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9.2.3 Transfer of Care from a Short Term Bed

This chapter was added to the manual in December 2013.


Contents

  1. Scope
  2. Principles of Good Practice
  3. Key Legislation and Local Policy
  4. Admission
  5. Giving Messages and Recording
  6. Usual Procedure (including the Escalation Policy)
  7. Choice
  8. Disputes
  9. Model Letters
  10. Active Transfer of Care (Eviction)
  11. Following an Active Transfer of Care

    Appendix 1: Important Information for Short Term Service Users

    Appendix 2: Model Letters


1. Scope

The Transfer of Care from a Short Term Service bed policy intends to give clarity to situations where a person is in a short term service bed that no longer meets their ‘assessed need’. Assessed need is what the Council has identified an individual as having and which the Council has a duty to meet with the provision of care and/or other services as they fall within the Council’s Fair Access to Care eligibility criteria. Short term means up to a maximum of six weeks, but it is more usually about 21 days.

This policy gives guidance on how the process should be managed when a service user refuses to move. This may result in an active transfer care which is eviction from the short term service. The service user is then moved according to their assessed* needs. This could be to their own home with or without services or to a further service that can meet their assessed needs.

This policy is only used as a last resort; professionals must work with service users in short term beds to enable them to move on in a timely manner.

This policy applies to all Brighton and Hove City Council short term beds, joint Health and Social Care Short Term beds and beds supplied on behalf of Brighton and Hove City Council or jointly by Brighton and Hove Health and Social Care.

This includes:

  • Community Short Term beds;
  • Transitional Beds;
  • Respite beds;
  • Crisis beds

    (Note: this list is not exhaustive and may change)


2. Principles of Good Practice

Professionals must treat everyone as an individual and in a person centred way. Assisting and supporting a person move through the Short Term Service bed must be firmly but sensitively managed. Professionals must be mindful that a person’s needs might change throughout the process. It may be a period of change for a person that can be stressful for them, their family and friends.


3. Key Legislation and Local Policy

Key National Legislation Local Guidelines
LAC (DH)(2009)1: Transforming Adult Social Care Process for Escalation of Sussex Community Trust (Brighton and Hove) Delayed Transfers of Care awaiting Social Care Support 2011.
Mental Capacity Act 2005 Deprivation of Liberty Safeguards. Choice on Transfer of Care Policy TCP 212 BSUH.
The Community Care (Delayed Discharges etc.) Act 2003. Sussex Multi-Agency Policy and Procedures for Safeguarding Adults at Risk.
The Care Standards Act 2000 FACS (Fair Access to Care).
  Brighton and Hove City Council Escalation Policy 2012


4. Admission

The professional referring the person to a short term bed must make the service user aware that it is short term service. It must be recorded that the service user has had this information and that it has been understood.

Information should also be given to them in writing (see Appendix 1: Important Information for Short Term Service Users). This must be signed within two days of arrival in a short term service. The care manager (or other professional) giving the information must record that the service user or their advocate has been given the information. They also have a responsibility to ensure that it has been understood, due regard must be taken with regard to capacity and language needs.


5. Giving Messages and Recording

The message that the service is time-limited must be reinforced and delivered consistently throughout a person’s stay. All professionals have a responsibility for doing this, including the manager of the home, staff working directly with the service user, care managers and allied professionals.

Everyone coming into a short term bed must have an introductory meeting with their care manager or allied professional and a representative of the home. This is the opportunity to explain the aims and objectives of the placement and to reiterate and record that the service user is aware that the placement is short term.

The length of time someone stays in a short term service bed is dependent on his or her individual need. They should be given an idea of the expected move on date within the first two days of their stay. This should be reviewed at least weekly. These meetings should be attended by those involved in the transfer of care planning and recorded.

If a person no longer needs short term service bed they must be moved on, either home with or without services or to a further service that can meet their assessed needs.

It is important that any issues that concern the service user’s capacity are fully investigated and the service user and their family/friends supported. Mental health professionals must be involved as appropriate.


6 Usual Procedure (including the Escalation Policy)

Every person in a short term service bed will have a Placement Planner. This document clearly defines the intended outcomes from the placement and sets out the sequence of tasks and activities to be completed to achieve these outcomes. Each task and activity has a named worker who has responsibility for completion and each has a timescale attached to it.

The Placement Planner must be completed within the first two days of admission. A discussion must take place between the care manager, senior care officer (or similar), care home manager and allied professionals about the outcomes expected for each person staying in a bed. The Placement Planner must be completed accordingly and shared with the service user.

The Escalation Policy is the set of procedures that govern a person’s timely move through the services and specific when a situation must be ‘escalated’ to a more senior manager. It is the responsibility of the Residential Unit Manager (or delegated manager) to monitor the escalation process and ensure that people move through the service in a timely way. Where there are difficulties escalation discussions will take place between the Residential Unit Manager (or delegated manager) and Operation Manager (assessment). These will ensure that a person moves through the services in a timely way.

People whose care is funded by Brighton & Hove will be expected to move to somewhere that can meet their needs. This may be a person’s own home with a care package or a care home. Privately funded service users can make their own decision regarding move on plans. No one will have the option to stay in a short term service bed when it no longer meets their assessed needs.

If a person in a Short term bed is thought to need an assessment for Continuing Health Care, this assessment must take place without delay. If the person is assessed as needing Continuing Health Care further decisions will be made on an individual basis.


7. Choice

If the person is returning home, the assessment must identify the support that is required and this must be place prior to a person returning home.

If a publicly funded person is moving to a long-term care home the care provided must meet their assessed needs and choice must be considered wherever possible. The service user and their family or friends are encouraged to view a home, prior to moving there. This must happen in a timely way, it is expected that it is usually within two days. If this is not possible, then the manager of the home (or their delegate) should visit them. This is a statutory requirement of Care Standards Act 2000.

If after visiting the home or meeting the manager, the service user declines the offer of a placement, the reasons for doing so must be clear. Where possible, changes should be negotiated to make the service suitable.

It is important to note that the person may have more choices regarding the care home after they have moved out of a short term bed – see below

If a longer term care home placement is needed it will usually be a single room, in a registered home managed by an approved provider. This may not necessarily be a room within Brighton and Hove. If a shared room is acceptable, this should be noted in a person’s assessment.

Once a person has moved they will be continue to be reviewed. It is at this stage that they will be offered up to three longer stay placements that will meet their assessed need and they will be supported to move if this is their choice.

In general, it is expected that the process of moving to a longer term service works relatively smoothly. Most issues can be resolved through the usual processes of good communication from all those involved. This must include the service user, their representatives, staff working in the service, the assessment team, allied professionals and related services.

If a person is returning home, a care package must be in place and if needed, and their home should be able to meet their needs. If a person insists on returning home before they are advised to do so, they must be made fully aware of the risks. Processes to manage these must be explored and recorded. The care manager is responsible for doing this.


8. Disputes

Whenever a person is refusing to move out of a short term service bed that no longer meets their needs, the reasons for this must be given by the service user and if possible the situation should be resolved informally.

All professionals including registered managers and general managers must be kept informed of what action is being taken throughout the process. Legal advice must be sought as appropriate.

If there are protracted difficulties in resolving the move, the service user must be made aware that the service initially identified for them may be lost e.g. a longer stay place in a specific care home may be allocated to someone else.

The service user and their advocate must be informed that they may be charged the cost of the placement from the date when it no longer meets their needs. This cost will be determined on a case by case basis and agreed by Director Adult Social Services/Lead Commissioner for People Adult Social Care. This must be recorded.

Throughout any dispute, support must be provided for the person using the service. The use of an advocate must be considered and the service user must be made aware of the complaints procedure.


9. Model Letters

Each decision must be made on a case-by-case basis. Model letters are included as Appendix 2: Model Letters. These may need to be adapted to ensure that the person receiving them or their advocate understands them.

The decision to issue the first letter is with the Service Manager; Residential Services Adult Social Care (Provider) and it should have their signature. The decision to issue the second letter is with the Director of Adult Social Care and it should have their signature.

Letters must be written must be in a style that is accessible to the person involved. The care manager should normally issue the letter by hand and ensure that the person receiving it, and/or their advocate understands the content. This may involve reading the letter. It might also be helpful to send a copy of the letter to a family member or friend. All actions must be recorded.


10. Active Transfer of Care (Eviction)

The service user and their advocate must be aware that if the placement no longer meets their needs they will have to move. It will be made very clear to the service user that they will be expected to leave and they have no legal rights to remain.

A risk assessment must be completed and it must be shared with the service user and signed. This will include details of support following the transfer.

Transport to move the service user will be arranged and assistance will be offered. The service user and their family/friends will be advised of the arrangements.

Any active transfer of care (eviction) must be handled very carefully and the service user involved must be well supported.

If the procedure has been followed and an active transfer of care is imminent and the service user refuses to comply with the arrangement, under no circumstances should it be affected by physical means. Legal advice must be sought.

Frontline staff also must be supported throughout the process. When there is an active transfer of care the service manager will be present at the care home.


11. Following an Active Transfer of Care

When a service user moves, the care management will be reallocated to the appropriate assessment team.

Following the dispute the service user will enter the reviewing system. They are likely to need support, and professionals working with them and their friends and family need to be aware and sensitive to this.


Appendix 1: Important Information for Short Term Service Users

Click here to view Appendix 1: Important Information for Short Term Service Users


Appendix 2: Model Letters

Click here to view Model Letter One

Click here to view Model Letter Two

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