We’re changing the way the NHS and social care services work with care homes across the Fylde coast so that the system is less complicated for staff, residents and families.
This will not only help to make sure staff and residents have more appropriate access to health and care professionals but it will also help make sure people receive support in their preferred place of care.
Through developing new ways of working in our neighbourhoods and taking the learning from projects which have shown good results in other parts of the country, we are starting to transform how the NHS, social care and care homes all work together.
The short video below provides an overview of how this work will benefit local people:
Please click on the links below to read more information about each specific subject.
We've brought together GP practices and community services across Blackpool to form six 'Neighbourhood Hubs' within the town.
Each hub has a point of contact either by telephone or email and allows primary care access to a wide range of services. These include:
Signposting and referral to other services such as Rapid Response, Enhanced Support Discharge, Nurse Led Community IV Therapy, Extensive Care.
Clinical Care Coordinators
Neighbourhood assistants (admin and HCA)
Drug and alcohol services
Citizens Advice Bureau
Rehabilitation and equipment via Rehabilitation Therapists (OT & physiotherapists)
End of life care advice and support with access to Trinity Hospice services
Links to Mental health support (including dementia)
Health and wellbeing support via Health and Wellbeing Workers
Routine community nursing and community matron support
Continence advice and support
Hydration and nutrition advice
Falls prevention and support for a fall
Education and training for care home staff
General advice regarding long-term conditions related queries (eg heart failure, COPD, diabetes)
Each referral is triaged so the appropriate person contacts the patient. Referrals do not need to specify a service or a type of equipment as this will be part of the triage process.
As with primary care, the neighbourhoods will support housebound patients who meet the housebound definition and other patients will be asked to attend the practice or relevant service.
Where appropriate, once the hubs have seen a patient, the patient is encouraged to contact the hub for future advice or self refer.
The neighbourhood hubs operate from 8am until 6pm, Monday to Friday. Contact details for each hub and the GP practices which they cover are listed below. Care homes should ring the hub which covers the resident’s registered GP practice.
The new care home model which we have launched across Blackpool provides support to all six neighbourhoods.
The model will provide planned care (chronic disease management reviews; education and training) and same day responsive care (triage; visits) which is integrated into the existing neighbourhood hubs with existing and newly appointed staff.
The CCG has been working closely with GPs and partners at Blackpool Council to develop the model over the last few months with the aim of providing greater support to care homes and primary care.
A pilot was undertaken within the South neighborhood which provided lots of learning to aid the development of the new model across the town.
Depending on capacity, as not all staff are in post yet, the model will complete the planned aspect. From December 2017, the staff will work with primary care to provide the responsive model.
We want to support care home staff to provide residents with the most appropriate and timely care possible by changing the way we manage and treat those living with complex conditions. We know that residents of care homes often have many illnesses and their health can deteriorate quite often meaning that they are frequently admitted to hospital. However, this isn’t always necessary and care could instead be provided in the community by a nurse or other healthcare professional.
The aim of the Care Home Connect scheme is to improve care home staff's access to healthcare professionals who can support them and their residents. By using approved technology to carry out video consultations, the aim is to improve the diagnosis and treatment of residents. As a result, this will not only mean that they can remain with in the home, which is often their preferred place of care, but it will also help to ease some of the pressures on our local hospital, other services and care homes themselves.
Through our Care Home Connect project, we are making the best use of technology within patient care. This video provides a short overview of how the technology works in practice.
Information for care providers:
The end of life care pathways are part of the neighbourhood hubs and will provide support to all end of life patients and complete EPaCCs template. They work closely with Trinity Hospice and Hospice at home and the Trinity Hospice Clinical Nurse specialists attend primary care GSF meetings.
The hubs will support primary care to complete continuing care fast track forms so end of life care patients with a rapidly deteriorating condition will have access to specific care packages to provide additional support.
The Hospice at Home service supports patients overnight in their own home, residential care or nursing home, where ever their place of residence is as they enter the final months of life.
The hope is that fewer unplanned hospital admissions will be needed if carers have the reassurance of Hospice at Home nurses just a phone call away. Many 999 calls are made at night as families and carers worry about a loved one’s deterioration and don’t want to wait until the GP surgery opens to get advice or prescribed medication for pain and symptom control.
There are two Hospice at Home teams, each consisting of a registered nurse and a healthcare assistant. One team primarily covers the ‘north’ of the Fylde coast, the other the ‘south’. The service runs 10pm to 8am seven days a week and the length of each home visit will depend on the patient’s needs.
Hospice at Home is working closely with GPs and district nurses, patients, and their families.To make a referral to Hospice at Home, the following criteria applies.
Patients must be 18 years and above with an advanced, progressive life limiting illness where reversible causes for deterioration have been considered.
Patients will live at home, have family and carers in support and where possible advance care plans in place.
A Do Not Attempt Resuscitation should be actively explored, particularly those referred to Hospice at Home e for symptom control at the end of life who’s preferred place of care and death is home.
Patients GP is aware of the referral.
Exclusions include patients with no life limiting illness (except in the cases of frail elderly in end stages of life) and those who have had chemotherapy and or radiotherapy in the last 14 days (they should seek urgent help via oncology).
Referrals are made via a dedicated healthcare professionals line at Fylde Coast Medical Services on 01253 957819.
The 'Red Bag scheme' is a brilliantly simple initiative to help people living in care homes receive quick and effective treatment should they need to go into hospital in an emergency. The "Red Bag" keeps important information about a care home resident's health in one place, easily accessible to ambulance and hospital staff.
The Red Bag contains standardised information about the resident's general health, any existing medical conditions they have, medication they are taking, as well as highlighting the current health concern. This means that ambulance and hospital staff can determine the treatment a resident needs more effectively.
It also has room for personal belongings (such as clothes for day of discharge, glasses, hearing aid, dentures etc) and it stays with the patient whilst they are in hospital. When patients are ready to go home, a copy of their discharge summary (which details every aspect of the care they received in hospital) will be placed in the red bag so that care home staff have access to this important information when their residents' arrive back home.
The Red Bag also clearly identifies a patient as being a care home resident and this means that it may be possible for the patient to be discharged sooner, because the care home has been involved in discussions with the hospital and has an understanding of the residents care needs so they are able to support the resident when they are discharged.
Watch this short animation for further information
Lisa Drinkwater, Pharmacist, provides a medicines management support service for Residential Care and Nursing Care providers in Blackpool. This service has been commissioned by the Blackpool Council Contracts team and offers practical support and advice that promotes best practice to focus on:
Handling medicines safely, securely and appropriately
Ensuring that medicines are given by people safely
Ensuring that published national Medicines Management guidance about how to use medicines safely is followed
This advice is free and the support will be tailored to your needs. Lisa can be contacted via the contracts team at firstname.lastname@example.org.
Listed below are useful templates and tools for care home managers and staff and will be added to over time when new documents are released.
By placing them here it does not mean that the CCG expect these particular tools to be used, but we hope to provide more options and save you a little time searching.