Learning Disability Services Acute Health / Community LD Team

1. Learning Disability ServicesAcute Health / Community LD Team Partnership Working & Service Delivery Tameside Hospital NHS Foundation Trust in conjunction with Tameside Community LD Services

2. Making it work Partnership Joint working Patient–Led services

3. Monitoring of Repeated attendances and readmissions • Flagging System • CLDT Admission list • Open Case information (nurse-held) • Patient Questionnaires • Easy-read-leaflets – desensitisation/ preventative Next steps: • Tighten up data capture • Leaflet expansion

4. Individualised MDT Discharge Care Planning • Commence discharge planning on admission • Hospital Passport • Personalisation of care plans • Admission Protocol, Flowchart & Referral processes • Carers Care Plan – Carer Involvement • Expected Date of Discharge within 24hours of admission at post-take Consultant Ward Rounds (Emergency admissions)

5. Individualised MDT Discharge Care Planning continued.. • Handover process between Assessment area and Inpatients • Individualised inpatient review of patient discharge care plan • Individualised referral process - to appropriate MDT members/ Transfer Team - Social Care services • Involvement of individual’s Community LDN • Involvement of Hospital LDN if unknown to CLDT • MDT Meetings – to plan/ activate discharge process

6. Patient & Carer Involvement in Discharge Planning • Meeting to suit the needs of the patient and carers - On ward in first instance - Flexible - can be held to suit need (i.e. elsewhere/ time) • Use of Easy-read leaflets/ personalised information package • Adaptation of follow-up treatment & appointments to suit need of individual • Follow-up appointments – Easy-read letters, double appointment slots, location variation

7. Health Inequality Training All staff: • LD Awareness Training - Induction - all staff – raising awareness of reasonable adjustments • Mandatory Training Workbook –linked to Safeguarding Adults to maintain staff awareness Clinical Staff: • Patient Focused Induction – for qualified & unqualified staff – held quarterly • Adhoc training - formal and informal sessions delivered by LD Team within both classroom and clinical settings Further Development: Interactive training sessions User/ carer involvement to co-facilitate/ improve training package

8. Hospital Liaison Nurse Learning Disability Participate in local and regional support networks to ensure sharing of current evidence and best practice To use Person-centred approaches to facilitate and support access to local acute services. To ensure the recommendations from six lives are implemented To ensure continuity of care following discharge To promote a positive image of people with LD Collaborative working with colleagues in the acute trust to ensure effective care planning and provision To lead on training and education sessions for acute trust staff in LD awareness The hospital liaison nurse will work in partnership with people with learning disabilities, their families / carers, and other professionals, to provide a specialist service for people with learning disabilities using hospital services To be the link person between hospital services and the community learning disability team, to act a resource and point of contact for acute trust staff

9. Hospital Liaison Nurse - Learning Disabilities • Case Study – Older People’s General Medical Ward, TGH • Lady with Down’s Syndrome and Dementia. Admitted • due to seizures and diagnosed with Epilepsy. • Initially had 1:1 support from community support workers. Ward staff joint worked with support workers when 2:1 support was required. • Comprehensive handover when community support was withdrawn. Ensured there was a member of hospital staff on each shift who was aware of her additional needs. • Additional Nursing Assistant on each shift to enable the 1:1 support to continue at key times • Moved to a bed by the nurse’s station to facilitate increased observation • Intro / desensitisation visit arranged to CT department. The patient was so relaxed during the visit that the Radiographer carried out the scan immediately even though it was his lunch break.

10. Moving Forward Future Plans for Service Development • Maintain actions from the Six Lives recommendations • Actions identified from Acute Service Review • Actions identified from Community Service Review • Actions identified locally from patient/ carer feedback • Actions/ Service review identified from complaints/ investigations

11. Sustainability Partnership Joint working Patient - led service

12. Thank you… ….any questions?

13. Thank you Contact details: Lisa Cooper Hospital Liaison Nurse LD Lisa.cooper10@nhs.net