NHS Devon - Provision of Hospital Discharge Scheme

The Live-in care reablement service was established in November 2021 as a pilot project to establish the benefits of 24/7 reablement support to people in their own home to both support hospital discharge and avoid admission. The proposed service is to run for 7 months to provide 9 carers across North and East Devon (Initial proposal for 6 across East and 3 across North). This service is to run across North and East Devon from 3rd October 23 - 31st March 24. The purpose of the Service is to support and enable Service Users to remain in their own homes, living as safely and independently as possible, with a focus on reablement and reducing reliance on the provision of social care. This block contract will focus on the following groups: • People who would benefit from reablement to enable them to return home and remain at home with a package of care suitable for their assessed needs. • People being discharged from Hospital to enable a smooth transition back to their home. • People at risk of being placed in short term care that could further disorientate them, including those with an organic mental health condition (e.g.) dementia and/or a temporary delirium which is unresolved. • People in the community who are at risk of being admitted to hospital. What is Live in Care A live-in carer can support people in their own homes with the following: • Preparing meals • Running errands • Completing household chores • Administering or prompting of medication (in line with CQC regulations). • Support with personal care • Mobility support • Support to engage in community activities. • Companionship and emotional support • Caring for a pet • Carry out reablement focused work with the correct training (e.g., exercises as directed by a HCPC registered Physiotherapist). • Complex care support with the correct competencies and training. It is important that live-in carers provide a reablement approach and encourage the person to complete daily living activities as independently as possible. It is also very important that live-in carers keep accurate records of their observations when working with a person, as this will inform part of the assessment of their future requirement for care and support. Support at night: It is not expected that a live-in carer would be disturbed routinely more than twice per night. If this occurs this needs to be flagged with the Live-in carer's employer as soon as possible. Requirements: • Carer requires their own bedroom, with adequate bedding. • Carer requires access to a bathroom with washing facilities. • Carer may require access to the internet - if they must upload electronic notes. • Carer requires 2 hours per day for a break time. • Carer requires space to store food and access to cooking facilities. • Carer will be required to provide their own food unless otherwise agreed with the Service User. This needs to be decided before package of care commences. If the person's property does not have a bedroom available for a Live-in carer, then the service can still be commissioned. This would mean that support is provided by 2 carers in a 12 hour shift pattern.

Based on the success of previous schemes we intend to offer a contract to provide support to discharge patients from hospital into a care home; to provide support on a one to one basis. The proposed service will support a minimum of 45 service users across North and East Devon with the management and leadership of this scheme to be led by the Provider between 3rd October 2023 and 31st March 2024 Care Services to be provided: • The Provider will source and supply 1:1 care worker, with the designated skill set as required to support the individual needs of the person. • The Provider will arrange the co-ordination of all 1-1 care workers for the duration requested. • The Provider will provide relevant details about the 1-1 worker to be provided via the Hospital Discharge Team to the care home. • The Provider will provide a 24/7 out of hours contact for 1-1 care workers, in the event that they are unable to attend the shift the Provider would find a replacement with minimal disruption / delay to the receiving care home. • Out of hours the Provider would communicate the issues directly to the care home ensuring to inform Hospital Discharge Team at the earliest next working day. • The Care provider will have appropriate contingency plans to be able to provide the support required. • The 1-1 care worker will accept all reasonable requests from the registered manager when on site. This is likely to include some distant working with the person, allowing assessment of the individual to be left at times, when safe to do so, supporting onward integration and reduced dependency on 1:1 support. • The Provider would report any concerns regarding their placement in sufficient time for resolutions to be found without causing disruption to service. Care tasks required: • To support the person to settle into their environment and help to orientate them to their surroundings. • To provide emotional support and comfort using best practice techniques for people with an organic mental health condition. • To support the care home care team in meeting the person's daily needs. • If the person is struggling to communicate their needs, work alongside them to try and understand their needs and wishes. • Where appropriate encourage the person to take part in activities within the care home. • Support the person if displaying any behaviours of concern; and help to divert their attention to meaningful tasks (e.g. the person is entering the space of other people at the care home). • To provide a kind and compassionate approach to any interactions with the person. • To work with the person in an enabling way and provide regular feedback to the relevant health and/or social care team. This includes making clear recommendations and suggestions about how the 1:1 support can be reduced.