Step down ward from SHH for patients suffering from predominately delirium, dementia and depression. For further assessment and rehabilitation.
- To optimise older people’s health, wellbeing and independence through medical, nursing and therapy interventions provided in a community setting (Saffron Ward).
- To provide rehabilitation for people with co-morbid physical and mental health conditions who are considered unsafe to remain in, or return, to their own homes, but who would have the ability to live at home if provided with suitable rehabilitation services.
- The ward provides a facility for patients with a delirium to be allowed to recover and achieve optimal level of functioning and thus avoid inappropriate placements.
- The ward adopts a bio-psychosocial model to deliver holistic care to patients with complex presentations who are cared for by a multi-disciplinary team
Aims and objectives of service
- Admissions from wards at Stepping Hill for patients who are medically stable and who would benefit from rehabilitation/further assessment with a view to returning home or to usual place of residence (Step down beds).
- Provision of a comprehensive assessment and structured individual care plan that involves active therapy or opportunity for recovery:
- All patients will receive a physio assessment on admission to the ward with the aim of mobilising the patient as quickly as possible – a care plan in relation to this is devised by the physio and enacted by the nursing staff on the ward.
- Patients receive OT input whilst admitted to the ward in the form of individual home assessments as well as structured activities that take place within the ward environment.
- A range of nursing assessments are carried out on the ward, including falls risk assessments, skin integrity assessment (Waterlow), nutritional assessments (MUST) and appropriate review by the dietician. Physical health screenings (physical health screening tool and MEWS) are completed on admission, and a general mental health assessment is ongoing.
- Referrals are made to Speech and Language Therapy Team where appropriate
- All patients are under the care of a contracted GP who through a contract accepts overall responsibility for the patient’s medical care. GP visits are daily to the ward (Mon-Fri).
- A consultant psychiatrist working in The Meadows Liaison services visits the ward on a weekly basis and takes appropriate referrals.
- Maximisation of independence to enable patients to resume living at home with or without social care/independent sector support according to assessed need
- Parity of esteem to be intrinsic to each admission i.e., equal status for mental health and physical condition appropriate to admission and discharge protocols.
Service description/care pathway
Saffron Ward comprising 20 beds to provide a rehabilitative environment capable of maximising individuals’ mental health and wellbeing in a comfortable and welcoming environment supported by skilled and competent staff in sufficient numbers to comply with the Francis recommendations.
- The prime admission route for step down referrals should be from the wards at Stepping Hill. Appropriate patients to be identified by liaison services working in the hospital. Transfer to Saffron to be agreed through Hospital Discharge Co-ordinator via liaison services. Patient has completed acute medical care for physical illness and is determined to be medically fit by their ward RMO.
Discharge pathways and length of stay
Average length of stay is currently 5 weeks. Saffron differs other intermediate care wards as others wards don’t accept patients suffering from dementia, depression or delirium. The Saffron Ward cohort is complex, targeting patients with co-morbid physical and mental health complexities. Therefore, some patient’s will stay longer than 5 weeks,
Discharge is achieved through the involvement of a mental health social work team working at The Meadows. The team consists of 2 social workers an assistant practitioner and an OT
The team has relevant mental health experience that allows it to co-ordinate a safe and effective discharge that avoids re-admission. Discharge where possible would be to the patient’s home however where this cannot be achieved even with appropriate packages of care, then discharge would be to appropriate residential or nursing home settings.
The overall of the safe discharge would be to ensure that the patient was not going to re-present at the general hospital and have a further acute inpatient admission. Patients will have follow-up on discharge in order to ensure that the care plan agreed, at the point of discharge, has been adhered to. Discharge follow-up will be either through the wider liaison team or through members of the discharge co-ordination team.
Once follow-up has happened, the patient will be discharged either to the area integrated team or GP.
- Patient over the age of 65yrs
- Resident of Stockport
- Those who have had a fall or experience reduced mobility
- Those with an exacerbation of a long term condition or readily treated medical condition (e.g. UTI)
- Those with dementia or significant cognitive impairment which places them at risk should they remain in their usual place of residence.
- Patients suffering from a delirium
- Patients requiring a longer period of assessment because of their mental health needs and co-morbid physical health problems (that are not acute in nature)
Patients with mental health problems who may face a prolonged hospital stay, or admission to residential care, without further support and rehabilitation
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