ROYAL BOROUGH OF WINDSOR & MAIDENHEAD AND WINDSOR, ASCOT & MAIDENHEAD PCT INTERMEDIATE CARE SERVICES JAYNE RIGG RAPID RESPONSE & REHAB TEAM MANAGER Windsor, Ascot and Maidenhead Primary Care Trust

WHAT WE HAVE ACROSS OUR AREA A MULTI DISCIPLINARY DOMICILIARY CARE TEAM (KNOWN AS RAPID RESPONSE & REHABILITATION TEAM) 1 x 24 BED PCT RUN REHAB WARD ON A COMMUNITY HOSPITAL SITE IN MAIDENHEAD A DAY HOSPITAL Windsor, Ascot and Maidenhead Primary Care Trust

WHAT WE HAVE ACROSS OUR AREA (continued) A 20 BED WING OF A NEW NURSING CENTRE IN PARTNERSHIP WITH PCT AND PRIVATE PROVIDER 6 FLATS IN AN EXTRA CARE SHELTERED HOUSING SCHEME IN PARTNERSHIP WITH HOUSING ASSOCIATION 1 Windsor, Ascot and Maidenhead Primary Care Trust

OPERATIONAL MANAGEMENT HEAD OF JOINT INTERMEDIATE CARE OVER ALL INTERMEDIATE CARE SERVICES IN AREA EACH SERVICE HAS ITS OWN TEAM MANAGER/WARD SISTER OPERATIONAL CONTROL AND INTEGRATION THROUGH MONTHLY MEETINGS Windsor, Ascot and Maidenhead Primary Care Trust

OPERATIONAL MANAGEMENT (continued) THERAPISTS HAVE WEEKLY MDT MEETINGS TO ‘PULL’ PEOPLE THROUGH SYSTEM AND REFER ON EXTRA CARE HOUSING SCHEMES ARE STAFFED 24/7 BY IN HOUSE HOME CARE TEAM – AND RAPID RESPONSE – Windsor, Ascot and Maidenhead Primary Care Trust

THE EXTRA CARE FLATS 3 BEDSITS 2 X 1 BED 1 X 2 BED SCHEME OF 32 PROPERTIES, REFURBISHED IN 2004 ALL EQUIPPED WITH A RANGE OF OT EQUIPMENT, WALK IN SHOWERS etc. Windsor, Ascot and Maidenhead Primary Care Trust

ACCESS TO FLATS SINGLE POINT OF ACCESS CURRENTLY ONLY FOR THE SOCIAL CARE SERVICES BUILDING TOWARDS INCLUDING ALL IC SERVICES BY AUTUMN 2005 Windsor, Ascot and Maidenhead Primary Care Trust

ACCESS TO FLATS (continued ) ANY HEALTH OR SOCIAL CARE PROFESSIONAL REFERS 24/7 PERSONAL SERVICE ELIGIBILITY FOR SERVICE = TRIAGED BY DUTY COORDINATOR AS TO MOST APPROPRIATE PLACEMENT Windsor, Ascot and Maidenhead Primary Care Trust

3 KEY POINTS IN THE PATHWAY OF CARE RESPONDING TO OR AVERTING A CRISIS ACTIVE REHABILITATION FOLLOWING AN ACTUE HOSPITAL STAY WHERE LONG-TERM CARE IS BEING CONSIDERED Windsor, Ascot and Maidenhead Primary Care Trust

THE OVERRIDING AIM OF THE JOINT INTERMEDIATE CARE SERVICES IS :- TO DELIVER THE RIGHT SERVICE AT THE RIGHT TIME IN THE RIGHT PLACE Windsor, Ascot and Maidenhead Primary Care Trust

CASE STUDY 1 MRS B LIVING AT HOME WITH DAUGHTER IN HOUSE HOME CARE PACKAGE/ CARDIOVASCULAR DISEASE ADMITTED TO HOSPITAL FOR AMPUTATION Windsor, Ascot and Maidenhead Primary Care Trust

CASE STUDY 1(continued) CRISIS OCCURS ASSESSED AS NEEDING NURSING CARE REVIEWED AFTER 1 YEAR MOVED TO ASSESSMENT FLAT FOR TRIAL OF INDEPENDENT LIVING NOW SUCCESSFULLY LIVING ALONE IN EXTRA CARE Windsor, Ascot and Maidenhead Primary Care Trust

CASE STUDY 2 86 YEAR OLD WOMAN LIVING AT HOME WITH FULL PACKAGE OF HOME CARE COPD - DETERIORATING / LOSS OF CONFIDENCE / SELF NEGLECT SEVERAL ADMISSIONS TO HOSPITAL VIA A&E Windsor, Ascot and Maidenhead Primary Care Trust

CASE STUDY 2(continued) AFTER 5 WEEK STAY ASSESSESSED AS BEING FIT FOR DISCHARGE BUT UNSAFE TO REMAIN AT HOME ADMITTED TO IC FLAT TO AWAIT PLACEMENT FOR RESIDENTIAL CARE SERVICE USER AND FAMILY FRIGHTENED OF HER GOING HOME Windsor, Ascot and Maidenhead Primary Care Trust

CASE STUDY 2 (continued) AFTER WORK WITH THERAPISTS AND REHAB. ASSISTANTS. CONFIDENCE WAS BUILT / RELAXATION TECHNIQUES USED / RELEARNT LOST SKILLS IMPROVED AND WAS DISCHARGED HOME WITH ORIGINAL CARE PACKAGE REDUCED Windsor, Ascot and Maidenhead Primary Care Trust

NOT ALL A BED OF ROSES! SOME HEAVY SMOKERS HAVE DAMAGED CARPETS AND SOFT FURNISHINGS 1 LADY WITH EARLY SIGNS OF DEMENTIA WAS VERY STRESSED BY MOVE TO NEW ENVIRONMENT UNIQUE HOUSEKEEPING CHALLENGES OF MANAGING 6 FLATS Windsor, Ascot and Maidenhead Primary Care Trust

STRENGTHS CARE MANAGERS ENCOURAGED TO CONSIDER EXTRA CARE HOUSING AS A REAL ALTERNATIVE TO LONG TERM RESIDENTIAL CARE PURPOSE BUILT AND ADAPTED FULLY EQUIPPED WITH A RANGE OF ADAPTATIONA AND AIDS TO ASSESS NEEDS AND TRIAL POSSIBLE SOLUTIONS Windsor, Ascot and Maidenhead Primary Care Trust

STRENGTHS GOOD RELATIONSHIP WITH THE ON SITE WARDEN. CLOSE RELATIONSHIP WITH THE ON-SITE STAFF Windsor, Ascot and Maidenhead Primary Care Trust

ANY QUESTIONS ? **************** Windsor, Ascot and Maidenhead Primary Care Trust