The Woodlands Intermediate Care Scheme Nigel Fain, Acting Head of Care The Community Housing Group Kate Pike, Reablement Team Manager Adult & Community Services

Setting the scene  Preparation, Planning and Set up  Aims of service  Operational / Working Procedures  Service User Involvement  Case Study  Statistics  Summary / Ongoing work

Starting Point  Key partners  Review of Intermediate Care Services  No Provision in Wyre Forest  Increasing levels of Older Population  Review of existing buildings  Remodelling v New Build

The bid  Successful bid to Department of Heath by Worcestershire County Council, Wyre Forest Primary Care Trust and Wyre Forest Community Housing  Bid included remodelling existing sheltered housing schemes, providing Extra Care at Arch Hill Court and Intermediate Care at The Woodlands

The Property  The Woodlands consists of:- 6 furnished bedsits, communal laundry room, rehabilitation gym, communal dining room/lounge, office facility.

Contract arrangements  Block Lease basis  3 year contract  Cleaner  Assured Shorthold tenancy basis  8 week stay at scheme  Inflationary increase  Service Review

Lunch Club service  Monday to Friday  Provision of hot 2 course meal  Link to Activities Co-ordinator  Link to Lunch Club Best Value Review

The Service offers  Prevention of unnecessary hospital admissions  Facilitation of hospital discharges  Prevention of premature admissions to long-term residential care & reduced need for home care  Person-centred, outcome-focussed rehabilitation, drawing from both the medical and social models.  An intensive multi-disciplinary assessment  A stay of up to 8 weeks, free of charge

Why not straight home?  The Woodlands provides a short term, safe, homely environment in which service users can rebuild confidence and gain enough independence with every day living activities to be able to return home safely.  An ideal environment for users … –Whose home environment is not suitable for rehabilitation –Who are not ready to face the enormity of running a home again following hospitalisation and ill health

The Team  Team manager  Occupational therapist  Physiotherapist  Rehabilitation support workers (2)  Care assistants (2)  Community scheme manager  Domestic support Staff cover between 7:30am – 9:00pm, 7 days per week

Eligibility Criteria Service users must agree with referral and…  Live within Wyre Forest and have accommodation to return to  Be over 60 years of age  Be registered with a Wyre Forest GP and be medically stable  Be safe to be alone between visits  Be motivated to participate in an intensive rehabilitation programme or need a complex multi- disciplinary assessment of their needs.

 The majority of referrals are made by Social Workers and Discharge Liaison Nurses  Single Assessment paperwork/ ‘Framework-I’  Trust other professionals assessments  Therapy assessment on admission to establish previous and current functional abilities, goals and to develop a Rehabilitation/Care plan.  Goals may relate to mobility, personal care, domestic tasks or social interests. Referrals/ Assessment

Intensive Case Management  Assisting service users to solve their problems, however small.  Addressing physical, mental health by referring to and liaising with other services and professionals e.g. GP ’ s, DN ’ s, Sensory impairment team, Community Mental Health Team.  Promoting healthy living – advice re diet, exercise…  Supporting service users to arrange and attend appointments, e.g. optical and dental  Assisting users with activities such as paying bills, obtaining a bus pass, organising household maintenance.  Addressing social and leisure needs by exploring options for Community re-integration  Identifying ongoing care and support needs

Team Working  PCT night nurses visit service users between 9pm – 7.30am to support with night-time needs  WFSH’s Central control provide back-up via pendent alarms  Weekly Team meetings – outcome focused  Quarterly Business meetings  Community Reablement & Arch Hill links  Extend group alternate Saturdays  Service users can return to the Lunch Club following discharge from the scheme

Service User Involvement  ‘Having your say in first week’ feedback form  Quality assurance questionnaires on discharge  Updated weekly Care/Rehabilitation plan  Service user forum  Coffee mornings  2006 analysis of feedback very positive

Benefits to Service Users  Returning home or to new suitable accommodation  Increased levels of independence, confidence and safety  Access to transport and social activities  Improved health, wellbeing and quality of life  Decreased isolation  Provision of adaptive equipment and adaptations  Staff have the necessary skills and knowledge to provide appropriate advice and support  Access to a timely, person-centred, outcome focused, intensive, holistic service where users are treated with dignity and respect

Case Study – Miss C  73 year old lady  Lives alone in rented house, never married and retired from the carpet factory five years ago.  No friends and her mother passed away two years ago.  Admitted to hospital with a urinary infection, confusion and reduced mobility.  Referral made to The Woodlands following concerns regarding Miss C’s home environment, her low mood and her mobility.  Following a diagnosis of depression, Miss C commenced on anti-depressants.

Case Study continued…  The Team supported her to make necessary payments to become up to date with her rent and liaised on her behalf with property services and cleaning services about her house.  Team also supported her to progress to using two walking sticks indoors and a three-wheeled frame outdoors.  Miss C made friends with another service user at the lunch club and now returns twice weekly.  The Reablement Team supported Miss C with shopping and settling back in at home on discharge.  Miss C thanked the team for their support and felt that the Woodlands had “changed her life”.

Referrals Sep 05 – March 06 = 21 April 06 – Jan 07 = 79 Admissions to the scheme Sep 05– Jan 07 = 59  42 returned home  7 moved to alternative accommodation (including 3 to Arch Hill)  4 admitted to hospital  1 chose Residential Home  5 currently at Woodlands Occupancy Sep 05 – March 06 = 72.48% April 06 – December 06 = 86.82% Average length of stay = 5.76 weeks Statistics

Summary / Ongoing work  Evaluation of success  Partnership working  Link to Worcestershire County Council Older People Strategy – Strategic Review  Development of activities  Fast track housing solutions

Questions?

Contact Information Kate Pike Nigel Fain