NHS support to providers

Enhanced Care at Home is part of the citywide HomeFirst Programme

The Enhanced Care at Home partnership brings together health and care providers from across the city to deliver fast and effective care outside of a hospital setting for adults in Leeds. This will help people who may not need to go into hospital stay at home, including care homes, where they are most comfortable and support others to return home more quickly after receiving care in hospital. You may have previously heard it referred to as Enhanced Community Response.                  

Currently, Enhanced Care at Home includes six main health and social care offers which we call:                  

• Quick Response
• Emergency Cover for Carers
• Rapid Response to Falls
• Home Ward
• Remote Health Monitoring
• Home Comfort

For more information on Enchanced Care at Home download the leaflet                     

Home Ward (Frailty)

The Home Ward (Frailty) HW(F) provides rapid assessment and wrap-around care to people in their usual place of residence, including in care homes and other residential settings, who become suddenly unwell and could normally be admitted to hospital.                                    

The HW(F) provides rapid access to diagnostics (e.g. pathology/ radiology) and treatments that can be safely delivered at home (e.g. intravenous medicines). However because it is a multiagency team including social care colleagues people also get rapid access to increased care packages and therapy services where required. People can be supported at home with multiple visits through the day and care overnight if needed.                                   

Medical responsibility – whilst the patient is under the care of the HW(F), the Consultant Geriatrician will have medical responsibility. There is a daily virtual MDT (Monday – Friday) where patients are reviewed and upon discharge, there is also a Discharge Advice Note so GPs are informed of the patient's time on the ward which will include any further actions to take post discharge as medical responsibility transfers back to the GP.                                    

The Home Ward (Frailty) is available citywide within Leeds.                                   

Referral information for health and care professionals

Referral leaflet                                    

The Home Ward (Frailty) are keen to encourage referrals to the service to avoid hospital admissions to LTHT. There is a referrer's information leaflet which is intended for health and care professionals describing how the Home Ward works, the referral criteria and how you can help someone in your care to access the service. This leaflet is not aimed at patients, carers or any other members of the public. If you would like a copy of this leaflet please email virtual.frailty@nhs.net                                    

Key messages:

• Rapid Referral within 2 hours of receipt – The HW(F) provides rapid assessment and wrap-around care to people in their own home who become suddenly unwell and would normally be admitted to hospital or are already under the care of Leeds Teaching Hospitals and who’s needs can be safely managed at home
• Referral through SPUR Service operating hours are 7 days per week,24 hours a day, taking referrals between 8am-8pm. For patients that require same day assessment or 2 hour response referrals will need to be made between 8am-5:30pm. Referrals between 5:30pm and 8pm will be assessed the next day. All referrals are made via SPUR on 0113 843 2291 you will then be connected to a Community Matron. If you’re not sure someone meets the criteria for the service fully please do refer them. Colleagues working on the service can then choose the most appropriate care option. You will be able to have a discussion regarding the referral with the Community Matron/Associate Community Matron. There may be times when you may have to wait as they are with a patient. If necessary they will call you back and/or this may be a Consultant Geriatrician to obtain more information

Referral Criteria:

The HW(F) accepts referrals of patients who are:                                   

• Registered with a Leeds GP
• Have been seen by a referrer/healthcare professional
• Aged 65 and above
• Needs can be managed safely at home
• People who have been identified as Moderately or Severely Frail using the electronic frailty index (eFI) and/or Rockwood score of 5

Care home referrals must have been seen by a registered professional, e.g GP, nurse paramedic, therapist etc or the care homes employed registered nurse.                                   

Example’s of people who could be eligible to be referred to the Home Ward (Frailty)                                   

• People with mild delirium of an unclear cause who can still be managed at home and when a change in environment may make the delirium worse
• People with mildly deranged blood tests that need short-term monitoring e.g. mild acute kidney injury
• People with cellulitis not resolving with oral therapy - these are typically people who would be admitted for probable IV antibiotics.

Neighbourhood teams will endeavor to promote the HW(F) within relevant MDT meetings.                                   

If you have any comments on the leaflet or the HW(F) in general, please contact virtual.frailty@nhs.net                                   

Pulse Oximeters

The Royal college of General practitioners have developed specific guidance for care homes and an accompanying short elearning that is freely available.                                                    

Please note this video does not work on some older versions of Microsoft Edge and Internet Explorer, it will work on more modern internet browsers. If the video does not work, there is a transcript                                                    

Care home capacity tracker

The Care Home Capacity Tracker is a web based portal designed to support minimising delayed transfers of care by enabling Care Homes to instantly share their live bed state and enable hospital discharge teams and other stakeholders to rapidly find available nursing and residential beds which significantly improves the speed and efficiency of finding capacity at the time it’s needed. Follow the link to register your home on the tracker.                                                    

NHSmail is a secure email service approved by the Department of Health and Social Care for sharing patient identifiable and sensitive information. NHSmail, messaging, and sharing can be accessed by any organisation commissioned to deliver NHS healthcare or related activities.                                                    

Social Care organisation can request NHSmail accounts to facilitate the secure sharing of personally identifiable information to support care provision between primary and secondary health services and social care provision.                                                    

NHSmail                                                    

NHSmail training guide (PDF)                                                    

The Data Security and Protection Toolkit (DSPT) is an online self-assessment tool for data security which supports organisations in demonstrating:                                                    

1. General Data Protection Regulation (GDPR)
2. Compliance with the expected data security standards for health and social care for holding, processing or sharing personal data
3. Readiness to access secure health and care digital methods of information sharing, such as NHSmail and summary care records (a summary of GP information about an individual) and local information sharing solutions. In Leeds this would be the Leeds Care Record
4. Good data security to the CQC is assessed as part of the Key lines of Enquiry (KLOEs) caring (keeping peoples information confidential) and responsive 2 and a range of safe in ensuring information to keep people safe is shared appropriately.

The Department for Health and Social Care recommends that all social care providers complete the DSPT as they will hold, process or share personal data. Completing the DSPT is a contractual requirement for those who provide care through the NHS standard contract and the toolkit helps all providers to demonstrate compliance for the GDPR, the CQC and supports information sharing.                                                    

The Care Provider Alliance developed support for the entry level for social care organisations, as it is understood that for many this will be a new process. entry level is a stepping stone to achieving at the 'Standards Met' level, will be time limited (subject to review) but will allow you to begin using NHSmail.                                                    

DSPT Team email England.DSPTNorth@nhs.net