North Lincolnshire Council assessment

Indicative score:

3 - Evidence shows a good standard

What people expect:

“When I move between services, settings or areas, there is a plan for what happens next and who will do what, and all the practical arrangements are in place. I feel safe and am supported to understand and manage any risks.”

“I feel safe and am supported to understand and manage any risks.”

The local authority commitment:

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Key findings for this quality statement

There was an integrated hospital discharge team that worked across health and care to deliver holistic support to ensure people were safe on discharge from hospital. There was a ‘Home First’ approach for this service that was understood by all partners and at all levels of the organisation from the front line to leaders. ‘Virtual wards’ were used, where a person was able to receive nursing care in their own home. The voluntary sector had been involved in the design of a ‘welcome home’ service to support people with non-eligible needs on discharge, for example shopping or social needs.

When issues were identified in the flow from hospital, such as capacity within the homecare market, the local authority piloted an ‘accelerated learning event’ to trial a ‘perfect discharge’ for 2 weeks. Learning from this had been embedded in the service and had improved outcomes for people and reduced the waits for discharge. The local authority had its own reablement service to support people on discharge, which helped with flow, so people could be discharged from hospital as soon as they were well enough. They had also repurposed a residential home specifically to support reablement for people on discharge from hospital who were unable to go straight home. People told us discharge worked well and described how they were supported with physiotherapy and occupational therapy, as well as support to regain their independence so that they could go home. Providers were paid financial ‘retainers’ so if a person receiving care went into hospital, the local authority continued to pay the care provider for 7 days. This helped continuity and meant people could be discharged back to the same care provider if it was still appropriate. Where there were challenges in relation to discharge, the responsible officers had regular calls each day to discuss discharge and find solutions across all partners.

There were robust transition pathways for young people. Transition started early at 14 years old, with close working between children’s and adults services continuing beyond 18 years old where necessary. People gave us positive feedback about the support they received, and described how direct payments were used to ensure personalised support that promoted the young person’s independence as they moved into adulthood, so they were less reliant on their family.

Joint working within the housing team supported safe pathways during transition for vulnerable people. For example, a staff member in the supported housing and homelessness function worked with probation to support people when leaving prison and a jointly-funded mental health post to support people on discharge from hospital. The team described how, by focusing on housing first, this meant the safety and effectiveness of other interventions and support was more likely to be successful. If people don’t have a safe place to live then they cannot deal with other issues such as domestic abuse, mental wellbeing or finding employment. One person gave negative feedback about their initial experience of support from the local authority in relation to mental health when moving between services. However, they said more recently they had a positive experience and had a good relationship with the new social worker with open discussions about the options available with a flexible approach to meeting their needs resulting in positive outcomes for them.