How care home professionals are acting to restore people’s independence after falls and strokes

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Hilltop Manor, Stoke-on-Trent

Getting patients out of a hospital setting and back to an independent life is what Hilltop Manor specialises in - and those patients have included a 104-year-old who was able to return home after a stay in the home.

The 80-bed home in Tunstall, Stoke-on-Trent, has 30 beds which are permanently commissioned by the NHS and four which are available to “spot purchase”.

Patients in these 34 beds will either have been admitted from a hospital - sometimes direct from A&E - or will have been referred from the community by healthcare staff.

mental health Depressed elderly woman sitting with a Zimmer

‘We aim to get everybody back home if possible,’ says home manager Kath Barcroft

They are all assessed before coming into the unit to ensure that they are able to benefit from what is on offer. Within 24 hours of being notified of a potential referral, the staff will see the patient and make a decision on suitability. In some cases they will react even quicker - for example, if a patient has had a fall and is going through A&E.

Typically, people referred to the unit will be elderly and may have suffered a fall or had an illness such as a chest infection (it is an old mining and potteries area with many patients with long term conditions from working in these industries).

Some will have a level of dementia, although those with very advanced dementia are not admitted. In many cases, they will have lost confidence in their ability to live independently and building up that confidence will be an important part of their recovery. Occasionally younger people are referred as well.

As well as receiving nursing care, the patients will be seen by physiotherapists and occupational therapists and a visiting GP, who attends the unit every day of the week under contract with the home. Within 24 hours of admission to the unit, the patient will be assessed by all of those involved in their care and personalised care plans drawn up which look towards a successful discharge as the key focus.

Family support

Weekly multidisciplinary meetings will discuss each patient and set goals for their recovery during the following weeks. Psychiatric input can be important with some patients and this is done through an arrangement with a psychiatrist who will visit to assess patients, when necessary.

“We aim to get everybody back home if possible,” says home manager Kath Barcroft. “It is not always possible - sometimes we have to look at nursing or residential care, or sheltered accommodation.”

It is important not only to have the aim of getting people home or into more suitable accommodation but to plan towards it. This involves staff visiting the proposed accommodation to assess suitability and recommend any modifications or equipment which would help the patient return there. Hilltop Manor can then arrange for the equipment to be ordered and installed, minimising any delays in discharging the patient.

They will then do a home visit with the patient to see how they cope. Patients can also be assessed for nursing care and continuing healthcare needs.

Once patients return home or to another setting, they will normally be transferred to local community teams.

Family support and involvement throughout the stay at Hilltop Manor and the transfer to another setting is very important, says Ms Barcroft.

The service has key performance indicators agreed with commissioners, covering average length of stay, patients not being readmitted to hospital within 30 days, days lost to infection, and the “destination” of the patient after treatment. To date the home has continually met all of the KPIs set. Contact with the commissioners and referrers is constant: Ms Barcroft emails the bed availability each day.

Average length of stay is currently 26.5 days - it has been as low as 21, though it obviously depends on the particular mix of patients within the unit at any time.


Westview Lodge, Hartlepool

Residents coming into the transitional and rehabilitation beds at Westview Lodge in Hartlepool have often had a fall.

In some cases this will not have led to serious injury but might have damaged their confidence and made it hard for them to return home. But in others, they have suffered a fracture such as fractured neck of femur and have had hospital treatment for some time.

The aim of all the staff supporting the 20 beds in the unit is to get them home again or to their previous residence, if possible. Eight of the beds are designated as rehabilitation beds, with support from occupational therapists, physiotherapists and support workers provided by the community team.

Patients admitted to these beds are likely to need relatively intensive input which can be provided throughout the day by the community rehab team who are based at the home - probably more than they would get in an acute hospital setting.

The 12 beds in the transitional unit are also overseen by physiotherapists but those admitted to these beds don’t need the same input. There are opportunities for people to move between the different types of bed if their needs change or turn out to be different to the original assessment. A nurse with prescribing rights is also available.

The transitional and rehabilitation beds have been commissioned by Hartlepool Borough Council for the past four years, but the home also has other residents in separate areas who require residential and dementia care.

Home manager Beryl Anderson says that the maximum length of stay is meant to be six weeks but the average stay is about three weeks. However, if further input is needed then this is provided following assessment by the rehabilitation team.

The home has a specially designed gym to help improve patient’s mobility and also a kitchen area which is used to help them become accustomed to everyday tasks again.

Figures from 2011-12 show the transitional beds had 123 admissions, of whom 44 per cent came from hospital, 26 per cent from home and 30 per cent from another rehabilitation unit.

Full house

Of 111 discharges, 36 per cent were able to return to their own home, 32 per cent were transferred to a short stay setting, 12 per cent went to residential rehabilitation, 15 per cent needed readmission to hospital and

3 per cent were transferred to a setting with extra care. Two per cent died from pre-existing conditions. Average length of stay was 17.5 days.

With the more intensive rehabilitation beds. 85 per cent of the 125 admissions in the same period were from hospitals, 11 per cent from a rehabilitation unit and only 4 per cent from home.

Of these, very close to half were able to return to their own home, 29 per cent went into transitional care, 14 per cent were readmitted to hospital and 7 per cent were transferred to a short stay setting. Average length of stay was fractionally over 18 days.

Ms Anderson says that an environmental visit is carried out before patients return home to assess whether equipment is needed to help them. Coordination with social workers helps to ensure that patients who need a package of care have it ready for them when they are discharged. And the team will ensure they have any medications needed and that their doctor and pharmacist are kept informed.

Not surprisingly, the rehabilitation and transitional beds are usually full, with patients waiting to be admitted from hospital - which sometimes means they have to remain in hospital for longer than their clinical condition demands. “We could do with more beds,’” Ms Anderson says.