Memorandum by Community and District Nursing
Association
RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES
(HSS78)
3. EXAMPLES OF
GOOD PRACTICE
3.1 In Croydon, the Community Trust and
Social Services have agreed a document "Working Together"
which details the role of Home Care and Community Nursing, and
lays down six rules of working together to ensure good collaboration:
— Home Care Staff have the right to
ask for a District Nurse assessment when a stable health situation
becomes unstable or changes in some way.
— Local interface meetings will be
held quarterly between the Home Care Co-ordinator and a member
of the local District Nursing team.
— When joint care is agreed, both agencies
must adhere to their part of the input. A review date must be
agreed and inputs may change at that point.
— The care plan, district nursing record
and any other relevant documentation will be kept together and
accessible to all providers of service, with the agreement of
the patient/service user.
— In each case, where joint care is
agreed, both agencies will identify the key person responsible
for liaising and co-ordinating their inputs to the care plan.
— If agreement cannot be reached about
joint care, the respective managers should have further discussions.
3.2 In Hounslow and Spelthorne, the Residential
Home Nursing Team has been a great success. First set up 14 years
ago by joint funding in Feltham, it was extended first to Hounslow
and then to Spelthorne.
3.3 The aim of it was to ensure that those
people living in residential homes received the same level of
nursing care as those living in their own homes. For example,
provision of equipment, nursing care as those living in their
own homes. For example, provision of equipment, nursing skills,
twilight and Marie Curie services, therefore there was no disadvantage
to the patient being in residential care.
3.4 Each resident is assessed on admission
for any existing or potential health needs, the team provide training
to the home staff in moving and handling residents, recognition
of common problems and prevention of complications such as pressure
sores and infection. The service has identified that when the
health needs of residents increases, they are able to remain in
the home for the rest of their lives because of this team.
3.5 Unfortunately because Health Authorities
are now taking on the funding, whilst Ealing Hammersmith and Hounslow
HA is able to continue, West Surrey HA is not and the scheme may
fold in Spelthorne.
3.6 During the life of this scheme, the
ownership of the homes has changed from wholly Local Authority
to partly charity owned (which still receive the service) and
private where a pilot is currently taking place in Spelthorne.
3.7 In Rochdale, the District Nurses provide
the Care Management function to those patients with complex nursing
needs. The target group is:
— People in danger of losing their
independence but remaining at home and becoming very dependent
upon a carer.
— People who have become so dependent
that they are no longer able to live at home.
— Situations where community care support
is in danger of breaking down or has broken down.
— Situations where an unpaid carer
is no longer able to offer support.
— Anyone entering any form of residential
care whether on a permanent basis or for rehabilitation, where
the above criteria are met.
— Situations where the abuse of an
older person is suspected, alleged or confirmed.
3.8 Set up at the start of Community Care
in 1993, by Social Services, Health Authority, Community Trust
and voluntary groups, the scheme ensured that patient and carer
were assessed and appropriate health and social care delivered.
If care cannot be provided with existing services, then it can
be bought in. The District Nurse assesses the total needs of the
patient and carer and refers the completed documentation to a
Central Forum who sanction it.
3.9 No-one has ever been refused as the
documentation gives a very clear picture of the needs. This system
does not create delays in providing care as telephone sanction
can be given if necessary. There are plans to devolve the budgets
this coming financial year to the District Nurses themselves.
3.10 In Somerset—Joint community care
assessments are done by District Nurses with Social Workers to
agree care needs and the balance of service contribution. There
is £78 difference in funding between residential and nursing
homes and if the patient has nursing needs but is not admitted
to nursing home care, that money is available for use for additional
district nursing. The budget is held by the Community Trust's
Locality Managers and the fact of joint budgetary responsibilities
is an incentive for collaborative working. As a result, Somerset
has far fewer nursing home placements than other counties.
3.11 In Gloucestershire—Joint training
sessions between District Nurses, Health Visitors and Social Workers
are being held with the aim of increasing understanding of each
others' roles and enhancing better working relationships. A pilot
project is currently being run on health and social care workers
jointly assessing patient need for nursing home care.
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