Download 2.1 Integrated Care Framework V0.6

EREWASH INTEGRATED CARE FRAMEWORK
1. Population Needs
1.1 National/local context and evidence base
It is acknowledged that in Erewash, access to community health and social care can be difficult and time
consuming, requiring professionals to coordinate access to and input from multiple services and providers. This
administration process does not represent an effective use of time.
It is also acknowledged that population projections show an ageing population, such that by 2033 27.5% of the
population will be aged over 65, 14.6% over 75 and 5.7% over 85. This ageing population will require more in
terms of health and social care. In a survey in 2010/11 68.8% of people in England said they felt supported to
manage their condition. However in Derbyshire only 53.9% said they felt supported, ranging from 50.8% in
South Derbyshire to 57.3% in North East Derbyshire. This Integrated Care framework will introduce the systems
and processes needed to support individuals with and without Long Term Conditions through seamless
partnership working.
(Source: Joint Strategic Needs Assessment 2012)
2. Scope
2.1 Aims and objectives of service
2.1.1 Aims
The provision of supportive and enabling care closer to home has been the constant central theme of recent
national health consultations and policies, to ultimately deliver better care for patients. To achieve high quality
and cost-effective healthcare closer to home, a robust model of integrated care is required. The following study
shows that integrated teams are a highly significant factor in improving care for people with long-term conditions:
‘Singh D. Transforming Chronic Care: Evidence about. Birmingham University (2005) meta-analysis’
This framework supports an Integrated Care Model which has been developed as part of the Erewash Integrated
Care Programme. This is designed to provide an equitable needs-based service and continuity of care across a
whole population. The aim is for all teams across health and social care to be integrated, sharing knowledge and
skills and having respect for each other’s strengths so that it is as if it is one team delivering a service in equal
partnership.
The framework aims to deliver:
 A Single Point of Access Service
 An integrated Community Delivery Team service, with the teams working together and jointly agreeing
how best to share work
 A common framework to ensure that individuals receive seamless care by accessing the right service at
the right time, through strengthened Partnerships between Health and Social Care. This will be through
the Integrated Care Model as described in Section 2.2.3.
2.1.2 Objectives
The principles of the integrated care framework is to:
 Provide a co-ordinated service to receive ‘urgent/short term care’ and ‘longer term case
management’ referrals from health and social care professionals within the community
 Establish and maintain a directory of services, detailing - where appropriate - daily capacity status,
referral process to be followed, contact details and all other appropriate details as determined to
support effective delivery of the service
 Facilitate and co-ordinate the provision of the care required to support the individual (health and
social care)
 Monitor the delivery of care to ensure that the agreed health and social care input is received in a
timely manner / to the timescales agreed
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


Improve accessibility to community services (health and social care)
Decrease time spent by referrers navigating services in an urgent or longer term case situation
Upon initiation of the agreed treatment plan/care, if the individual is assessed as requiring input
from supporting services (see blue boxes in Section 2.2.3 (Model)), the service will facilitate the
additional input required and provide feedback to the originating referrer.
2.1 Service description/care pathway
2.1.1. General Overview
The integrated care service will be a single point of access to receive ‘urgent/short term care’ and ‘longer term
case management’ referrals from health and social care professionals within the community. Urgent/short term
care referrals will be routed into either ‘rapid response’ or ‘intermediate care team’ and longer term referrals will
be directed to the Community Delivery Teams.
2.2.2 Service Description
The different functions of the integrated care service includes:
 Single Point of Access
 Rapid Response
 Intermediate Care Team
 District Nursing Team (specific to Integrated Care)
 Community Delivery Teams.
The individual specifications can be found in the Appendices section.
2.2.3 Service model
Referrer
t
ee
tm A
no SP
es for
Do eria
crit
SPA
Un
pla
nn
ed
Pl
an
Navigator
ne
Care Co-ordinator
Routine Task
Nomination Criteria
Non Critical
Rapid
and Intermediate
Response Care/Reablement
YES
Community
Delivery Team
DN
team
Nomination Criteria Score
determines bias
Health
Critical <2hrs
Referral Criteria
Manage for
required period
Continual Assessment
Secondary Screening
Discharge/Refer
Practice
Acute
Trust
Appropriate for Case Management?
Social
Community
Care Delivery Team
Personalised
Budgets
Other
- Case finding
- Risk strat
- MDT co-ord
d
Triage
Manage for up to 6 weeks
Role of CC
Do
for es n
Ca ot m
se
Ma e e t c
na rite
ge ria
me
nt
Social Care
Colour code
Decision point
Tool/Criteria
Services
Supporting services
For
assessment
YES
NO
NO
Case
Manager
DN
team
Complex long-term If regular tasks
management or
required
safeguarding
Supporting
NO
Referrer
Social
Care
Or
signposting?
Personalised
Budgets
Services
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2.2.4 Care Pathways
The service will support the provision of community services for the following care pathways:
 Rehabilitation and maintenance
 End of life care
 Urgent care services
 Falls
(see also exclusion criteria section 2.4.3)
2.2.5 Days/Hours of operation
SPA function - will be provided from 10am-6pm (accepting the last call/referral at 5pm) Monday to Friday.
Rapid Response function- will be provided from 10am – 6.00pm Monday to Friday with the intention to move to 7
days per week.
Intermediate Care function- will be provided from 8am – 6.00pm Monday to Friday with the intention to move to 7
days per week.
District Nursing Team - the service operates 365 days of the year between 8.00 hrs and 18.30 hrs including
weekends and bank holidays. The service is supported out of hours by the evening and night services. The
hours of the three services will be continuous.
Community Delivery Teams - will be provided from 9am – 5.00pm Monday to Friday.
2.2.6 Referral route
Referrals will be received via a single dedicated telephone number.
2.2.7 Response time & detail and prioritisation
The providers for each of the services must demonstrate the ability to match capacity with expected levels of
demand, including predictable fluctuations.
2.2.8 Transfer of patient data
The providers must establish and maintain clearly documented responsibilities and procedures in relation to the
transfer of patient demographics and clinical information to receiving services in line with information governance
standards.
The service will provide to the referring community health care professional and the patients GP practice (if the
referring community health care professional is not based in the GP practice), details of the outcome of the
clinical navigation referral contact within 1 working day of the case closure.
2.3 Population covered
It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the
referral routes detailed in section 2.4.2.
2.4 Accessibility/acceptability
2.4.1 Accessibility/Acceptability
• The Integrated Care Service will ensure that all individuals presenting with a health or social care need
that can be appropriately & safely managed in the community are accepted for assessment and triage,
as defined in the Model in section 2.2.3.
• In addition case finding will focus on Long Term Conditions and Complex Case individuals selected by
using a nomination criteria tool, secondary assessment and also a risk stratification tool.
2.4.2 Referral criteria and sources
Referrals into the integrated care service will be accepted from the following professionals: General Practitioners
 Community Matrons
 Community Specialist Nurses*
 Advanced Nurse Practitioners*
 Practice Nurses*
 District Nurses*
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 Senior Practitioners (Adult Care)
 Emergency Care Practitioners
 Investigation of others including Emergency Department
*following consultation with GP re patient condition and needs
The provider will be responsible for the marketing and promotion of the service to the list of referrers as above.
2.4.3 Exclusion Criteria
 Individuals must be 18 years or over
 Individuals must be registered with an Erewash GP
 Individuals must have been assessed as not requiring acute hospital care (Category A patients)
2.5 Interdependencies with other services
2.5.1 Whole System Relationships
The service will support effective flow across the health and social care system and reduce the number of nonelective admissions into an acute hospital which could be appropriately managed within a community setting.
2.5.2 Interdependencies
• Social Care
• Primary Care
• Derbyshire Health United
• Local hospice, palliative care team, care homes
• East Midlands Ambulance Service
• Patient Transport Service Providers
• Derbyshire Hospitals NHS Foundation Trust
• Nottingham University Hospital
• Derbyshire Community Health Services (DCHS)
• Medequip
• Continuing Health Care
• Derbyshire Health Foundation Trust
• Erewash CVS with the local voluntary and community sector
It is acknowledged that a key success factor of effective service delivery will be robust and productive working
relationships between health and social care colleagues both at provider and commissioner levels.
2.5.3 Sub Contractors
N/A
3. Applicable Service Standards
3.1 Applicable national standards eg NICE, Royal College
NHS Outcomes Framework
Domain 2: Enhancing quality of life for people with long term condition
Domain 4: Ensuring people have a positive experience of care
Right Care Recommendations for Derbyshire
Cancer
Chronic Obstructive Pulmonary Disease
Cardio Vascular Disease
QIPP
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Long Term Conditions QIPP Workstream Programme
CQC for care providers/homes
Social Services standards**
• Appropriate safeguarding arrangements
• Integrated working with the NHS
• Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention
and early intervention
• Universal information and advice services for all citizens
• Proportionate social care assessments processes
• Person centred planning and self-directed support to become mainstream activities with personal
budgets which maximise choice and control
• Mechanisms to involve family members and other carers
• A framework which ensures people can exercise choice and control with advocacy and brokerage linked
to the building of user-led organisations
• Effective quality assurance and benchmarking arrangements
(**Source: Derbyshire County Council Adult Service Plan 2010-2014)
3.2 Applicable local standards
3.2.1 The following dataset is required to be provided on a monthly basis
Basic Inform ation
Referral Inform ation
Assessm ent Inform ation
Outcom es
Full Name
Referred From
Clinical Top to Toe (Y/N)
Avoided Use of Services
Pr actice
New Patient (Y/N)
Clinical Findings
Attendance, Admission or Service Prov ided
NHS Number
Type of Contact (f2f, etc)
Clinical Interventions
Referred to and Accepted by
iFramew ork PIN
RISC Level
Social Care Assessment (Y/N)
Other Outcome (e.g. Refused Intervention)
Initial Contact Date
Pr imary Diagnosis
Social Care Findings
Early Discharge (Y/N)
Gender
Current Condition Ex acerbating
Social Care Interventions
Number of Bed Days Saved
Age
Number of LTCs
Therapist Assessment (Y/N)
Self Reported Change in Condition
No. of Prescription Medications
Therapist Findings
Medication Issues Addressed
No. of ‘Over the Counter’ Medications
Therapist Interventions
Recent Professional Attendance
Medication Review Complete (Y/N)
Medication Findings
Medication Intervention
3.2.2 Service Audits
The provider must undertake regular random sample audits. The reports are to be made available to
commissioners. Examples may include:
• Number of Right Care plans completed and shared across primary, secondary and social
services
• Significant event audit of people admitted to hospital who are being case managed
• National Social Services measure: NI 135 – carers who have been assessed and in receipt of
services
• National Social Services measure: NI 136 – people supported to live independently through
Social Services
4. Key Service Outcomes
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•
•
•
•
•
•
•
•
•
Reduction in average LOS of patients aged 65+
An increase in the number of people feeling supported to manage their own conditions
A reduction in the number of falls experienced by older people
Reduction in inappropriate unplanned admissions
Increasing community-based treatment of Long Term Conditions
Ensuring individuals have a positive experience of care
Ongoing use of a Risk tool to continually monitor case list
Reduction in the use of care homes
Reduced overall costs of low level services
5. Location of Provider Premises



SPA – based at Clay Cross Hospital
Integrated Community Team South Erewash – based at Long Eaton Health Centre
Integrated Community Team North Erewash – based at Ilkeston Community Hospital
6. Individual Service User Placement
N/A
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Appendix 1
NHS Standard Contract for Community Services
Schedule 2 Part 1
Gateway Reference XXXX
Service
Single Point of Access
Commissioner Lead
Provider Lead
Period
1. Scope
1.1 Aims and objectives of service
The Single Point of Access (SPA) service will support individuals to receive appropriate care at home or as close
as home as possible, and to prevent inappropriate hospital attendances and admissions through:
 Clinical Navigation
 Integrated Teams
The SPA will accept referrals from the following Erewash CCG Senior Health Care Professionals:
 General Practitioners
 Community Matrons
 Advanced Nurse Practitioners*
 Practice Nurses*
 District Nurses*
 Community Specialist Nurses*
 Emergency Care Practitioners
 Investigation of others including Emergency Department
These referrals will then be navigated to either the North or South Erewash Integrated Care Teams. The SPA
‘Navigator’ will take a full history from the referrer and complete the relevant documentation so that the referral
can be patched out to the two Erewash teams with immediate effect. Examples of referrals may include
Intermediate Care Beds, Packages of Care at Home, Occupational Therapy, Physiotherapy, Equipment.
*following discussion with GP re patient condition and need
1.2 Service description/care pathway
The service will be provided from 10am – 6pm accepting the last incoming call/referral at 5pm, allowing the
Single Point of Access to complete the final calls of the day. This service will initially operate Monday to Friday.
Existing services are available outside of these hours.
The SPA will receive calls for access to community services, primarily from GPs and Community Matrons. All
community/rehabilitation and re-ablement beds to be booked via the SPA. Direct bookings will not be taken. This
will allow the current bed state to be managed and individuals to be prioritised by need.
1.3 Population covered
It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the
referral routes detailed in section 2.4.2 of the Integrated Care Framework.
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1.4 Accessibility/acceptability
1.4.1 Accessibility/Acceptability
 Individuals over 18 years of age
 Care pathways may include for example:
 Frail Elderly – Falls
 Rehabilitation/maintenance – new difficulty with activities of daily living affecting ability to maintain
independence at home resulting in risk of hospital admission
 Urgent Care – urinary retention, blocked catheter, acute infection
 End of Life – place of choice, anticipatory drugs
1.4.2 Exclusion Criteria
 Individuals under 18 years of age
 Individuals with an Acute Mental Health problem including alcohol and substance misuse
 Individuals with an acute dental problem
 Individuals with life threatening emergency health needs defined as Category A patients
 Individuals who require diagnostics i.e. X-Ray, Ultra-sound
 Individuals who are not registered with an Erewash GP
 Individuals who solely have social care needs.
1.5 Interdependencies with other services






Derbyshire County Adult Care
Derbyshire Health United
Derby Hospitals NHS Trust
Nottingham University Hospitals
East Midlands Ambulance Services
Derbyshire Healthcare NHS Foundation Trust
2. Applicable Service Standards
2.1 Applicable national standards eg NICE, Royal College
NHS Outcomes Framework
Domain 2: Enhancing quality of life for people with long term condition
Domain 4: Ensuring people have a positive experience of care
Right Care Recommendations for Derbyshire
Cancer
Chronic Obstructive Pulmonary Disease
Cardio Vascular Disease
QIPP
Long Term Conditions QIPP Workstream Programme
CQC for care providers/homes
Social Services standards**
• Appropriate safeguarding arrangements
• Integrated working with the NHS
• Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention
and early intervention
• Universal information and advice services for all citizens
• Proportionate social care assessments processes
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•
•
•
•
Person centred planning and self-directed support to become mainstream activities with personal
budgets which maximise choice and control
Mechanisms to involve family members and other carers
A framework which ensures people can exercise choice and control with advocacy and brokerage linked
to the building of user-led organisations
Effective quality assurance and benchmarking arrangements
(**Source: Derbyshire County Council Adult Service Plan 2010-2014)
2.2 Applicable local standards
The SPA will be required to show the volume of activity coming through the service and to report back to
Erewash CCG on a monthly basis. The Minimum Data Set required will be:
 Number of calls/referrals accepted
 Number of calls/referrals rejected
 Number of calls/referrals signposted to other services
 Nature of calls/referrals
o Planned
 Long Term Case Management
o Unplanned
 Critical (response required within 2 hours)
 Non critical (response required within the next 2 days)
 District Nursing
 Destination of calls/referrals (where this information is known)
 Source of calls/referrals
3. Key Service Outcomes
The SPA is responsible for contributing to the delivery of the overarching outcomes as set out in the Integrated
Care Framework.
5. Location of Provider Premises
Clay Cross
6. Individual Service User Placement
N/A
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Appendix 2
NHS Standard Contract for Community Services
Schedule 2 Part 1
Gateway Reference XXXX
Service
Rapid Response Function
Commissioner Lead
Erewash CCG
Provider Lead
DCHS
Period
April 2013 - 2014
1. Scope
1.1 Aims and objectives of service
The focus of the Rapid Response Function is the prevention of potentially avoidable admissions to hospital
services. The team will work in partnership with health care professionals and other agencies where assessment
indicates that the patients’ immediate, individual needs can be met by the team in a timely and responsive
manner. This may involve the option of multidisciplinary intervention if required and timely transfer to generic
services.
The Rapid Response function is available from within the community team, accessed via the SPA only and are
for action the same day - when the individual is at risk of admission to hospital or care home. It includes:
– Community Matrons on rotation
– Therapists - now with extended working hours
– Erewash Care team – Crisis Intervention
1.1 Aims
 To prevent, where possible, the potentially avoidable admission of patients to hospital services by
providing support and therapeutic interventions during acute illness or sudden deterioration in condition.
 To ensure the speedy delivery of a high quality service that meets the needs of those, within the
Erewash CCG registered GP population, at risk of a potentially avoidable hospital admission.
 To provide holistic assessment of need and necessary support, equipment and interventions to promote
stability in the patients condition and enable them to remain in their own home.
 To work with partner professionals, agencies and organisation to enable the patient to be managed
safely at home.
 To liaise and negotiate with other community based services to facilitate the transfer and continuity of
high quality care.
 To address Erewash CCG and national priorities and targets whilst retaining a patient centred service.
1.2 Service description/care pathway
The Rapid Response function is an Erewash CCG wide service available between the hours of 10.00 – 18.00,
Monday to Friday with the intention to move to seven days a week.
Varying levels of intervention are available in order to prevent avoidable hospital admission and incorporates:
 Rapid response and assessment.
 Crisis support.
 Support/intervention during acute illness.
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The service is provided by a variety of disciplines, identified by patients need.
 Ensure holistic assessment and care planning.
 Provide timely interventions which focus on stabilising the acute situation and identifying on-going need.
 Facilitate timely and seamless transfer of care.
Disciplines available:
 Community Matron
 Community Nurses
 Physiotherapist
 Occupational Therapist
 Support Workers
Erewash Care Team
Erewash care team work in partnership with Community Services and Social Services to provide the highest
possible quality of care and services to patients and their families 365 days per year. The team will provide
individualised flexible programmes of care to people within their own homes.
Crisis intervention up to 7 days - The service will support primary care teams enabling a period of
assessment, monitoring and review to be undertaken. This will potentially avoid inappropriate admission to
hospital, give time for a crisis situation to stabilise and enable mainstream health and social services to develop
appropriate care packages to meet patient and carer need.
1.3 Evidence Base
Erewash CCG serves a registered population of 96,985. The vision is to improve the health, well being and
quality of life of people in this area; by focusing on quality health and social care based on need which is
provided in the right place, at the right time, by the right person with the right skills.
The Government white paper “Our Health, Our say” – A new direction for community services’ (2004), proposed
a significant change to the way Health and Social Care is delivered in the future, particularly through the
development of capacity in primary care to deliver services historically provided by the hospital sector.
1.4 Population covered
It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the
referral routes detailed in section 2.4.2 of the Integrated Care Framework.
1.5 General Overview
The service has recently been developed within the Integrated Care Pathway to refocus activity on the
prevention of potentially avoidable hospital admissions. This element will proactively engage with key partners
and providers within primary, community and secondary care to ensure timely support and interventions during
the following each episode of care. This will involve response within four hours to community based referrals to
the team and a smooth transfer to the intermediate care function or generic services as appropriate.
1.6 Accessibility/acceptability
1.6.1 Geographic Coverage / Boundaries
The registered adult population of Erewash CCG. Excluded are citizens who are registered in Neighbouring
CCG boundaries. .
1.6.2 Days / Hours of Operation
The service will be operational between 10.00 to 18.00 hours (last referral accepted at 5.00pm), Monday to
Friday with the intention to include seven day working during financial years 2013/14.
1.6.3 Response Time, Detail and Prioritisation
 A response time of 4 hours from receiving the referral is anticipated.
 All referrals will be assessed by Rapid Response Clinicians and the treatment / interventions will be
planned and delivered in accordance to need.
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1.6.4 Referral Criteria and Sources
Any health and social care related professional referral source is accepted.
 Adults over the age of 18 years.
 Acute exacerbation or sudden deterioration in the patients’ condition in circumstances which leave them
at risk of a potentially avoidable hospital admission.
 The patient must be registered with an Erewash GP practice as details in 1.4.1 above.
1.6.5 Referral Route
 Telephone referral via DCHS SPA.
 Information to support referrals can be faxed to the SPA.
 Contact number for any other communications via team landline.
1.6.6 Exclusion Criteria
 Those patients under 18 years of age.
 Those patients assessed as requiring hospital admission.
 Those patients requiring assessment by GP
1.7 Objectives
To maximise the use of skilled clinicians to be benefit of patients during urgent/crisis episodes:
 To provide care closer to home.
 To prevent potentially avoidable hospital admissions
 To maximise the opportunity for patient choice regarding the location of care.
–
–
–
A health professional will visit within four hours in 100% of referrals accepted for assessment for Rapid
Response.
100% of patients will be given 4 Harms Leaflet.
100% of patients will be screened for PU Risk.
Improving Service Users Experience:
– 100% of patients will be offered a service information leaflet.
– 100% of patients will be offered a comment/complaint leaflet on admission to the service.
– 100% of care plans will be formulated in collaboration with patients/carers.
– Full explanation to patients/carers of any referrals made and the transfer of care arrangements will be
evidenced in the patient records in 100% of episodes.
1.8 Interdependencies with other services
1.8.1 Whole System Relationships
The Rapid Response function will be supported by the IC function and CDT to deliver a seamless services to
safely support the individual:
. 1.8.2 Interdependencies
• Social Care
• Primary Care
• Derbyshire Health United
• Local hospice, palliative care team, care homes
• East Midlands Ambulance Service
• Patient Transport Service Providers
• Derbyshire Hospitals NHS Foundation Trust
• Nottingham University Hospitals NHS Trust
• Derbyshire Community Health Services (DCHS) teams
• Medequip
• British Red Cross
• Continuing Health Care
• Derbyshire Health Foundation Trust
• Erewash CVS with the local voluntary and community sector
• Specialist services eg tissue viability, heart failure, respiratory, diabetes, neurological and continence
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teams
1.8.3 Sub Contractors
No sub contractors are arranged for this service.
2. Applicable Service Standards
2.1 Applicable national standards e.g. NICE, Royal College
NHS Outcomes Framework
Domain 2: Enhancing quality of life for people with long term condition
Domain 4: Ensuring people have a positive experience of care
Right Care Recommendations for Derbyshire
Cancer
Chronic Obstructive Pulmonary Disease
Cardio Vascular Disease
QIPP
Long Term Conditions QIPP Work stream Programme
CQC for care providers/homes
Social Services standards**
• Appropriate safeguarding arrangements
• Integrated working with the NHS
• Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention
and early intervention
• Universal information and advice services for all citizens
• Proportionate social care assessments processes
• Person centred planning and self-directed support to become mainstream activities with personal
budgets which maximise choice and control
• Mechanisms to involve family members and other carers
• A framework which ensures people can exercise choice and control with advocacy and brokerage linked
to the building of user-led organisations
• Effective quality assurance and benchmarking arrangements
(**Source: Derbyshire County Council Adult Service Plan 2010-2014)
2.2 Applicable local standards
2.2.2 Service Audits
3. Key Service Outcomes
The Rapid Response function is responsible for contributing to the delivery of the overarching outcomes as set
out in the Integrated Care Framework.
3.1 Service Model
The service strives to deliver a responsive service in keeping with Care Closer to Home principles combined with
measurable high quality care in accordance with the domains that are set out in the Standards for Better Health
Framework.
3.2 Care Pathways
The team will respond to a referral within a four hour target. Assessment will take place and from the initial
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contact an individualised plan will be formulated. The patient will access such pathways that are available in
mainstream services.
3.3 Expected Outcomes
 To improve collaborative working across primary Care, Secondary Care, Voluntary and Independent
Sector Organisations and Social Services.
 Reduce hospital admission.
 Reduce A&E attendance.
 Greater proportion of people supported to die in their preferred place of choice.
Target response time of 4 hours will be achieved.
5. Location of Provider Premises Discharge Criteria and Planning
Discharge planning will commence from the point of referral and form part of the assessment and care /
intervention planning process. This will result in a smooth transfer to independence or generic services. (IC
Function or Community Delivery Team).
6. Individual Service User Placement Self-Care and patient and Carer Information
N/A
Information leaflet to be developed providing details of the service in keeping with current policy on the
production of patient information resources.
7. Quality and performance Standards
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Appendix 3
NHS Standard Contract for Community Services
Schedule 2 Part 1
Gateway Reference XXXX
Service
Intermediate Care Function
Commissioner Lead
Provider Lead
Period
1. Scope
1.1 Aims and objectives of service
Referrals will be received via the SPA.
The aim of the Intermediate Care element of the integrated care pathway is to increase the health and wellbeing
of the population of Erewash, by providing prompt assessment, treatment, advice and education to individuals in
their own home who have experienced a recent deterioration in function or condition, and who may be at risk of
admission or prolonged stay in acute or community hospital care, or residential care.
A comprehensive assessment will result in a structured individual care plan that involves active therapy,
treatment or opportunity for recovery, working closely with other health and social care professionals (e.g. social
care staff, community nurses, community matrons and hospital-based staff),
Interventions will normally be time limited up to a maximum of 6 weeks, (but will often be shorter) and which can
be extended if the MDT can demonstrate the individual is making continued progress.
1.2 Service description/care pathway
The Intermediate Care function aims to provide highly skilled multi disciplinary assessment and intervention to
patients in their own home or current place of residence, with physical problems affecting their functional
abilities.
There is a patient-centred holistic approach, including comprehensive assessment and identification of
problems.
Goals are established in conjunction with patients and carers.
There is on-going close liaison with other health and social care professionals to enable patients to achieve
goals and maintain / achieve optimal independence.
Close working with Derbyshire County Council Adult social care teams to ensure adequate provision of home
support to enable patients to remain in their own home during their rehabilitation programme.
Expected outcomes:
 Improve quality of future care
 Maximise and individuals functional ability and independence
 Timely transfer from acute or community hospital settings to facilitate on-going rehabilitation
 Prevent inappropriate / avoidable admission to acute or community hospital care
 Reduce or delay admission to long term residential care
 To reduce or minimise long term care packages
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The service is currently available Mon – Fri 8am – 6pm with the intention to move to 7 days per week during
2013/14
Within intermediate care function is also the Erewash Falls service and Erewash care team:
Erewash Care Team
Erewash care team work in partnership with Community services and Social Services to provide the highest
possible quality of care and services to patients and their families 365 days per year.
The team will provide individualised flexible programmes of care to people within their own homes.
Palliative care for up to 6 weeks - The service will allow patient choice where possible and support primary
care teams to care for patients within their own homes during the final few weeks of life.
Bereavement – The service will provide follow-up for carers/relatives of patients that have passed away.
EREWASH FALLS PREVENTION SERVICE
This service offers assessment for people who have fallen or who have fear of falling. Physiotherapists and
Occupational Therapists from the Falls Team, see people in their own homes to assess their falls risk and offer
advice and treatment.
The Team’s role includes:
•
•
•
•
•
•
•
Taking a detailed falls history
Assessing mobility, balance and muscle strength
Providing advice on home hazards
Discussing osteoporosis risk
Providing equipment for support
Helping to increase confidence
Providing home exercise plans
1.3 Population covered
It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the
referral routes detailed in section 2.4.2 of the Integrated Care Framework.
1.4 Accessibility/acceptability
1.4.1 Accessibility/Acceptability
 Individuals over 18 years of age and agreeable to receiving the service
 Recent deterioration in function
 At risk of hospital or residential care admissions or prolonged length of stay
 Individuals must be medically stable
 Requirement for intervention to have been assessed as being safely and effectively provide outside of
an acute hospital, and within an individuals own home or current place of residence.
 Individuals motivated and able to undertake a rehabilitation programme
1.4.2 Referral criteria and sources
Referrals will be accepted from the following:
 General Practitioners
 Acute hospital health and social care professionals
 Community specialist nurses
 Other members of the Integrated Care Teams
 Social care colleagues
 Practice nurses
Page 16 of 28
1.4.3 Exclusion Criteria
 Individuals must be 18 years or over
 Individuals must be registered with an Erewash GP
 Individuals must have been assessed as not requiring acute hospital care.
1.5 Interdependencies with other services
1.5.1 Whole System Relationships
The Intermediate Care function will support the rapid response function, as well as the community delivery teams
and the community nursing team to deliver a seamless service to reduce the number of avoidable hospital
admissions and reduce length of stay where an admission is required
1.5.2 Interdependencies
• Social Care
• Primary Care
• Derbyshire Health United
• Local hospice, palliative care team, care homes
• East Midlands Ambulance Service
• Patient Transport Service Providers
• Derbyshire Hospitals NHS Foundation Trust
• Nottingham University Hospitals NHS Trust
• Derbyshire Community Health Services (DCHS)
• Medequip
• British Red Cross
• Continuing Health Care
• Derbyshire Health Foundation Trust
• Erewash CVS with the local voluntary and community sector
• Specialist services eg tissue viability, heart failure, respiratory, diabetes, neurological and continence
teams
1.5.3 Sub Contractors
N/A
2. Applicable Service Standards
2.1 Applicable national standards e.g. NICE, Royal College
NHS Outcomes Framework
Domain 2: Enhancing quality of life for people with long term condition
Domain 4: Ensuring people have a positive experience of care
Right Care Recommendations for Derbyshire
Cancer
Chronic Obstructive Pulmonary Disease
Cardio Vascular Disease
QIPP
Long Term Conditions QIPP Work stream Programme
CQC for care providers/homes
Social Services standards**
• Appropriate safeguarding arrangements
• Integrated working with the NHS
• Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention
Page 17 of 28
•
•
•
•
•
•
and early intervention
Universal information and advice services for all citizens
Proportionate social care assessments processes
Person centred planning and self-directed support to become mainstream activities with personal
budgets which maximise choice and control
Mechanisms to involve family members and other carers
A framework which ensures people can exercise choice and control with advocacy and brokerage linked
to the building of user-led organisations
Effective quality assurance and benchmarking arrangements
(**Source: Derbyshire County Council Adult Service Plan 2010-2014)
2.2 Applicable local standards
2.2.2 Service Audits
3. Key Service Outcomes
The Integrated Care Team is responsible for contributing to the delivery of the overarching outcomes as set out
in the Integrated Care Framework.
5. Location of Provider Premises
Integrated Community Team North Erewash – based at Ilkeston Community Hospital
Integrated Community Team South Erewash – based at Long Eaton Health Centre
6. Individual Service User Placement
N/A
Page 18 of 28
Appendix 4
NHS Standard Contract for Community Services
Schedule 2 Part 1
Gateway Reference XXXX
District Nursing (this is extracted from the ‘Community Nursing Contract
Schedule)
Service
Commissioner Lead
Provider Lead
Period
1. Scope
1.1 Aims and objectives of service
The Community Nursing service provides skilled, flexible nursing care to meet the needs of individuals and
carers in the community. The service is delivered in a caring and non-judgmental manner in agreement with the
individual and carer, taking into account their physical, social, psychological, cultural and ethnic requirements.
To provide high quality nursing care, in the most appropriate setting to reduce hospital admissions, promote
quality of life, facilitate early discharges and coordinate complex packages of care.
The principles of district nursing practice are to:







Provide high quality, culturally sensitive nursing care for people in their own homes or community
setting.
Promote and maintain independent living.
Enable patients to live independently by rehabilitation.
Promote a co-ordinated approach to hospital discharge that facilitates a seamless service leading
to improved health outcomes.
Reduce the incidence of admission and re-admission by supporting and educating both patients
and carers to seek early intervention for potentially debilitating conditions.
Adopt a public health approach to clinical activities thus ensuring the most clinically effective use of
resources to improve patient care.
Promote user involvement in both service planning and delivery
1.2 Service description/care pathway
The specification covers the roles of the district nursing team across 7 days a week.
Patients suitable for a referral to Community Nursing services are those registered at the practice who require an
out-of-surgery service performed by a suitably trained and skilled member of the community nurse team, so
they are treated equitably with those who can attend surgery.
The service will not be exclusively out-of-surgery as there will be circumstances where the specialist district
nursing skills necessitate the service to be delivered in a clinic setting e.g. leg ulcer clinics.
The service will include delivering care for people in residential care homes and care in nursing homes not
usually expected of registered general nurses. Opportunistic support of those RGNs to develop their skills will
also be undertaken as a routine part of caring for their patients.
Page 19 of 28
Record Keeping
There will be a system of record keeping integrated with the practice system so that care-givers and patients
themselves can see a comprehensive record of activity within the record. It is expected that the improved
system will eliminate duplication and improve the level of face to face contact time with patients.
Training & Development
The staff will be highly trained and professional. They will be valued and supported with access to continuing
professional development provided by DCHS to enable professional progression.
Work-placements will be provided for pre and post registration students as part of the agreement at cluster level
with the provider to promote workforce recruitment and retention.
The community nursing team will be practice-facing and take part in practice activities such as planning, clinical
meetings, significant event meetings, regular case discussions, PBC meetings, and where appropriate to
participate in in-house training including Quests and performance review.
In some cases the teams will provide services on a locality basis where specialist skills are required, such as leg
ulcer clinics.
There will be regular face to face contact between the community nursing team and the GPs with a minimum
expectation of a weekly contact. This is particularly important in practices where the district nurses are not
based in the practice.
The provider will develop a case management approach, integrating with the practice team to manage patients
with long-term condition. These multi-skilled trained teams will have sufficient resource to meet need including
for contingencies so that a core team will be available at all times.
Arrangements for sickness and absence cover will be clearly defined with a clear process for resolving disputes.
Each team will have administrative support in the style of a ward-clerk so that nursing time is maximised.
Individual consortia will have the flexibility to create their own arrangements for accessing the District Nursing
service and setting up lines of communication.
Practices will have the opportunity to be involved in the recruitment of members of the DN team, and the
appraisal process.
As the Integrated Care model is rolled-out, the teams will integrate with social services according to the
principles of the model.
The following associated tasks that are considered to be core include:
 Advising residential homes on client care
 Specialist advice and guidance to Nursing Homes
 Safeguarding Vulnerable Adults
 Bowel Management
 Continence Management
 Catheter Management
 Ear Care
 End of Life – Terminal Care / Palliative Care
 Eye Care
 Hickman and PICC Line Management
 Leg Ulcer Management
 Medicine Administration
 Non medical prescribing
 Percutaneous Endoscopic Gastrostomy Tube Management
 Syringe Driver Management
Page 20 of 28



Wound Care/Tissue Viability including complex wound management
Phlebotomy
Setting up or contributing to SAP personal held records
The following additional tasks could also be included but would need to be negotiated by the joint team, with
agreement within the team of who delivers which elements of the whole service.





Chronic Disease Management (other than diabetes) including associated tasks i.e. spirometry, ECG,
BPs, inhaler technique etc
Flu and pneumonia vaccines
Participation in an annual review of older people to include a multi-disciplinary assessment if required
Medication review
Health promotion
The following core services requiring indirect intervention not listed above are:
 Ordering and requesting collection of equipment
 Greater use of assisted technology to maximise the potential for the patient to stay at home
 Nursing needs assessments for persons requiring a nursing home placement
 Telephone contact advice
 Planning effective discharge from hospital / hospice for patients with complex needs.
 Continuing care assessments
 Report writing for case conferences
 Documenting in GP practice patient records
 Specialist advice and guidance to nursing homes beyond the scope of a registered general nurse
employed by the nursing home
The above lists are not exhaustive and will change over time taking account changes in clinical practice and
policy development.
The service operates 365 days of the year between 8.00 hrs and 18.30 hrs including weekends and bank
holidays. The service is supported out of hours by the evening and night services. The hours of the three
services will be continuous.
1.3 Population covered
The service will be provided for the patients registered with the practices within NHS Derbyshire. What about
non registered patient emergencies e.g. older visitor from Europe….
1.4 Accessibility/acceptability
1.4.1 Accessibility/Acceptability
The service monitors acceptability through patient questionnaires.
1.4.2 Referral criteria and sources
The assessment of whether a patient is judged to be in need of an ‘out of surgery’ service will be made by the
integrated team and be based on wider interpretation of social and environmental factors.
The team will reach agreement on treatment of patients discharged from hospital in need of follow up care within
the context of flexible working and an integrated team approach.
Referral route
The referral process should be uncomplicated and auditable e.g. Emis tasks.
The information to be provided is:
Page 21 of 28
Patient’s name, address, date of birth, NHS number, telephone number, contact details, reason for referral,
access details and the patient’s mobility status.
Response time & detail and prioritisation
When referring to the District Nursing service patients should be advised that the actual care and time that the
nursing team will visit cannot be agreed until the District Nurse has received the referral details and assessed
the patient’s need. All referrals to the service are prioritised and acted upon, the response time being dependant
in the information received.

High Risk- to be seen within 4 hours
Patients in the community who require urgent nursing intervention (not medical), to prevent a potentially serious
risk affecting the individual’s ability to stay at home.

Medium Risk- telephone contact the same day and to be seen within 24 hours
Nursing needs are clearly identified, actual risk of deterioration of patient’s condition if nursing intervention is not
provided.

Low Risk – telephone contact within 72 hours and visit within 7 days
Nursing needs are clearly identified indicating potential deterioration without nursing intervention/monitoring.

Minimal Risk- telephone contact within 72 hours and planned arranged visit arranged within 8 weeks
To undertake a specialist needs led assessment/health screening where advice/support will maximise the
continued independence of patient/carer. (Whereas continence assessments may be classed as minimal risk,
the exception to this is faecal incontinence, where the underlying cause may be a nursing need, and should be
classed with medium risk)
1.4.3 Exclusion Criteria
1.5 Interdependencies with other services
1.5.1 Whole System Relationships
Community Nurses work in partnership with statutory, voluntary and private agencies to deliver continuing health
care within the community setting. Patients are encouraged and assisted to maximise their level of
independence and quality of life in the context of their own lifestyle with a view to being discharged from the
Community Nursing caseload.
1.5.2 Interdependencies
The key interdependencies are with the patient, carer, the Primary Health Care Team, Social Services, and
Acute and Community Hospitals.
1.5.3 Sub Contractors
2. Applicable Service Standards
2.1 Applicable national standards e.g. NICE, Royal College
2.2 Applicable local standards
Quality standards, outcome and performance management will be carried out at GP cluster level according to
the matrix below.
Page 22 of 28
The CCG expects the nurse management to be practice facing and to work with the practices to develop the
teams, and to resolve outstanding issues relating to equity, record keeping, IT.
Any changes to the level of service or the method of delivery will be negotiated with the practice and the cluster
prior to the change being implemented. Wherever possible consideration should be given to skill mix and the
introduction of administrative support. Practices will be given the opportunity to be fully involved in the
recruitment process.
Quarterly reviews will be held between GP clusters and DCHS locality managers to monitor and review
performance and delivery against the quality standards as defined below and discuss proposed changes. Any
issues that cannot be resolved within the quarterly review meeting will be escalated through the formal contract
performance structure and discussed within the contract performance group.
If a practice has significant concerns about the quality of the service delivered, these will be communicated to
the appropriate DCHS manager outside of the formal review process and if appropriate raised formally through
the contract management processes.
The provider will implement appropriate national directives and best practice initiatives e.g. lean processes.
The Provider delivering this service will be registered with the Care Quality Commission and compliant with the
essential standards relating to quality and safety.
3. Key Service Outcomes
An effective District Nursing team which is able to manage complex nursing intervention and packages of care
within the skill mix of the teams, in patients’ own homes
5. Location of Provider Premises
If the practice can provide adequate accommodation and appropriate working conditions, the District Nursing
Team will be based in the practice. In cases where this is not possible, there will be regular meetings and
communication links established to engender mutual respect and the development of shared goals.
Where appropriate the District Nurses will provide care in a clinic setting to ensure that appropriate skills are
utilised, such as tissue viability services.
The practice will provide named links within the practice team, and have arrangements in place for induction of
new members of the DN team.
6. Individual Service User Placement
N/A
Page 23 of 28
Appendix 5
NHS Standard Contract for Community Services
Schedule 2 Part 1
Gateway Reference XXXX
Service
Community Delivery Teams
Commissioner Lead
Provider Lead
Period
1. Scope
1.1 Aims and objectives of service
Integrated Care is an innovative service aimed at providing coordinated care for adults identified at high risk of
hospital admission or admission to a care home (for long or short term stay), who would benefit from a multidisciplinary and multi-organisational approach. Integrated Care in Erewash represents collaborative working
between key stakeholders to deliver effective planned and unplanned care from health and social care
organisations and also from other services, e.g. therapies and mental health.
Community Delivery Teams (CDT’s) are responsible for managing planned long term care through accessing
services from primary care, secondary care, community care, social care, mental health, out of hours and
voluntary organisations. Further information about each of the roles within the CDT team can be found in the
‘Roles’ section of this pack.
1.2 Service description/care pathway
General Practitioner
The CDT GP attends the weekly CDT meetings and provides medical advice as required on individual patients,
supporting all members of the team but in particular the Community Matron. They provide ad hoc medical advice
to the Community Matron, District Nurse and the Social Worker about patients on the case load if their usual GP
is not available. In addition to this, they have the following duties:
 Liaise with the usual GP regarding actions from CDT meeting or if patient has no usual GP, arrange
appropriate person to action decision and liaise with that GP/clinician
 Liaise as appropriate with secondary care consultant looking after a patient
 Contact GP for consultants wishing to discuss a patient with the practice unless they have a usual GP
 Provide a medical overview to the CDT
 Review, with the team, the risk stratification data and notes of patients identified by the care co-ordinators
as being at risk of admission.
Community Matron
Community matrons provide a service for people with multiple long term conditions who are at high risk of
hospitalisation. The aim of the service is to provide proactive case management of patients with long term
conditions in order to enable them to stay in their own home and avoid unplanned, unnecessary hospital
admissions. Community matrons aim to provide better access to health and social services as well as
optimization of medication, regular monitoring reviews and agreement of management care plans.
All community matrons have received training in advanced practice including top to toe physical examination and
pathophysiology of common conditions. In addition to this they are non medical prescribers and have access to
community matron led beds in local community hospitals where they can admit patients who require short term
in patient care during an acute exacerbation of their condition.
Care Co-ordinator
Page 24 of 28
The Care Co-ordinator is a pivotal role to the CDT and will be the interface between service users, carers,
primary care, secondary care, community care, social care, mental health, out of hours and voluntary
organisations. They will have overall responsibility for the weekly CDT meetings and the smooth running of
integrated care within the team setting. The key role of the Care Co-ordinator will be to schedule the weekly CDT
meetings, manage the meeting agenda items, ensuring that all new referrals are identified and information
circulated to team members in advance of the meeting. Please see Integrated Care Co-ordinator specification for
further information.
Social Worker – The social worker will identify and respond to aspects of a person’s situation that may be
resolved either by utilising the persons own skills, contacts or other assets, or by organising practical support
from other organisations. The social worker will contribute to the identification of situational risks to
independence. These might include loneliness, isolation, interpersonal relationships problems or access to
meaningful activity, which impact on wellbeing and the motivation to be independent .The social worker will
consider eligibility for DCC home care re-ablement service and in discussion with Delivery Team colleagues
refer as necessary.
The social worker will also provide information about DCC financial contribution requirements to long term
community or residential support (including respite care). The social worker will also be responsible for the
assessment that is required to establish or adjust the personal budget which may be required to purchase
long term social support .
Practice Nurse – The Practice nurse will support the Care Co-ordinator and CDT by supporting risk profiling and
case selection from their practice patients. The practice nurses will be offering their support and expertise in
patient care and disease management to the CDT as applicable under QOF or any other practice protocol
relevant to their practice registered patients. The practice nurse will liaise with and volunteer and share any
information relevant to the patient care with the Care Co-ordinator, the lead GP or any appropriate member of
the CDT.
District Nurse
The Community Nursing service provides skilled, flexible nursing care to meet the needs of individuals and
carers in the community. Community Nursing Teams have a specialist understanding of caring for people at
home, who, because of illness or disability, are unable to attend to attend surgeries or clinics for assessment or
treatment. The service is delivered in a caring and non-judgmental manner in agreement with the individual and
carer, taking into account their physical, social, psychological, cultural and ethnic requirements.
To provide high quality nursing care, in the most appropriate setting to reduce hospital admissions, promote
quality of life, facilitate early discharges and coordinate complex packages of care.
Occupational Therapists
Occupational Therapist’s aim is to promote and restore health, independence and well-being in people of all
ages, using purposeful occupation/activity.
Occupation means any way in which the individual spends their time, for example: in work, leisure and every
day activities.
The Occupational Therapist will visit the individual at home, discuss any identified difficulties and agree
treatment aims. The Occupational Therapist will do this by assessing the ability to complete everyday tasks.
Following agreement with the individual, treatment may involve rehabilitation, providing advice and information,
equipment provision and referrals to other agencies.
Physiotherapists
Community physiotherapists offer assessment, treatment and advice in people’s own homes. They see people
with conditions such as falls, general mobility problems, respiratory problems, Parkinson’s disease, stroke and
MS.
The focus is on home exercise programmes to improve strength and balance, the provision of appropriate
walking aids to assist mobility, the management of breathing problems, management of pain etc.
Page 25 of 28
1.3 Population covered
It is anticipated that during the contractual year 2013/14 the service will be rolled out across Erewash as per the
referral routes detailed in section 2.4.2 of the Integrated Care Framework.
1.4 Accessibility/acceptability
Referral Criteria: Over 65 with 2 or more of following:
Long term condition
Change/deterioration
Cognitive impairment
History of Falls
Care/Community Breakdown
Admission to hospital in last 12 months
Medication Issues
1.5 Interdependencies with other services
1.5.1 Whole System Relationships
The CDT will support effective flow across the health and social care system and reduce the number of nonelective admissions into an acute hospital which could be appropriately managed within a community setting.
1.5.2 Interdependencies
• Adult Social Care
• Primary Care
• Derbyshire Health United
• Local hospice, palliative care team, care homes
• East Midlands Ambulance Service
• Patient Transport Service Providers
• Derbyshire Hospitals NHS Foundation Trust
• Nottingham University Hospital
• Derbyshire Community Health Services (DCHS)
• Continuing Health Care
• Derbyshire Health Foundation Trust
• Erewash CVS with the local voluntary and community sector
It is acknowledged that a key success factor of effective service delivery will be robust and productive working
relationships between health and social care colleagues.
1.5.3 Sub Contractors
N/A
2. Applicable Service Standards
2.1 Applicable national standards eg NICE, Royal College
NHS Outcomes Framework
Domain 2: Enhancing quality of life for people with long term condition
Domain 4: Ensuring people have a positive experience of care
Right Care Recommendations for Derbyshire
Cancer
Chronic Obstructive Pulmonary Disease
Cardio Vascular Disease
QIPP
Long Term Conditions QIPP Workstream Programme
Page 26 of 28
CQC for care providers/homes
Social Services standards**
• Appropriate safeguarding arrangements
• Integrated working with the NHS
• Commissioning Strategies, which maximise choice and control whilst balancing investment in prevention
and early intervention
• Universal information and advice services for all citizens
• Proportionate social care assessments processes
• Person centred planning and self-directed support to become mainstream activities with personal
budgets which maximise choice and control
• Mechanisms to involve family members and other carers
• A framework which ensures people can exercise choice and control with advocacy and brokerage linked
to the building of user-led organisations
• Effective quality assurance and benchmarking arrangements
(**Source: Derbyshire County Council Adult Service Plan 2010-2014)
2.2 Applicable local standards
2.2.2
Community Delivery Team report for Care Co-ordinators
The Care Coordinator utilises a spread sheet to manage day to day activity within the CDT. It can be also used
to gather and report on the following:
 Number of people who are on the CDT register, when admitted and who is case managing them
 Number of high risk individuals who are in hospital, length of stay, diagnosis, blocks in discharge
process
 Number of individuals currently in a short stay, respite, rehab or reablement facility
3. Key Service Outcomes
The Community Delivery Team is responsible for contributing to the delivery of the overarching outcomes as set
out in the Integrated Care Framework.
5. Location of Provider Premises
There will be six CDT’s that will work across the Erewash GP Practices. Please see Resource Plan* for detailed
information.
6. Individual Service User Placement
N/A
Page 27 of 28
*Resource Plan – Community Delivery Teams
Long Eaton Patch
Ilkeston Patch
TEAM 1
TEAM 2
TEAM 3
Total Population = 14,910
Total Population = 18,534
Total Population = 17,610
Adam House – 7,736
College Street – 7,174
Aitune – 9,478
Goldenbrook – 9,056
The Moir -14,485
Park View - 3,125
Community Delivery Team
GP leads - tbc
Care Coordinator – Farhana Chishti
Community Matron – Jenny Garner
1 x AC Service Manager
Community Delivery Team
GP leads - tbc
Care Coordinator – Caroline Hudson
1 x Community Matron (vacancy)
1 x AC Service Manager
Community Delivery Team
GP leads- tbc
Care Coordinator – Marie Coates
Community Matron – Dawn Brookes
1 x AC Service Manager
Additional health
1 x band 6
5 x band 5
1 x band 3
Additional health
1 x band 6
7 x band 5
1 x band 3
Additional health
1 x band 6
5 x band 5
1 x band 3
Additional Adult Social Care
Erewash wide team
Additional Adult Social Care
Erewash wide team
Additional Adult Social Care
Erewash wide team
TEAM 4
TEAM 5
Total Population = 17,303
Total Population = 17,948
Old Station – 13,801
Eden Surgery – 3,502
Littlewick - 12,847
Gladstone House – 5,101
Dr Purnell & Partners – 3,855
Dr Webb & Partners – 3,889
Community Delivery Team
GP leads - tbc
Care Coordinator – Laura Ashby
Community Matron – Sharon Vallis
1 x AC Service Manager
Community Delivery Team
GP leads - tbc
Care Coordinator – Steph Elkin
Community Matron – Gill Goodfellow
1 x AC Service Manager
Community Delivery Team
GP leads - tbc
Care Coordinator – Angela Shaw (0.6)
0.6 x Community Matron (Sharon Vallis)
0.6 x AC Service Manager
Additional health
1 x band 6
6 x band 5
1 x band 3
Additional health
1 x band 6 (30hrs)
6 x band 5
1 x band 3
Additional health
0.5 x band 6
2 x band 5
0.5 x band 3
Additional Adult Social Care
Erewash wide team
Additional Adult Social Care
Erewash wide team
Additional Adult Social Care
Erewash wide team
Telephone Numbers for Care Coordinators
Team 1
Team 2
Team 3
Team 4
Team 5
Team 6
Farhana Chishti
Caroline Hudson
Marie Coates
Laura Ashby
Stephanie Elkins
Angela Shaw
07827 346970
07827 346846
07827 354181
07827 349108
07827 354523
07827 355022
TEAM 6
DCHS (West Hallam Patch)
Total Population = 9,293
Page 28 of 28
DCHS staff:
Shared Team with
West Hallam (SDCCG)
West Hallam – 4987
Littlewick (WH pts) – 2,000*
Health team Hours shared
0.5 x band 6
3 x band 5
0.5 x band 3
*The Community Matron in
team 6 will manage the
2,000 Ilkeston Practice
West Hallam pts