The examples below provide insight into how other Good or Outstanding rated services are succeeding in this area of inspection.
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Tackling failed discharges
Exceptional systems were in place to proactively improve the service, this included how staff worked with external stakeholders. For example, the registered managers collaborated with other professionals to proactively identify which areas were causing delays or failed discharges and fed this back to their stakeholders to continue to improve the discharge experience for people.
They worked together to look at patterns and trends which caused failed discharges and implemented systems to reduce the risk of these re occurring. This enabled people to return home with a package of care that met their needs, in a safer and more efficient way. This helped to accelerate people's recovery.
Read more about this service here.
Care provider: Community Support Services Micare
Date published: March 2023
Positive feedback from professionals about moving people out of long term hospital placements
The service had successfully supported several people to move from long term hospital placements to live in the community. Health professionals spoke of the exceptional skill and management of these transitions by staff.
Comments reported to the CQC included, "In my experience Orbis spend a great deal of time getting to know the person prior to commencing their individual care package. This includes working with professionals to understand the person's history, diagnosis, treatment plan etc, but also observing the person being supported in the inpatient environment (for example) before then gradually taking over the persons care and support before transition into community and finally discharge. It is always very intensive leading up to discharge which serves as an excellent model of transfer of care and support by Orbis staff" and "Orbis have recently supported a very complex individual out of hospital who was suffering unnecessarily in hospital. They are now living their best life and engaging in activities that no-one in the inpatient service thought were possible."
Read more about this service here.
Care provider: Orbis Support Offices
Date published: March 2023
Appointing an Admissions Manager and Coordinator
The service had demonstrated innovative thinking around managing safe admissions to the home. They had not been able to conduct face to face pre-admission assessments throughout the pandemic, leaving them to rely on trusted assessor documentation.
To make this process as safe and effective as possible, the company had appointed an Admissions Manager and Coordinator, who had joined them from the local hospital where they led on discharge planning to care homes. This meant the team had very close contacts within the hospital and that they were getting a more complete picture of people's care needs to ensure the care provided was truly person centred.
Read more about this service here.
Care provider: Cedars Place Care Home
Date published: March 2023
Better health equality and outcomes for people
Staff personalised people's support around healthcare, to ensure better health equality and outcomes for people. People's sensory sensitivities were accounted for on an individualised basis so they were supported with health appointments in a way they could manage. For example, ensuring clinicians understood one autistic person could not go from one room and back again, as this would 'end' the appointment for them.
Read more about the service here.
Care provider: Avenues South East
Date published: November 2022
Helping people transition to a new service with trusted staff support
The service worked with other agencies such as the Dementia Intensive Support Team, as well as the person’s GP and family, to support the person to stay at Davers Court as long as possible when their needs increased. The person's condition deteriorated further, and the service was no longer able to support them safely. However, staff continued to work with the service the person had moved to, ensuring the transition was as smooth as possible. This included providing input into the person's care plan at the new service.
Read more about the service here.
Care provider: Davers Court - Care UK Community Partnerships Ltd
Date published: March 2020
Enabling a person to go home
The staff approach to supporting people and managing risks and their safety was exceptionally person-centred to enable people to take maximum control over their lives. One person was desperate to go home after living at the service for three years following a stroke.
Staff completed an emotional and physical risk assessment to help facilitate this. Even though the physical risk was identified as high, staff had still proceeded with supporting the person to achieve their aim and respect their wishes, including visits home which enhanced their emotional wellbeing.
Read more about the service here.
Care provider: Landermeads Care Home
Date published: March 2020
Improving support to people discharged from hospital
An extra care housing scheme that provided independent living worked closely with their NHS Foundation and local authority to improve hospital discharge support.
Referrals were made via social workers when people were ready to be discharged from hospital but need time to rebuild skills and confidence, or move to more suitable alternative accommodation. The rooms are fitted out with aids, adaptations and technology that the individuals are likely to need when back at home so they can get used to using them.
Each person has a keyworker who’s their main contact throughout their stay, but they also receive the support they need from a multi-disciplinary team, including the local housing association’s dedicated care and support team, led by the deputy manager, and community health staff such as occupational therapists, physiotherapists and district nurses.
Care provider: Anonymous
Date published: April 2018
Helping people settle back in from hospital
The organisation developed a 'home and settle' service which supported people out of hospital to settle back into their own home. The community-based service ensured staff visited people in hospital and assessed their needs to gather information such as when they were likely to be discharged. This enabled the service to best prepare for the person’s return home, purchasing food needed and ensuring someone was there to support them. In one instance where the person had been in hospital for nine months, the service arranged a new bed and appropriate furniture.
Care provider: Anonymous
Date published: April 2018
Supporting hospitals with discharge in busy periods
Over Christmas the registered manager had arranged to admit people that were ready for discharge from hospital, but where community care could not be arranged. This enabled the people to be in a ‘safe and homely environment’ over Christmas and also free beds up in the hospital over a very busy period. The hospital was so impressed with the service, they since contacted the manager to see if further joint work could be organised.
Care provider: Anonymous
Date published: April 2018