doctors.

10.10.2 Discharge Slips

For Paediatrics and all other specialities (except community dental patients): Discharge Slips should be generated by the SHO present at discharge on day of discharge and are sent to:

Parent/carer to take home Liaison Nurse Sent to GP Health Visitor/School Nurse

10.10.3 Discharge Summary

If required the discharge summary is dictated by the Medical Registrar for secretaries to type and be completed within seven days (or PDNS in the case of Paediatric Diabetes Admissions under the care of Dr Samuel).

10.10.4 Medical Notes

If no summary is required the ward clerks return the notes to file in Medical records post discharge. The secretaries will return the notes to file after summary completed by them.


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All notes are tracked on the HISS system indicating at all times their location.

11. SELF DISCHARGE

11.1 A patient wishing to take his/her own discharge from hospital either from the Hospital ward or whilst on a Home Assessment visit will:

11.1.1 If a person takes their own discharge against medical advice they should

still be offered standard care and management e.g. follow-up OPA, TTOs, discharge letter, DN referral. If they refuse that is their decision and should be documented. If they refuse to wait for arrangements to be made then they should be given the opportunity to return to the ward/department to collect TTOs etc at a reasonable time. Our duty of care does not stop because they have chosen to leave hospital against advice.

11.1.2. Be advised by a Medic (or in their absence) by a Senior Nurse in the

presence of a witness, that he/she is discharging themselves against advice and do so at their own risk.

11.1.3. Sign a declaration to the effect that their situation has been explained to

them and that they have elected to discharge themselves at their own risk. If the patient is unwilling to sign the declaration they should not be impeded in any way from taking their discharge but a written record will be made in their health record (See appendix 4).

11.1.4 If suffering, or suspected of suffering, from an infectious disease and

where no legal order for detention has been obtained, the patient shall be advised that they are discharging themselves against advice at their own risk. Contact should be made with the appropriate agencies as required e.g. GP, Community Health Services, Social Services and Public Health Department.

11.1.5 A copy of the declaration is kept within the Patient’s Health Record. 11.1.6 Staff should refer anyone thought to be at risk without support services to

Social Services or intermediate care teams. 11.1.7 If out of normal working hours the Nurse in charge must contact the

medical staff on call and inform them of the patient’s intent. The above procedures must then be carried out if possible and, if not, as soon as possible during normal working hours. A written record must be made in their health record (see Appendix 6).

11.2 Children under 16 years of age 11.2.1 Permission must be obtained from whoever has parental responsibility.

Children who are deemed “Gillick” competent i.e. they have the capacity and understanding to consent to their own treatment, must have their


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rights adhered to and can self-discharge. This can, however, be overruled by their parents.

11.2.2 Where necessary the Trust’s Policy framework for Safeguarding Children

Policy and/or Staffordshire Area Child Protection Committee Guidance and Procedures (1996) must be followed (available in ED and Paediatric areas) for further information reference The Children Act 2004.

12. IMPLEMENTATION OF THE POLICY

The successful implementation of this Policy is based upon a robust system of multi-disciplinary and inter agency working at ward level. The Trust will work collaboratively with external organisations to ensure that the Policy is a working document, which takes into account current legislation and local policies and procedures.

13. MONITORING EFFECTIVENESS

The processes for monitoring the effectiveness of the Discharge Policy is through a number of routes:

13.1 SITREP Reporting: - A formalised process for monitoring delays with discharge

across both health and social care for all 3 counties. This information is collected weekly and sent to the Department of Health monthly via Unify 2 It is also used to highlight areas of discharge where a focus needs to be made to address issues. Head of Capacity will take issues to various agencies for action and report progress to the partnership meetings. Ongoing issues will be monitored through the A&E Delivery Group and escalated to the A&E Delivery Board

13.2 Operational Meetings and Ward Board Reviews:- Issues are collected if irresolvable and taken to the Operational meetings for escalation. The Head of Capacity will make every effort to resolve the issue and seek help and advice from all relevant external partners i.e. Community Hospitals, Social Care and CCG leads. Issues will be discussed at the District operational Group and any ongoing issues/service improvements recorded on the action monitoring with a designated person.

13.3 Patients Surveys: - The Picker Patient Survey is conducted annually and

includes questions related to discharge from hospital. The survey report is received by the Quality Review Group

13.4 Social Discharge Issues: - are discussed weekly between the Lead discharge nurse and the Team Leader for Social Services. Other issues are discussed at ward level during Multi-disciplinary meetings. Trends in incidents are identified and are reported to the Business Unit Governance Meetings.


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Appendix 1 BURTON HOSPITALS NHS FOUNDATION TRUST

CONFIRMATION OF ASSESSMENT FOR TRANSFER OF CARE

There is consistent evidence to suggest that best practice in Hospital discharge involved multidisciplinary teamwork. Patients with complex needs should receive a multidisciplinary assessment. Completion of this form will demonstrate compliance with both local and National standards in discharge planning and enable tracking of patients whose discharge may be delayed. Patient Details - please affix label Assessment Required By (please tick relevant box)

Referral Date

Signature Safe to Transfer Date

Consultant/Reg/SHO

Ward Nurse

Occupational Therapist

Physiotherapist

Social Services

Other (Specify)

Date of Admission _______________________ Planned Date of Discharge _______________________ DELAYED TRANSFER OF CARE A delayed transfer of care occurs when a patient is ready for transfer from an acute hospital bed, but is still occupying such a bed. A patient is ready for transfer when: -

1. A clinical decision has been made that the patient is ready for transfer and

2. A multidisciplinary team decision has been made that the patient is ready for transfer and

3. The patient is safe to discharge/transfer Please confirm when the patient is ready is ready for transfer, i.e. the above criteria have been met. Signature of Nurse ___________________________ Date ________________


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Does the patient need referral for continuing

health care or social care support?

YES NO

Complete CHC checklist and send Assessment

notification.

Reassess during

admission

Consider Meals on

Wheels/CIT / carers

support if required

Positive CHC

checklist

Further assessment

for DST mtg

Negative CHC checklist

– submit assessment notification

- await social worker allocation

- refer to Discharge team via

order entry if complex issues

If require > 3 calls day/24 hr start

the CCA assessment.

Arrange DST

mtg. Complete

CCA & send to

funding panel &

await decision

Arrange

discharge in line

with care plan

agreed at DST

Social worker

assesses patient

Offer contact number

for area Social Services

office & Discharge.

If relatives haven’t found NH

in 7 days – issue choice

directive letter to family

If discharge prior to 7 days

– no further action req.

If exceed 7 day target issue letter 3 for

Trust to assume responsibility for

discharge. Find suitable placement for

discharge Discharge Liaison to

inform family.

Care Package

Req. If no

date agreed

or delayed

EDD issue

Discharge

notification

Appendix 2


33

Appendix 3

CHECKLIST FOR PATIENTS DISCHARGED FROM HOSPTIAL WITH A MEDICAL DEVICE

General Considerations Is the device suitable for home use (have, for example, robustness, back-up systems, alarms been considered if appropriate, modifications needed, patient care and instruction)? Has the person responsible for the use of the device been identified, i.e. is it patients and/or carer? Is the loan equipment schedule maintenance status compatible with the loan? Has the device been fully tested with confirmed full functionality and fitness for purpose? Patient / Carer Instructions

Does the patient/carer know the name of the device? Does the patient/carer know how to set up the device in the home? Has the patient/carer been trained in the use and function of the device? Has the patient/carer been provided with written instruction specifically about the

device? Has the patient/carer been trained in how to deal with fail-safe features, e.g.

alarms? Has the patient/carer been trained in the care of the device? Does the patient/carer require accessories? If so, does the patient/carer know

where to obtain these and how often? Is maintenance required? If so, is the patient/carer aware and in possession of

instructions about how this will be achieved? Does the patient/carer have a point of contact in the Trust for any queries? If relevant, does the patient/carer have a contact point in case of emergency?

Return

Does the patient/carer know when to return the device? Does the patient/carer know where to return the device once treatment is

complete, to whom and at what time.


34

Appendix 4

BURTON HOSPITALS NHS FOUNDATION TRUST Queen’s Hospital

Part A – Patient taking own discharge I, __________________________________ of ______________________________

_________________________________________________ hereby declare that I wish to be

discharged immediately from:

_______________________________of ____________________________________

Part B – Relative requesting discharge of patient

I, __________________________________ of ______________________________

_____________________________being the * parent, guardian, husband, wife or nearest

relative of _________________________________________________________ who is my

__________________________________ hereby declare that I wish him/her to be discharged

immediately from:

The _________________________________ Hospital, and affirm that I have made this decision freely and of my own volition, fully realising that it is contrary to the advice I have received on my/the patient’s behalf. I hereby agree that the Burton Hospitals NHS Foundation Trust responsible for the said hospital, their officers, servants and agents are wholly absolved and discharged from any responsibility or liability of any description whatsoever arising directly or indirectly out of my/the patient being so discharged at my request from the said hospital. Dated this__________________________ day of _____________________ 20__________ Signature _____________________________________________ Witness (signature) __________________________________________________________ Address ___________________________________________________________________

__________________________________________________________________________

N.B. Part B – This form is only to be used where the patient is unable to complete Part A, or is a minor. * Strike out whichever is inappropriate.

Discharge Policy / October 2017 36

Risk Assessments Appendix 5

1.4.10 The organisation has approved documentation which describes the process for managing the risks associated with the discharge of patients.

OR

As a minimum, the approved documentation must include a description of the:

a. duties

b. discharge requirements which are specific to each patient group

c. documentation to accompany the patient upon discharge

d. information to be given to the patient

e. process for discharge of hours

f. process for monitoring compliance with all of the above

2.4.10 The organisation can demonstrate implementation of the approved documentation which describes the process for managing the risks associated with the discharge of patients.

OR

The organisation can demonstrate compliance with the objectives set out within the approved documentation described at Level 1, in relation to the:

discharge requirements which are specific to each patient group

documentation to accompany the patient upon discharge

The assessor will select two patient groups at random to assess the organisation’s compliance with the above minimum requirement.

3.4.10 The organisation can demonstrate that there are processes in place to monitor compliance with the approved documentation which describes the process for managing the risks associated with the discharge of patients.

OR

The organisation can demonstrate that it is monitoring compliance with the minimum requirements contained within the approved documentation described at Level 1:

discharge requirements which are specific to each patient group

documentation to accompany the patient upon discharge

The assessor will select two patient groups at random to assess the organisation’s compliance with the above minimum requirement.

Where the monitoring has identified deficiencies, there must be evidence that recommendations and action plans have been developed and changes implemented accordingly.

_______________________________________________________________________________________ Discharge Policy / October 2017 37

Appendix 6

Monitoring Matrix – Discharge Policy

Minimum policy require-ments to be monitored

Process for monitoring e.g. audit

Responsible Individual/ Committee/Group

Frequency

Responsible Individual/ Committee/Group for review of results

Responsible Individual/ Committee/Group for development of the action plan

Responsible Individual/ Committee/Group for monitoring of the action plan

Monitoring the delayed transfers of care

sitrep

Lead discharge nurse

weekly Lead Discharge Nurse Social Care and Health

Social care and health Relevant CCG- SSOTP

Head of discharge

Achieving a safe and timely discharge

Patient survey Sitrep PALS CHC process

Head of Discharge Lead Discharge Nurse

6 monthly Head of Discharge Lead Discharge Nurse Matrons Divisional Nurse Directors

Discharge team Matrons Divisional Nurse Directors

Discharge team Matrons Divisional Nurse Directors

_______________________________________________________________________________________ Discharge Policy / October 2017

Appendix 7

Transfer of Care

Protocol


Contents Page Number

1. Introduction 3

2. Purpose 3

3. Process 3

4. Delays to Transfer 5

5. Audit 4

Appendix 1 Patient Information Leaflet 6

Appendix 2 Letter Number One 7

Appendix 3 Letter Number Two 8

Appendix 4 Letter Number Three 9

Appendix 5 Monitoring of the Implementation of the Procedures 10

Appendix 6 Action Form for Transfers of Care 11

Appendix 7 Transfer of Care Flowchart 12


Burton Hospitals NHS Foundation Trust Transfer of Care Protocol

1. Introduction 1.1 These procedures have been developed within the principles of the Community Care (Delayed

Discharges etc) Act and LAC (2004)2, the current New Care Act guidelines 2014 overides the delayed discharge Act. 0 “Choice of Accommodation” Directives, in that “Patients receive the right care, at the right time, in the right place”, and will only be invoked when appropriate assessment of potential for rehabilitation, and consideration of a return home has been thoroughly explored.

1.2 The procedures support the National Framework for Continuing Healthcare and NHS and Funded

Nursing Care 2007(2012) In addition all parties to these procedures accept that no patient has a right to occupy a hospital bed un-necessarily.

2. Purpose 2.1 The purpose of these joint procedures is to minimise delays for all adult patients assessed as fit for

transfer, discharge or rehabilitation including those who need permanent Care Home Placements whether publicly funded, self-funded, or fully funded by NHS Continuing Care or Terminal Care as described in the NHS Continuing Care National Framework (Revised October 2009). These procedures will ensure efficient bed utilisation.

2.2 It identifies target time-scales from multidisciplinary assessment to date of transfer and the process for

resolving problems if transfers are not achieved within the stated times. 2.3 Nothing in these procedures removes the need to follow standard procedures relating to the Community

Care (Delayed Discharges etc) Act 2003, LAC.(2004)20 Choice of Accommodation Directions and/or patient confidentiality including the Mental Capacity Act. Where the procedures refer to carers, family or the patient’s representative (including independent advocate) those providing information, advice or letters of confirmation, must ensure that patient confidentiality procedures are adhered to.

2.4 Planning for patients to leave hospital should begin prior to admission or be commenced within 24 hours

of admission and/or as soon as practicable. It is however recognised that Delays to Transfer of Care attributed to Choice/Family and patients meeting the eligibility criteria for Continuing Care health funding, are excluded from financial charging within the reimbursement arrangements

3. Process 3.1 Social Services will be advised that a patient may need community care assessment using the jointly

agreed procedures such as section 2 and Continuing Health Care check list in line with the Community Care Delayed Discharges Act. Health staff must first screen patients for continuing care using the check list and if positive should adhere to the CHC guidelines.

3.2 Where a Care Home placement is strongly indicated, health staff working on the ward will issue the

patient/carer with the agreed Patient Information Leaflet (appendix 1) and verbally advise them of the time scale and expectations should a Care Home be indicated on completion of a multidisciplinary assessment. Patients/carers should not be advised by health staff that on-going care needs will be met within a care home setting without a multidisciplinary assessment having been completed. The ward


staff must complete the action form and attach to the patient’s notes (appendix 6) and document this on the monitoring form( appendix 5).

3.3 The adult social worker will initiate an assessment of needs as soon as practical during the continuum of

the patient’s hospital stay and be involved in the multidisciplinary discharge assessment. The MDT must first assess the patient against the National Framework for NHS funded Nursing Care prior to determining an outcome of a care home placement. The outcome should clearly indicate whether it is a Care Home with nursing or residential placement that is required, and whether there is a need for any equipment to support the placement.

3.4 Having first determined the level of continuing health and social care, and where a Care Home

placement is agreed, a Nursing Assessment will have been completed. Self-funding patients are eligible for an assessment of needs (Section 47 of the NHS Community Care Act). Where specialist equipment is required to support the transfer, initial and on-going costs must be identified within the request for funding. Whilst awaiting funding approval, social services staff will identify and advise the patient and/or family/carer of Care Homes where vacancies exist which meet the patient’s assessed needs. The multidisciplinary team will agree a date by which transfer should occur.

3.5 The adult social care worker will request the family/carer to identify up to 3 homes with vacancies. It may

only be possible to locate one suitable Home. The adult social care worker will document and communicate this stage of the process to the ward team. For acute settings this is where section 5 should be issued showing the agreed date.

3.6 Where applicable, the adult social care worker will advise the patient and/or family/carer of the usual fee

paid by Social Services and whether the patient’s needs can be met within the fee level, and their rights within LAC (2004)20 Choice of Accommodation Directions. The discussion will also include potential for benefit entitlements, and the contribution by the CCG towards care in a Nursing Home placement or the patient’s own home.

3.7 Upon completion of the multidisciplinary discharge assessment, Standard letter 1 (Appendix 2) should

be issued, by the relevant Senior Sister/Matron/Social Services Service Manager within 48 hours. A referral should be made to the Complex Discharge Team via HISS for ongoing support. If the placement meets the criteria for fully funded care and this is confirmed by the Continuing Care Team, they will then advise the patient and health team and lead on future liaison. This should be documented on the monitoring sheets on the ward.

3.8 A period of 7 days should be given for the patient and/or family/carer to find a vacancy, which will meet

both the assessed needs of the patient and be within available resources if being publicly funded. If transfer has not been achieved within 7 days the adult social care worker, family and ward nursing staff will meet to identify the reasons and will try to resolve the situation. At this point a designated member of the complex discharge team will be identified for liaison with the family for facilitation of the transfer, and a further 7 days will be given. Letter 2 (appendix 3) will be issued and a further 7 days will be given.

3.9 Where the transfer has still not been achieved within 7 days (14 in total) an appropriate interim

placement will be established, with a potential cost to the patient. The adult social care worker and Ward Nursing staff/Complex Discharge Nurse will meet to identify the reasons and will try to resolve the situation. Should there be no resolution found the Matron will need to inform the appropriate Associate Director of the actions to be taken for safe placement for the patient. If necessary, a meeting will be convened promptly which will involve the patient/relative/carer or representative, adult social care worker and relevant health representative. At this meeting the patient/family/carer will be issued with letter 3 (appendix 4) which will state a discharge destination for the patient with a discharge date set.


3.10 The ward team should undertake a further assessment on the clinical safety of making an interim placement. This should be documented in the patient’s health record. Where patients and/or carers refuse an offer of an interim placement, this will be documented in patient records.

3.11 It is implicit that throughout the process, the patient, relatives/carers or representative are appraised

of their rights and provided with written information/letters as identified within these procedures.

4. Audit 4.1 A record of the patient’s progress through the process will be maintained and held at ward level with a

copy sent to the Complex Discharge Team each week, this is the Monitoring of the Implementation of the Procedures (Appendix 5). A copy will be sent to the relevant CCG and the relevant Adult Social Care department when the process is completed or terminated. If the process is terminated part way then this should be identified within the record. Any communication to social care should be sent password protected by email or posted to the relevant social care manager.

4.2 The Trust may choose to take legal action to discharge the patient at any time during this process.

Relevant procedures are in place to support the rights of the patient and complaints can be raised throughout using the Trust, CGG and the relevant Adult Social Care department’s complaints procedure. However, invoking the Complaints procedure will not mean that the Transfer of Care Protocol is not applied

4.3 The Action Form for Transfer of Care (appendix 6) must be competed for each patient to ensure the

correct process is followed and provides an audit trail for each stage of the procedure and filed in the patient’s notes.


Appendix 1

Burton Hospitals

INFORMATION LEAFLET ABOUT YOUR DISCHARGE FROM HOSPITAL

As part of planning your discharge you may require a needs assessment by a member of the Adult Care team.

The aim of this is to see whether, with the right sort of help, you may be able to return home once your medical treatment is completed, or whether you may need a period of care in another setting including a Care Home

It is not appropriate for you to stay in hospital any longer than is necessary.

If you are assessed as needing a period of rehabilitation, this may be provided in your own home or you may be transferred to another facility to receive this care.

Please note that services may vary across localities.

If you are assessed as needing a period of nursing or residential care, you will be given help to find a home with an available vacancy. You will find that our Discharge Team will provide you with all the necessary information to help you make the right decision.

We appreciate that it can take time to make arrangements and find the right home. At the same time, it is not possible for patients to stay in hospital for long periods of time whilst they wait for a vacancy at the home of their first choice. You should consider moving into another home, on a temporary basis, until a vacancy arises in your preferred home. You have the right to choose any home within the UK that holds a contract with the adult social care department or local CCG where you live. (If you are funding your own placement then you have the right to any home including the ones without a registration within your County Council).

We will do our best to help you to organise arrangements as swiftly as possible, taking full account of your personal circumstances and need for any follow up care and support in the place where you plan to live

A copy of this information can be given to your carer, or the main person helping with your arrangements, if you are happy for this to happen.

Please do not hesitate to ask the ward social worker or any ward nurse if you have any questions about these arrangements.

We would like to make you aware that we operate a joint Health and Adult Social Care Home of Choice policy. This will be invoked should your length of stay in hospital be longer than is necessary. A copy of this is available, should you wish to see this please ask a member of the ward staff.


Appendix 2

f Date Letter 1 to be given when funding agreed

Dear

YOUR DISCHARGE FROM HOSPITAL

As a result of recent discussions with the multi-disciplinary staff team responsible for your care, it has been agreed that your need for hospital care has now ended and that your needs will be best met by moving to a Residential Care or Nursing Home. (delete as appropriate following assessment) It is very important for your health and wellbeing now and for the future that you are given help to move out of hospital as soon as possible and to a suitable registered care home that can offer you the appropriate care and support you need. As part of your discharge arrangements a member of the adult social care team should have discussed with you the choice of service provider available in your area. In planning your move into a Residential or Nursing Home you or your representative should have been provided with information by Adult Care staff to help you choose an appropriate Residential or Nursing Home and make arrangements for your move as soon as possible. If you have not received this information yet, please ask a ward nurse immediately. Every effort will be made to ensure that the care home you chose is able to meet your needs and that the service will commence as soon as practicable. However, if you have not identified a home of choice over the next 7 days, or the home you have selected or prefer has no vacancies; we will help you locate suitable alternative care homes where there are current vacancies. You will not be able to remain in hospital and you will need to choose one of these homes to move to until a vacancy in your home of choice becomes available. A copy of this letter will be given to the main person helping with your personal arrangements. Please do not hesitate to ask a member of the adult social care team or any ward nurse or consultant if you have any questions about these arrangements or the decision that you no longer require care in hospital. Yours sincerely Matron/Senior Sister Adult Social Care Worker


Appendix 3

Letter 2 given at meeting with social worker and DLN on day 7

Date:

Dear

YOUR DISCHARGE FROM HOSPITAL As we said in our previous letter your need for hospital care has now ended. We understand that up to now, you have been unable to find or accept a place at a Residential Care or Nursing Home. This may be due to a number of factors including the level of support necessary to meet your assessed needs. It may also be that your home of choice does not have a vacancy at this time. While we recognise that this is an important decision and do not wish to cause you or your family undue anxiety or distress, we do need to be able to offer treatment to others requiring hospital care at the earliest opportunity. Consequently, we would like to assist you to complete your move out of hospital as smoothly as possible. We have therefore provided you with a listing (enclosed) of those homes with current vacancies which will be able to support you whilst you identify or finalise your home of choice; or until a place becomes vacant in the home you have chosen. As one of these homes will be able to provide you with the level of care and support that you currently require, we expect that you will have identified an alternative place of discharge within the next 7 days. All members of the multi-disciplinary staff team will assist your discharge and answer any questions about your care. If you, or someone representing you, would like to discuss your situation with them or a Senior Manager, please do not hesitate to contact us at the above number. If you wish to contact a manager in Adult Care, your local contact will be: add details here of adult social care worker. If you would like help with finding the placement, your Adult Care Worker will advise you further. If, within a month of your discharge to an interim placement, a place then becomes available at your first home of choice, your Adult Care Worker (if you so wish) will help you to transfer there as soon as possible. A copy of this letter will be given to the main person helping with your arrangements. I would like to take this opportunity to thank you for your co-operation.

Yours sincerely Matron Adult Social Care Worker


Appendix 4

Letter 3 Private and Confidential Dear RE: In our letter dated we asked that you identify alternative arrangements until a place becomes available at your preferred home of choice. I am aware that you have been listed for a place/on the waiting list at ………….. Residential Care/Nursing Home (delete as appropriate) but at this time the home does not have accommodation available. Unfortunately, to date we have not received from you a decision on any alternative placement, which has meant we have been unable to proceed with your discharge from hospital. I now feel that you have been given ample time to have arranged for a Care Home to accept the on-going care. Therefore, I am writing to inform you that in order to resolve the situation, a discharge has now been arranged to (insert name of home). This will take place on insert date…………….., This will be an interim placement and you will still have the option of making arrangements to move to the Home of your Choice if and when a place becomes available. I am requesting that you contact (insert name and contact details) ………….., immediately who will discuss your discharge arrangements with you. There is continual pressure on Hospital beds due to ever increasing emergency admissions. Therefore, it is essential that when patients no longer require "hospital treatment" we are able to facilitate their transfer to a more appropriate environment as smoothly as possible. A copy of this letter will be given to the main person helping with your arrangements Yours sincerely Helen Scott South Chief Executive Burton Hospitals NHS Foundation Trust


Appendix 5

Monitoring Implementation of the Procedures

Ward

Patient ID Patient Information

sheet

Date letter

1

Date letter

2

Date letter

3

Comments

____________________________________________________________________________________

___ Discharge Policy / October 2017

Appendix 6

ACTION FORM FOR TRANSFER OF CARE

Surname: …………………… Forename: ………………… NHS No:

………………….

Location of person: Ward ……… Site: (delete one)

____________________________________________________________________________________


Action Date Initials Designation

Patient Information issued and process discussed with patient/representative

Standard letter 1 issued

Vacant placements offered (complete details overleaf):

Confirmation that Social Services have put alternative vacancies in writing to service

user/representative?

Patient is self funder ? Yes No

Funding requested?

Funding agreed? (including self funders if applicable)

Meeting with Patient/Representative/MDT

Date Arranged…………………… Held on: ………………….. (dd/mm/yy)

Invited to attend Actually Attended ………………………………………. ………………………………………… ………………………………………. ………………………………………… ………………………………………. ………………………………………… ………………………………………. …………………………………………

Designated Transfer Facilitator ………………………………………………………..

Standard letter 2 issued?

Standard letter 3 issued?

Stand letter 4 issued?

Further Consultation assessment completed on / /

Process Terminated on: / /

Reason:……………………………………………………………………

____________________________________________________________________________________


Appendix 7 Patient will need ongoing care in a care home setting post discharge. Begin monitoring sheet – appendix 5

↓ Complete section 2 and CHC check list Issue Patient Information Leaflet and advise of time scales – Appendix 1

↓ Complete assessments (CCA, DST, FNCC)

↓ When funding is agreed by social care or health issue letter 1 and allow up to 7 days from this point for a Nursing or Residential home to be found.

↓ If no home identified in the 7 days then Senior Sister must call a meeting with the family, Matron, Social Worker and Discharge Liaison Nurse – Issue letter 2. Inform family they now have 7 days to find a placement from the list of homes with vacancies (to be provided by social worker) or placement will be found on their behalf.

↓ No home identified in further 7 days issue letter 3 by Matron/Head Nurse and meeting held with ward staff/ DLN and social worker to discuss a resolution of any issues. Matron to inform Associate Director of action to be taken and patients imminent placement in a care home.

↓ Discharge takes place

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