Download dudley agreed definition of housebound

Service Specification No.
Service
District Nursing Service
Commissioner Lead
Dan King
Provider Lead
Period
1 April 2012 – 31 March 2013
Date of Review
31st March 2013
1. Population Needs
1.1 National/local context and evidence base
The Borough of Dudley is home to around 306,000 and the population diverse.
Contained within the 38 square miles, there are 132,000 residential houses, a range of businesses
and industries: one 849 bedded District General Hospital, 52 General Practices and a Mental Health
NHS Trust.
Within Dudley there are some of the most deprived areas in the country – with some of the deepest
pockets of inequalities. There are areas, which have a concentration of poor dietary habits, poor
uptake of physical exercise, poor housing, poor levels of employment, poor educational attainment
and poor mental well-being.
Eight out of the 72 wards are classified as the most deprived in the Country. Some of these areas
have a very high proportion of Black Minority Ethnic communities and many experience difficulties in
accessing health care services.
Conversely there are some wards, which are among the most affluent in the country. People living in
these wards tend to have better education, jobs, housing, self-confidence and higher life expectancy
than those from the more deprived areas.
The Population - an updated Joint Strategic Needs Assessment has shown that:
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The number of over 85’s will increase by 52% by 2020
Increase in life expectancy will be slower in Dudley than the rest of the country
The biggest cause of premature death is circulatory diseases and cancer
After cardiovascular disease and cancer, respiratory diseases have the third next significant
impact on premature death
About a fifth of the population smoke and reducing this will have the biggest impact on
premature death
One in five people in Dudley are reported to have a long-term condition, which limits their daily
activity, and 35,000 people care for someone with a long-term condition
Accident mortality has increased; almost entirely within the over 65’s age group and Falls are
an important element of this statistic
Obesity levels have more than doubled between 1992 and 2002
Alcohol-related diseases have risen rapidly and deaths from these are increasing
The incidence of alcohol related hospital admissions has increased rapidly in Dudley and is
above the National rate
Life expectancy for the people of Dudley continues to rise but the gap between the most and
least deprived widens. (The gap widened from 6.6 years in 2005 to 8.6 years in 2008)
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To meet the increasing needs that are developing as a consequence of the above population trends
(e.g. increase in the number of people who will need access to nursing care or support to enable them
to remain in their place of residence and avoid unnecessary hospital admissions), the District Nursing
service will provide a quality, comprehensive and accessible generalist nursing service to patients all
Dudley GP Registered patients who are either temporarily or permanently housebound. Services will
be delivered through clearly defined packages of nursing care, either within the patient’s own home or
in a residential setting.
The service will be made available within the newly created four localities;
1. Dudley, Netherton & Sedgley, Coseley and Gornal (DN) (SCG)
2. Halesowen and Quarry Bank (H&QB)
3. Stourbridge, Wollescote & Lye (SWL)
4. Kingswinford, Amblecote and Brierley Hill (KAB). (See Appendix 1 for Dudley GP
Practices by Locality) (October 2011).
It is expected that the allocation/attachment of district nursing resource will be examined during 20122013. Any new design of the attachment being based on demographic data reflecting social, economic
and environmental determinants rather than the existing historically based allocation. (See Annual
Report of the Director of Public Health, 2009 – GP Practice Locations and Primary Care
Indicators)(Pages 70 – 389)6
ACTION: DISTRICT NURSING STEERING GROUP
The service will continue to build upon a patient-centred approach to delivery, this in partnership with
individuals, families, carers, General Practice and other professionals, in statutory, voluntary and
independent sectors: this process of working thus creating improved needs assessed service, leading
to improved health outcomes.
District nurses will also have access and training to and from a number of specialist services which
include: those offering palliative care, tissue viability services, lymphoedema care, cardiovascular,
respiratory and Diabetes care. There is also a very clear and definite link to the working of the Virtual
Ward. It is accepted that, as a result of the continued working with these specialist services that
‘interaction and close working pathways’ (all containing clear guidance of referral and discharge
arrangements), will be in place.
ACTION: DISTRICT NURSING STEERING GROUP.
The service will operate within and adhere to the National Priorities and Policies including National
Service Frameworks (NSF’s), NICE and other relevant Clinical Guidance and Local Commissioning
intentions identified within section 3 of this service specification.
This list of evidence base is not exhaustive, so it is expected that the service will take account of all
National and Local sources of Guidance and examples of Best Practice (both existing and new), apply
it to the local service, thereby enhancing the quality and effectiveness of care provided.
It is expected that a newly created Steering Group will ensure the use of all relevant guidance when
considering the changes required in the attachment and delivery of the District Nursing Service during
2012 – 2013.
ACTION: DISTRICT NURSING STEERING GROUP
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Annual Report of the Director of Public Health, 2009 – GP Practice Locations and Primary Care Indicators
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2. Scope of the service
2.1 Aims and objectives of service
Dudley Commissioning Objectives
The Provider will contribute to the delivery of Dudley Clinical Commissioning Group & Dudley Primary
Care Trust: Commissioning Intentions 2012/2013: These include:
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Raise the quality and safety of patient services, which delivers high levels of patient
satisfaction.
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Commission services that are high quality, offer improved outcomes, deliver patient choice and
offer Value for Money (VFM).
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A service configuration that supports best practice and makes best use of local resource –
implementation of model(s) of generalist nursing care across Dudley, which delivers care
closer to home.
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Support the commissioning framework for the three strategies for Urgent, Planned and Long
Term Conditions care.
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Working towards developing the capability to share patient level data with primary care and
social care services via a shared IT system.
West Midlands Regional Commissioning Objectives
The Provider will contribute to the delivery of the Regional Commissioning Ambitions, these being:
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Eliminating avoidable pressure ulcers.
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Making Every Contact Count – through the systematic delivery of health improvement.
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Significantly improving quality and safety in primary care.
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Ensuring radically strengthened partnership between NHS and Local Government.
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Creating a revolution in patient and customer experience.
Objectives for the service during 2012-2013
The service will deliver the following objectives during 2012-2013:
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Provide quality care for all adults referred to the service, designing and delivering tailored care
plans to meet individual health needs.
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Work in an integrated way with primary care and social care to deliver patient centred care.
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Deliver a service, which communicates effectively across critical professional interfaces,
including primary care, social care, specialist services, Virtual Ward, voluntary care
organisations, secondary and intermediate care services, placing the patient at the centre.
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Avoid unnecessary admissions to secondary care.
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Support the potential reduction of admission and re-admission by supporting and educating
patients, families and carers to seek early intervention for potentially debilitating conditions.
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Facilitate early discharge from acute providers and residential care.
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Enable patients who have long-term and degenerative conditions to continue to live as
independently as possible in their own homes.
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Support patients in fulfilling their aspiration of dying in their preferred place of death: thereby
supporting the delivery of choice at the End of Life (EOL).The choice options being supported
by the use of appropriate Gold Standard pathways adopted for use at the time of care.
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Address the wider health needs of differing client groups and their families and carers, to
include health promotion, promoting healthy lifestyles and prevention.
Expected Outcomes for the service:
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Reduction in the number of crises; minimised admission and re-admission rates
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Care staying closer to home
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Delivery of Person-centred care
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Promoted independence
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Minimised effects of disease and reduced complications
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Enhanced quality of life
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Fair access to service
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Delivery of safe and culturally sensitive care
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Use resources wisely, ensuring Value for Money.
The Aims of the service
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The District Nursing Service will be central to the ability of adults (aged 18 years and over) to
remain in their own homes, maximise their independence and improve their health outcomes
and quality of life. The service will play a pivotal role in assessment1; care co-ordination and
the provision of general nursing care, aiming to optimise health and health improvement.
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The fundamental constituent of the service is that it will work in an integrated way with primary
care teams and with social care providers to ensure multi-disciplinary working, patient centred
approaches and importantly, continuity of care.
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A central aim of the service will be to support the provision of multi-professional, seamless
care, which is delivered as close to patient’s home as possible, thereby reducing avoidable
admission to hospital and facilitating speedier discharge
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The District Nursing service will play a fundamental role in enabling and supporting adult
patients who choose to die at home at the end of their life. This support and enablement will
also extend to their families and carers
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The service will provide a quality, comprehensive and accessible generalist nursing service to
patients in Dudley who are either temporarily or permanently housebound4. Services are to be
delivered through clearly defined packages of nursing care, either within the patients own home
or in a residential setting.
1
4
RCN Response to the DOH document ’Common Assessment Framework for Adults’ April 2009
Dudley Agreed Definition of Housebound. December 2011
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DUDLEY AGREED DEFINITION OF HOUSEBOUND
‘The District Nursing Service will provide care to patients who require nursing care, who have proven
morbidity and mortality and/or who are genuinely unable to leave their home, either on a short term or
long term basis and/or where there is a nursing need. Where it is apparent that the patient could be
assisted to, or is able to attend clinic or surgery, then this should be discussed with the patient and
facilitated. In the event of a referral being made which does not meet these requirements the Team
Leader will discuss the issue with the referrer to agree a way forward. However, to avoid any delay in
providing care, the patient should be seen, where this is assessed to be the case, in advance of a way
forward being agreed’.
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Provide a quality, comprehensive and accessible generalist nursing service for ambulant
patients in Dudley. The definition of ambulant for this purpose is in relation ‘to patients who
have been temporarily housebound and who have, during the delivery of a package of nursing
care, become mobile and are able to attend a local clinic setting for the continued provision of
the package of nursing care’. In these circumstances, the most appropriate place of care will be
determined at the discretion of the District Nurse/Team Leader in conjunction with the referrer.
In relation to wound care the definition of ambulant may include patients who are ‘mobile’ at the
point of entry to the service.
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Provide a generalist palliative care for patients who are suffering a life threatening illness,
cancer or non-cancer, who wish to die at home this provision enabling patients to remain at
home where they wish to do so, thus enabling choice at the end of life. Services will be
delivered in line with common core competency and principles of integrated care provision of
all professionals working with adults at the end of their life. These competencies to include:
communication skills, assessment and care planning, symptom management and advanced
care arrangements.
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Promotes a co-ordinated approach to Discharge for elective and non–elective interventions that
facilitates a seamless transition from secondary care and one that leads to better health
outcomes.
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Proactively case-find individuals at risk by close working with primary care teams, Virtual Ward,
secondary care and social care providers.
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Adopts a public health approach to all areas of practice to reduce ill health and promote healthy
lifestyles. Where appropriate, this may include sign posting to other services/agencies.
2.2 Service description/Model/Care pathway
2.2.1 Service Description
The service will provide:
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Comprehensive assessment: of patients accepted by the service, including the agreement of
outcomes and the creation of an individual care plan. The care plan will determine the principal
environment for the delivery of the nursing care package, whether this is in the patient’s home
(temporarily or permanently housebound), or in a community setting (e.g. where a patient becomes
ambulant during the delivery episode of care, or in cases where the practitioner has determined
that the patient is well enough to attend a community clinic setting).
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Single Assessment Process: where appropriate to support the seamless provision of care
through and the production of a single multi-disciplinary care plan; this facilitating shared working
arrangement. This to include:
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o
o
o
o
o
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Shared assessment of the patient in respect of health and social needs
Agreed provision of care to meet nursing needs
Referral to specialist and social services to meet other needs
Assessment of equipment needs
Delivery of health lifestyle and prevention messages
Waterlow scores will be determined on admission to the district nurses caseload and
documented as necessary throughout the care process. Scores should also be
documented on discharge from caseloads. All pressure areas Grade 3 and above should
be reported as a Significant Untoward Incident.
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Provision of carer’s assessments (informal carers, family or neighbours): using available
assessment tools, and Carer Stress/Strain Index ( see Appendix 3), undertake any necessary
carer assessment. Where appropriate, signposting carers to suitable alternative support services,
including social services and voluntary care services, including local Carer Support groups and
Financial Support Agencies.
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Ongoing assessment: including frequent diagnostics monitoring and treatments for patients with
Long Term conditions as required as part of their ongoing package of care. This input is critical for
those that are housebound or finding it difficult to access regular healthcare.
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Tissue Viability in support of the existing Dudley Tissue Viability Guidelines, the service will
provide generalist-nursing interventions to those patients suffering chronic wounds.
The Dudley Tissue Viability Guidelines should be applied in conjunction with the following Local
and national policies, guidelines and procedures:
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The Wound Management Formulary
Infection Control Policies
Moving and Handling policy
Safeguarding Adults Guidelines
National Institute for Clinical Excellence Guidelines on Pressure Ulcer Prevention and
Management (2001 and 2005)
European Pressure Ulcer Advisory Panel Guidelines on Pressure Ulcer Prevention and
Management (www.epuap.org)
Tissue Viability Society (2009) Seating and Pressure Ulcers: Clinical Practice Guidelines
www.tvs.org.uk
(a) Wound Management: district nurses will complete a comprehensive assessment to ensure
the development of an evidence-based treatment plan for all patients with wounds. For the
purposes of this specification, ‘a wound is defined as a defect or break in the skin that results
from physical, mechanical or thermal damage, or that develops as a result of the presence of
an underlying medical or physiological disorder7. This aspect of service maybe provided as part
of a locally, accessible community clinic based service for ambulant patients on the district
nurses caseload.
All wound care should be consistent with the agreed Wound Formulary wherever possible/
appropriate. Authorisation should be sought from a Tissue Viability Nurse(s) in order to initiate
‘off formulary’ treatments. It is also expected that expensive dressings will be requested in the
smallest number possible but any restriction should not compromise ongoing patient care.
The patient will be provided with information relating to the proposed care plan in a manner that
is considerate of their age and cognitive status and which will facilitate their understanding and
informed consent to assessment and planned care. Examples:
7
Thomas 1990
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o
Post-operative wounds
o
Pressure ulcers
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Larvae therapy
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Maintenance of wound vacuum pump
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Acute exacerbation of skin conditions
(b) Prevention and treatment of Pressure Ulcers The Service will work towards the
achievement of the NHS Midlands and East‘s Ambition to ‘eliminate avoidable Grade 2, 3 and
4 pressure ulcers by December 2012. Prevention to be achieved through published step
approach:
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Surface: make sure that patients have the right support
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Skin inspection early inspection means early detection
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Keep patients moving
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Incontinence/moisture patients need to be clean and dry
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Nutrition/hydration, help patients to have right diet and plenty of fluids
o
All intervention from initial assessment to discharge should be delivered against a
‘Best Practice’ Pressure Ulcer Path
(CQUIN Targets for Tissue Viability – Pressure Ulcers Grade 3 & 4 are contained within the
main body of the National Standard Contract attached to this service specification. However,
Commissioners will be considering in year as to how the current position can be improved and
through negotiation it is hoped that Grade 2 Pressure Ulcers can be included as a Quality
Indicator in both Acute and Community contracts)
(c) Leg Ulcer Management: using the recently published evidence based Guidelines8 deliver a
quality driven assessment and treatment plan for those patients presenting with a leg ulcer –
(Definition: any wound on the lower limb that has been present for more than four weeks) the
treatment plan developed against the stated Competency Framework. Treatment to be
delivered in-line with the agreed Leg Ulcer Pathway
Annual Doppler Assessment to be carried out on all patients on district nursing caseloads.
Lymphoedema maintenance in conjunction with the specialist service
(d) Community Equipment: regardless of who has made the initial assessment for specialist
equipment to be delivered to patients in the community, the service will ensure a three
monthly review of all specialist pressure relieving equipment supplied.
(Excluding patients in Nursing Homes and IP within the Mental Health Trust)
. The review should respond to the following requirements:
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Does the patient still meet the criteria for loan of equipment; if yes then this should be
documented in patient’s notes and/or on the loan of equipment database.
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Does the equipment still meet the patient needs; if yes, then this should be confirmed as
above, if differing or new equipment is needed then this should be actioned through a new
referral to the service.
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Is the equipment still needed; if no, then the patient/family should be informed of the return
procedure. This decision should also be recorded as above
Leg Ulcer Management Guidelines - The Dudley Group of Hospitals, October 2011
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It is acknowledged that not all patients will be on the district nursing caseloads, but it is
expected that the reviews should take place irrespective of this validation.
(These requirements will be a critical component of the soon to be released Tissue Viability
Guidelines, and the success of the intervention will be critical for the alignment of cost-pressures
within the Equipment budget).
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Continence Management: comprehensive assessment and advice for those patients referred with
continence issues. The resulting care plan will focus on identifying and treating the cause of the
problem: if this proves impossible, then appropriate information should be given on obtaining
aids/appliances or initiating a pad service. The planned approach will be determined against the
use of a Continence Care Pathway supported by the Royal Marsden Guidelines9
The referral for an External Assessment should only be sought if all internal avenues of clinical
support have been exhausted or unsuccessful.
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Urethral Catheterisation and Catheter care: a comprehensive assessment should be
undertaken, to include such areas as general health, bladder capacity, bowel habit, dexterity,
comprehension and sexual activity. The service will have the competencies to:
o
o
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o
o
o
o
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Insert and secure Urethral catheters
Care for patients with Urethral catheters
Undertake Trials without catheter
Assess residual urine by use of a portable ultrasound
Carry out intermittent catheterisation
Enable individuals to carry out intermittent catheterisation
Manage Supra-Pubic catheters
Together with secondary care services ensure that all patients with a catheter in place are
given a checklist for ongoing care following discharge from hospital.
Through the production/agreement of locally agreed Guidelines in 2012-2013, the district nursing
service will contribute to the achievement of the National Priority of reducing the number of
catheter acquired urinary tract infections2
The Guidelines to be developed should take into account the Reduction in the incidence of urinary
tract infections (UTI) in line with High Impact Actions for Nursing and Midwifery, essential Steps
Management of Urinary Catheter Care and preventing the spread of infection and Saving Lives
clean safe care high impact intervention no. 6 urinary catheter bundle.
ACTION DISTRICT NURSING STEERING GROUP
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Infection Control: The Provider is required to comply with the Health and Social Care Act 2008,
Code of Practice of the NHS on the prevention and control of healthcare associated infections and
related guidance. The provider should have policies, procedures and systems in place to ensure it
meets it legal obligations in relation to control of infection and hygiene. Effective prevention and
control of HCAI should be embedded into everyday practice and applied consistently by all those
working within the District Nursing service. Compliance with the following is required:
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2
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All staff with clinical and non-clinical roles working within the District nursing service will
receive Infection Control training every three years
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Essential Steps/Saving Lives Audit Reports demonstrating conformance with standards
and assessment across all teams
The Royal Marsden (2008) Royal Marsden Hospital of Manual of Clinical Nursing Procedures
DOH-The Operating Framework for the NHS in England 2012/13
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Through preventative measures and relevant screening inputs contribute to:
O
the further reduction of the number of Clostridium Difficile cases associated with nonacute care; consistent with the HCAI reduction plan
O
the further reduction of Pre 48 hour bacteraemia cases associated with community
services; measured against the outturn of 2010/2011
Policies for the purchase, cleaning and maintenance of all clinical equipment should take into
account infection control advice given by relevant expert or advisory bodies. Policies should be in
place for handling devices designed for single use only or limited re-use. These policies and
procedures should be comprehensive, up-to-date and reflect appropriate practices
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Long Term Conditions: in support of the emerging commissioning framework for the care of
patients with Long-term conditions the service is expected to link with all relevant GPs, health and
social care professionals and Expert Patient Programmes (EPP) in the management of care in
order to
(a) Deliver care through the use of agreed and emerging pathways (See Appendix 2 –
hyperlinks to pathways)
(b) Ensure consistent high quality condition/disease management
(c) Reduce inappropriate admissions to hospital and the reliance of secondary care.
(d) Support self care and manage health inequalities
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Coronary Heart Disease
Diabetes
Cancer
Respiratory
Chronic Kidney Disease
Stroke
Neurology
Dementia
It is expected that district nurses will carry out Health Checks on those patients on their caseloads
who suffer Long Term conditions and are unable, for whatever reason, to access normal
healthcare service provision. These could form part of the initial assessment with Annual reviews
taking place as part of the ongoing assessment process. Any abnormalities detected, as part of the
screening process, should be communicated to primary care and a decision on how to proceed
with care delivery agreed between the key worker and the referring General Practitioner - this
conversation documented in patient’s notes and a copy relayed to the patient’s General
Practitioner. (Where teams access Practice IT systems then this information will be inputted
directly).
Examples of abnormalities that maybe found include: (a) raised Blood pressure readings and
(b) irregular pulse (when checked manually) suggesting the possibility of Atrial Fibrillation11
The service should be aware of the soon to be released ‘Dementia Pathway’ and the
consequence to the service.
11
Atrial Fibrillation - Primary Care Diagnosis & Management Pathway. See Appendix 1 hyperlink
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British Heart Foundation intravenous (IV) Diuretics project: The Out-of Hours district nursing
service will actively support, through nursing intervention and the administration of medication, the
introduction of the developing British Heart Foundation intravenous (IV) Diuretics project 12, to
ensure continuity of care over the 24hour period.
This project will be delivered by the Community Heart Failure Team and will focus on the giving
of IV diuretics in the home/community settings and potentially nursing homes (this last setting
for discussion and agreement), resulting in admission avoidance for the housebound and
support to End-of-Life patients.
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Diabetes Management and Treatment: regular home visits to provide diabetes treatment to those
patients who are housebound or find it difficult to access regular healthcare. This would include
monitoring advice and support, to promote independence for patients with Diabetes. This aspect of
general nursing delivered in conjunction with the lead Primary Care Diabetic clinician for the
patients practice, be that doctor or nurse.
The service will provide the following treatment processes for those patients who are unable, for
whatever reason, to perform these tasks for themselves and attend normal healthcare service
provision:
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Blood Glucose Monitoring – random and profile (every six months)
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Injection maintenance of Insulin
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Annual Diabetic Review; this should include:
 Blood pressure, pulse readings
 Weight and height measurement
 Dip stick urine testing
 Depression screening: (NICE recommends that any patient who may have
depression (especially those with a past history of depression or who suffer from a
chronic physical illness associated with functional impairment) should be asked the
following two questions:
(a) During the last month have you been feeling down, depressed or hopeless?
(b) During the last month have you often been bothered by having little interest or
pleasure in doing things?
If patients with a chronic physical illness answers 'yes' to either question, the
following three questions should be asked: During the last month, have you
been bothered by:
(a) Feelings of worthlessness? (b) Poor concentration and (c) Thoughts of death?
 Observing insulin injection sites
 Recommendation of an eye check by an ophthalmic optician (patient refusal
should be recorded)
 Annual Foot Check, this to include assessment of pedal pulses and microfilament
checks. Referral to a podiatrist for patients with more than one or more risk factors
for foot ulceration (patient refusal should be recorded)
This activity to assist primary care colleagues and Diabetes specialist practitioners to achieve
the targets/standards set out within the NSF for Diabetes.
12
Draft Policy for IV Diuretics in the Community. See Appendix 1 hyperlink
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End of Life Care: all district nursing teams will provide care and support to adults with palliative
and end of life needs, through ongoing assessment of patient condition and provision of pain
management and symptom control. They will also provide care for transitional adults in conjunction
with the Dudley Children’s Palliative Care team13.
Delivery of End of Life Care, which supports and ensures the use of End of Life tools including
advanced care planning and the locally agreed use of the Liverpool Care Pathway14.
Where appropriate, ensure the necessary referral and access to Specialist Palliative Care
services, third sector and other relevant community based services for patients, families and
carers. The service to provide specifically:
o Pain management and symptom control
o Maintenance of subcutaneous line and syringe driver
o Advice on medication and medicine management
o Support to families and carers
Palliative Care/End of Life Care: The provision of personal care that meets the comfort and
hygiene needs of patients at the end of life stage will be delivered in conjunction with other
specialist services over a twenty-four hour period with a maximum of five visits taking place.
The Out-of Hours service will receive handover from the daytime services in order to ensure both
co-ordination and continuity of care. District nurses who work within the Out-of Hours Team will be
trained in ‘Verification of Death’ and should be authorized to verify expected deaths if they have
previously gained consent from the patients general practitioner and family members.

Post Bereavement visit: at this visit carers and families of the deceased will be offered support
and guidance and where appropriate, signposted to suitable support services.

Medication Administration: support and advise patients to safely administer their prescribed
medication, enabling the patient to remain within their own home. The delivery of nursing
interventions will cover medicines management, prescribing and the supply and administration of
medicines this delivered by appropriately trained and competent district nurses and will specifically
include:
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Syringe pump medication
Percutaneous endoscopic gastroscopy feeding.
Rectal insertion
Transdermal medication
Intramuscular injections
Subcutaneous injections
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IV Antibiotics – A new Cellulitis Pathway to be completed by Secondary care in order to
recommence a community based treatment service in January 2012, the developed pathway to
be shared with Primary Care colleagues.
 Immunisation programme delivery: for influenza and pneumococcal infections for all patients
who are housebound (see definition page 2), at home and in residential settings. This provision
should also be extended to include those ambulant patients who in the short term, become
housebound and are unable to access standard health care services.
13
14
Dudley End of Life Strategy
.
Liverpool Care Pathway
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 Nurse Prescribing: this will be undertaken by appropriately trained, experienced and competent
District Nurses who are required to prescribe against a clearly defined formulary. It will be critical
that prescribing competencies are maintained and up-to-date. The National requirements for all
Non-Medical Prescribing are noted below:
Non Medical Prescribing

Competencies: All non medical prescribers (NMPs) to demonstrate compliance with the
competencies within the clinical governance framework for non medical prescribers (See
schedule 13: Documents relied on) demonstrated through PDR and an annual prescribing visit
to demonstrate competencies are kept up to date.
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Annual Update: All Non Medical Prescribers to attend update training every 18 months
demonstrated through a record of attendance of one of the annual update training sessions
offered at least once every 18 months used in conjunction with NMP database

NMP database/register: Organisation to provide commissioner with assurance that an up to
date register of all NMPs and their competencies is maintained at all times, this will include a
list of all those NMPs who will require access to the commissioner prescribing budget. All NMP
prescribers from the commissioner prescribing budget should be authorised by the NMP Lead
in the Commissioning organisation.
All Prescribers
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Governance: Organisation to report regularly to Commissioner Prescribing and Medicines
Management Committee providing assurance that appropriate governance procedures are in
place for all prescribers.
o Access to prescription pads to be authorised by named individual from the commissioner
organisation
o Organisation to ensure that actions resulting from NPSA alerts and other safety
announcements are identified and implemented across all parts of the organisation

Formulary: All NMPs prescribing from the primary care prescribing budget to prescribe from
the Dudley Formulary of medicines and prescribable products.

Service Provision: Organisation to ensure that prescribing service continuity is maintained at
all times.

Medicines Management
o
The Provider will have clearly defined processes (including policies and procedures for
obtaining and storing medication and for medicines management, which includes
prescribing, dispensing, preparation, administration and monitoring (including adverse drug
reactions) where applicable.
o
The Provider should regularly audit all medicine management processes
o
The Provider will have a system/policy in place for the safe and appropriate disposal of
unused medicines where applicable
o
The service should adhere to all relevant NICE guidance NSPA safety guidance unless
clinical justification for variance can be proved/given
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
o
The Provider is required to have an incident reporting policy in place which is approved by
commissioners.
o
All medications incidents (and near misses) must be reported via the approved Incident
Reporting system
 Clinical care, governance and risk management
o
The service should adhere to all relevant NICE guidance NSPA safety guidance unless
clinical justification for variance can be proved/given
o
The Provider is required to have an incident reporting policy in place which is approved by
commissioners.
o
All medications incidents (and near misses) must be reported via the approved Incident
Reporting system
 Controlled Drugs
The Provider should have procedures in relation to the management and use of controlled drugs to
comply with the misuse of drugs regulations including: access, storage, security including the
transportation of drugs), disposal/destruction and record keeping.
o
The Provider should undertake regular audits of the systems in place for the use of
controlled drugs
o
The Provider should be aware of the Accountable Officer for Controlled Drugs in the PCT
and report any concerns and incidents in relation to controlled drugs
 Key Legislation and Guidance
1) Medicines Act 1968
2) Misuse of Drugs Act 1971, Misuse of Drugs Act 1971(Modification) Order 2001 and Safer
Management of Controlled Drugs: Guidance on Strengthened Governance Arrangements
(Department of Health 2006)
3) Building a safer NHS: Improving Medication Safety (Department of Health 2004)
4) Best practice Guidance on Joint Working Between the NHS and the Pharmaceutical
Industry and other Relevant Commercial Organisations (department of Health 2008)
5) Relevant NICE guidelines and technology appraisals
6) Relevant NPSA and MHRA safety guidance/alerts
7) Healthcare Commission Standards for Better Health Standard C4d
 Annual Declaration
The service will be required to complete an annual declaration to state that it complies with
requirements relating to medicines management as stated above and additionally in relation to
Standards for Better Health and any subsequent successor regulatory requirements via the care
Quality Commission. To be Reviewed at Annual Review of Contract.
 Safeguarding Adults: ensure that local safeguarding procedures are an integral part of the
service delivery to ensure particularly the Protection of Vulnerable Adults. The Provider will be
expected to ensure that all District Nursing staff have been (a) appropriately trained in local
safeguarding procedures and (b) maintain this competency.
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
All relevant staff members working within the District Nursing service will have CRB checks and
action plans in place to comply with the vetting and barring policy, which covers the requirements
of the Independent Safeguarding Authority.
The Provider will be expected to ensure that all staff are professionally supported in order to
implement safeguarding procedures where concerns have been identified.
The relevant district nurse(s) will attend joint serious case reviews where a vulnerable adult when it
is confirmed or there is strong evidence to suggest that an adult has died, been significantly
harmed or put at risk as a result of abuse or neglect. The nursing team clinical notes will be made
available to those bodies investigating the incident
 Safeguarding Children: It is expected that the Provider will ensure that all staff who come into
contact with children in the course of their normal work will be trained to be alert to potential
indicators of abuse. All district nursing staff should be inducted with local policy and procedure in
the event of suspecting child abuse.
The Provider will have a medical and nursing professional lead appointed within the Organisation.
 Support patients to make health choices: ensure that information on health choices is available
within differing community care settings for patients and their families, which supports the delivery
and understanding of healthy lifestyles complex information. To ensure the delivery of CQUIN
target in respect of making every contact count. Main priorities being:

Proactive management of patients on caseload who are obese:
(a) Be aware of adult obesity pathways and referral routes and refer/signpost appropriately to
these services
(b) Carry out measurements to assess obesity as part of the core assessment,
(c) Promote importance of healthy weight, diet and physical activity as part of care package.
 Support to patients and families who want to stop smoking:
(a) Establish smoking status at initial contact assessment for all patients and reinforce risk to
health, offer support and where agreed provide brief interventions
(b) Where brief intervention is provided this should be recorded, indicating whether the patient
has been referred on or signposted; this action to be followed up at subsequent visits.
(c) Awareness of the stop smoking services and referral routes; referring/signposting
appropriately to these services (where patients consents).
(d) Raise awareness of the implications of ‘second hand smoke’ for those patients who are
non-smokers but living with smokers.

Action to tackle alcohol abuse
(c) Clear understanding of referral protocols between primary and secondary care and
specialist alcohol services in order to signpost or refer.
(d) The Provider will raise awareness of district nursing staff to ensure that they are able to
identify alcohol problems and intervene appropriately.
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
 Health Checks programme
(a) Awareness of Health Checks pathway and referral routes and refer and signpost
appropriately to these services.
(b) Promote the importance of Health Checks programme

Falls: the service to complete Level 1 assessment on all patients to evaluate the risk of
potential falls. If risk is apparent, then steps should be taken to eliminate immediate danger
and the patient to be referred to the Local Falls service for comprehensive assessment and
intervention. This in line with Dudley Falls Pathway.
The district nursing service to be aware of the Local Commissioning Intentions for this service
in 2011 and 2012-20131, and where necessary, provide an appropriate level of ‘Provider’
representation to ensure decision-making that reflects the likely need for community-based
generalist nursing input to any new integrated pathway of working.
The Commissioning intentions being:
 Introduction of ‘A First on the Scene Response’ service – in place from late 2011
 Review of existing Falls pathway, to allow for the development of a revised integrated
pathway, which spans acute, community and primary care. This development to be
included in service contracts for 2012-2013.

MECC CQUIN Target: The Provider will ensure, consistent with CQUIN targets for Making
Every Contact Count (MECC) ‘that all front line staff receive training to provide Brief
Opportunistic Advice (BOA) and signposting to lifestyle services for smoking, alcohol and
obesity’
As per CQUIN the targets for this are:
o
o
No of staff trained in MECC - 90% of staff trained
No of BOA delivered - 80% of contacts offered BOA ( it is noted that this target may change
following the collection and validation of baseline data)

Phlebotomy: all district nursing teams, in alliance with the community based Phlebotomy
services will carry out emergency phlebotomy on those housebound patients requiring
emergency/urgent blood tests: this supporting a collaborative approach to care with general
practitioners, leading to timely primary care decision-making about the continuation or
necessary change of medication and/or care packages: this intervention enabling patients
wherever possible, to remain at home and importantly avoiding any unnecessary admission.

Lymphoedema: the district nursing service to deliver Lymphoedema care in conjunction with
the Specialist Lymphoedema service. They will provide care to all patients with uncomplicated
lower limb lymphovenous or gravitational oedema16. All care delivered through agreed Local
pathways of care, policies and National Best Practice guidelines (www.lf.cricp.org).
Individual plans of care that foster self-management will be developed in partnership with
patients at risk of, or with Lymphoedema (involving relatives and carers where appropriate) in
an agreed format and language
1
Dudley Clinical Commissioning Group & Dudley Primary Care Trust: Commissioning Intentions 2012/2013.
16
LymphCare UK Discharge Policy 2011
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
District nurses will work predominantly with the above patients, however, with increased
awareness and improved levels of specialist training from the Lymphoedema service a number
of designate nurses, with specialist support should become sufficiently skilled to treat patients
with increased severity of condition.
Gap in Service - care issue for resolution during 2012-2013: It has become apparent during
2011 that bariatric patients presenting with Lymphoedema treatment needs are not, because
of assessed manual handling/health and safety risk reasons receiving a reliable level of shared
nursing care; this joint provision necessary to ensure that these patients are treated in an
equitable manner, with care provided by specialist and general trained nurses.
RESOLUTION: DISTRICT NURSING SERVICE AND LYMPHOEDEMA TEAM

Continuing Health Care (CHC): the district nursing teams will support patients and their
families throughout the process of referral and assessment for access to Continuing Health
Care funding for potential placement or home based provision.
Patients should not be discharged from the caseload until nursing home or home-based
packages of care are agreed and in place.
With regard to home-based packages of care, patients should only be discharged from district
nursing caseloads if no further nursing needs have been identified and importantly, that the
initial Referrer and families are confident that the replacement service can deliver the level of
care necessary to sustain patients safely within their own home. Attached key workers should
attend any follow-up review meetings.

Intermediate care: the district nursing teams will support patients and their families throughout
the process of referral and assessment for access to Intermediate care where placement in a
bed based service is necessary. This will include ensuring any necessary
equipment/continence products are transferred with the patient as appropriate.
For home based provision of service, in conjunction with the Community based Intermediate
care Team (LIT) and their attached nurses, will deliver agreed levels of generalist nursing care
to compliment individually tailored programmes of rehabilitation.
Patients should be reviewed/monitored, whilst in Intermediate care placements to ensure their
care needs can be met in a timely and appropriate manner on discharge home.

General Treatments:
(a) Eye and Ear care:




Post operative care and acute incidents
Trauma/infection/artificial eye care
Administration of eye/ear drops (4-10 weeks)
Ear syringing for housebound patients
(b) Oxygen therapy/Nebuliser maintenance
(c) Doppler Assessment: where requested from general practitioners undertake diagnostic
Doppler testing for housebound patients exhibiting symptoms of PVD.
(d) Colostomy/Urostomy care until patient is competent and self managing
(e) Spirometry, COPD and Asthma checks for housebound patients
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
(f) Injection maintenance therapy e.g. B12, Zoladex, Epo
(g) Administration of enemas where patients are unable to self administer
2.2.2 Service model
(a) Registered nurses, nurses with a Degree in Community Nursing, Nurse Prescribers who are
appropriately trained, experienced and competent, will provide the service. The service will
also comprise healthcare assistants with at least an NVQ Level 3 qualification. The service
will be available to all adults through open referral. It will be critical to the success of the
service that competency is maintained and skills continually updated.
(b) The service will be made available within the newly created five localities;
1) Dudley, Netherton & Sedgley, Coseley and Gornal (DN) (SCG)
2) Halesowen and Quarry Bank (H&QB)
3) Stourbridge, Wollescote & Lye (SWL)
4) Kingswinford, Amblecote and Brierley Hill (KAB). (See Appendix 1 for Dudley GP
Practices by Locality) (October 2011).
(c) The Provider will ensure that the service is equitably provided across all five localities in
response to need, particularly in relation to the allocation of resources to ensure that patients
have equal access to services, which are comparable in terms of quality and responsiveness.
The allocation/attachment of district nursing resource will be reviewed in-year (2012-2013). The
design of the attachment being based on demographic data reflecting social, economic and
environmental determinants rather than the existing historically based allocation.
ACTION: DISTRICT NURSING STEERING GROUP.
(d) The Provider will ensure that the management arrangements are in place to ensure
appropriate leadership, guidance and clinical supervision is consistently available to all District
Nurses across the service.
(e) Each patient will be assigned a key-worker who will co-ordinate the initial assessment and the
delivery of the ensuing care plan. As part of the delivery of care, the key-worker will liaise
effectively with other professionals as appropriate.
(f) District nurses will attend MTD meetings in primary care for patients on their caseload with
complex care needs. The referring member of the primary care team will be kept advised
about:
 Who is the allocated key worker for each patient,
 And importantly who will be the alternative contact in the absence of the allocated keyworker.
(g) Patients will be seen in their own homes or in DN community based clinics with appointment
slots available at differing times and locations; these organised to match predictable
fluctuations in demand and importantly, to allow a reasonable degree of flexibility/choice for
patients and their families.
(h) The patient will be advised how to access the Out of Hours services and the contact point for
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
the District Nursing service in-hours: this information given when the initial assessment is
undertaken and the patient is accepted into the service.
(i) District nursing teams attached to GP Practices will be responsible for the provision of a
generalist nursing service to adult ‘housebound’ patients registered with the practice. They will
be responsible for organising their workload, using resources available to them in the most
efficient way whilst ensuring communication systems are in place to ensure regular contact
with appropriate primary care colleagues, thus ensuring an integrated approach to care
delivery. The allocated key-worker will ensure regular communication is maintained with GPs,
other health and social care colleagues who have a continued active role in the delivery of the
patients care.
(j) If a patient is not registered with a General Practitioner but lives in the area, then care will be
provided on a geographical basis.
2.2.3 Care Pathway to the Service
A simple pathway reflecting the referral process to the service is shown below and must be
underpinned by robust communication between the service, primary care, social care and other health
professionals actively involved in the patient’s care. (See proposed Referral Criteria in Section 2.4 –
Any acceptance and exclusion criteria):
Referral into the District Nursing Service
Triage:
DN
allocated
From
GP
Practice
allocated
district
nursing
team
according
to
available
skill mix
Initial
assessment
undertaken.
Package of
nursing care
determined
and
patient
outcomes
agreed
GP advised
of key worker
and
contact
details.
Information
Shared
on package of
care
Package of
nursing
care
delivered
and
completed
Patient
discharged
from
the
service
When a referral is made to the service it will be triaged by a registered nurse: decision-making will be
based on defined prioritisation criteria and the complexity of the case. Patients will be contacted on
referral and appointment to visit made.
Following the initial assessment, the GP will be advised by the allocated key worker of information
culminating from the visit and the proposed package of care to be put into place.
The key-worker will ensure regular communication with the GP and other health and social care
professionals who have an active role in the delivery of the patient’s care. The overall responsibility
for the appropriateness of the assessment and delivery of the care package will be that of the District
Nurse managing the caseload and the Team (Team Leader).
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
Proposed prioritisation criteria are as follows (for further consideration as part of on-going
contract negotiation):

Simple: two or three visits required before discharge from service i.e. suture removal,
monitoring, post-operative, medication administration post discharge.

Complex: two to three co-morbidities, two or more poly-pharmacy and intensive support
required over a short-term basis. Case management should be undertaken at complex level.

Multi-complex: three or more co-morbidities, four or more poly-pharmacy or intensive
support required as in Palliative care cases or long-term condition patients in relapse.
For multi-complex cases the service should also consider the referral of the patient to a
relevant specialist nurse and/or the Virtual Ward.
2.3 Population covered
The Provider should have systems, procedures and policies in place to identify specific issues that are
potential barriers to prospective and ongoing access.
There should be improved integrated working between health and other agencies, including but not
limited to primary and social care, housing and third sector services. All patients whose care requires
the involvement of other agencies having a care plan that reflects this requirement.
The service will be offered to all adults who are Dudley registered patients, regardless of residence
and will be available throughout the five geographical localities:
1. Dudley, Netherton & Sedgley, Coseley and Gornal (DN) (SCG)
2. Halesowen and Quarry Bank (H&QB)
3. Stourbridge, Wollescote & Lye (SWL)
4. Kingswinford, Amblecote and Brierley Hill (KAB).
The service will also be available for transitional adults in alliance with the Dudley CHildren’s PAlliative
CAre team.
2.4 Any acceptance and exclusion criteria
Exclusion from the service will be as follows: however, the commissioners expect that the service will
signpost any patients to other services if they do not meet the proposed Referral Criteria set out in
Section 4 - Referral, Access and Acceptance

Where a patient has social needs only (it is accepted that this may not become apparent until
after the initial assessment has been completed), in which case if safe to do so, the patient
should be appropriately referred onwards to Social Services and discharged from the district
nursing service; or

If a patient has been referred for a ‘one-off’ intervention and the patient is not on the caseload
of a district nurse and intervention would normally fall within the remit of the primary care
team, commissioned under separate arrangements. e.g. LES
As a consequence of detailing this service specification it has been accepted that District
Nurses will not provide cover for practice nurses in cases of sickness and absence and that
this will be for general practices to make their own arrangements with their chosen
Provider(s).
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
2.5 Referral Route and Criteria
2.5.1 Referral Criteria
The referral criteria and service priorities must be in harmony with those of other relevant services e.g.
Virtual Ward, specialist nursing services and social care services and with RCN Guidelines.
Referrals should be accepted by the District Nursing Service on the basis that the patient:
(a) Has given consent prior to the referral.
(b) Meets the requirements of the definition of ‘Housebound’ (see Section 1 Purpose).
In relation to wound care, the definition of ambulant may include patients who are ‘mobile’ at the point
of entry to the service: in these circumstances the most appropriate place of care will be determined at
the discretion of the district nurse in conjunction with the primary referrer.
While it is accepted that this will predominantly be a ‘housebound’ delivered service, it is also
expected that the service will be available to those patients whose nursing needs indicate it is more
suitable for them to be cared for in their own home, e.g. those undergoing chemotherapy and requiring
care and maintenance of a central venous line.
(a) Requires generalist nursing provision either on a urgent, non urgent or routine basis
(b) Can be appropriately treated by the District Nursing Service.
(c) Is a Dudley Registered patient.
All referrals will be treated as new admissions to the caseloads for example: patients who have had
episodes of care in the past may not necessarily have the same treatment needs as previously
delivered, therefore requiring new assessment and identification of care package.
As part of the initial assessment process, referrals may be made to other health and social care
professionals and third sector services.
The service will be required to put systems in place to ensure that all relevant information is provided
at the point of referral, including information to ensure the safe administration of medicines whilst the
patient is within the care of the District Nursing Service.
2.5.2 Referral route
Patients should be referred to the service by the following:
o
o
o
o
o
o
o
o
o
o
General Practitioners and primary care colleagues
Self-referral
Social Care professionals
Virtual Ward
Secondary care (Acute)
Secondary and community based mental health teams
Community Learning Disability services
Specialist nursing services
Third Sector services
Children’s Palliative Care Team
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
All referrals will be sent directly to the locally based service either via phone, fax, post or secured email. The most appropriate clinician (district nurse) will screen all referrals to ensure the
appropriateness of urgency is assessed and unnecessary waits for inappropriate referrals reduced.
The service will be required to put systems in place to ensure that all relevant information is provided
at the point of referral, including information to ensure the safe administration of medicines whilst the
patient is within the care of the District Nursing Service.
2.6 Response time and prioritisation
2.6.1
At the point of referral the district nurse will establish the urgency of the visit and will be
categorised as patients requiring:
 In need of urgent nursing care
 Needing support in managing their own care
 Needing some co-ordinated assessment and intervention (specifically linking to elderly and
frail and LTC patients)
 Requiring palliative/End of Life care
2.6.2
Response times:
It is expected:
2.6.3
o
Urgent – Urgent: All urgent referrals will be telephoned and discussed with receiving nurse,
clinically triaged within 4 hours of documented receipt of referral, any inconsequential
incidents to be reported to Provider line manager; but significant failure to meet the Urgent
Referral Criteria should be reported to Commissioners as a Serious Untoward Incident
(SUI) in accordance with the agreed protocol.
o
Non-urgent – will be clinically triaged with access to service within 24-48hours of
documented receipt of referral.
o
Routine – will be clinically triaged with access to service with 1-3 days of documented
receipt of referral.
o
Post-operative visit – access to service on specified date.
o
Timed visits – for specified medication requests only
o
Ear syringing – assessment within 4 working days, treatment within 2 weeks from
assessment.
Prioritisation
The service will ensure that, wherever possible, prioritisation of patients is in line with the
following expected outcomes:




An acute admission is avoided
An early discharge is facilitated
Intermediate Care (bed-based service) is secured if required e.g. GP Respite
Patients with palliative and End of Life care needs are supported and able to die in their
preferred place of death.
Prioritisation to be re-assessed at each visit and care plan modified as required and any
change are made based on the patient’s needs.
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
2.7 Discharge Criteria and Planning
Patients will be discharged once:
(a) The package of care is complete and district nursing intervention is no longer required and
appropriate statement should be reflected in the patient’s care plan. If the patient moves
out of the area and is transferred to another health provider, or the patient dies.
(b) Where appropriate, discharge planning should be discussed with the patient and their
family from admission to the D/N caseload. The patient should have a clear care plan and
expected outcomes with predicted timeframes if possible. Review dates should be included
in the care plan. The patient will be given a 24hour contact number to enable them to
contact the service in case of crisis or urgent nursing care - this not applicable to life
threatening cases.
(c) When a patient is transferred to another provider service a summary of the assessment
and care given should accompany the patient wherever possible. The District Nursing
record should be returned to the D/N Team.
(d) As part of the discharge process patients will be given the opportunity to comment about
the service they have received to inform the Provider’s understanding of the patient’s
experience of the service. In turn, the commissioner will wish to receive information to
support patient outcome reporting.
(e) The key-worker will be responsible for ensuring that contact is made with the general
practitioner within 24hours of discharge from the service, and if appropriate, explanation of
referral to another agency.
(f) All patients where capable, will be supported to undertake self-care management of their
condition and support the ongoing care management through involved self-care.
2.8 Interdependencies with other services
The following services will have a relationship/interdependency with the District Nursing service:















General Practitioners, primary care MTD setting
Virtual Ward
Community and Acute based specialist-nursing services
Community-based Therapy services
Community Equipment services
Community and bed-based Intermediate care services
Social Care and Housing
Lymphoedema service
Acute services
Discharge Teams – Secondary services
Third sector services
Residential services
Children’s Palliative Care services
Community and secondary care mental health services
Public Health
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
2.9 Patient and Carer Involvement
All patients where capable, will be supported to undertake self-care management of their condition
and support the ongoing care management through involved self-care.
o
All patients will be provided with patient held records, which include a care plan detailing their
nursing needs.
o
The needs of the patient/carer over a 24hour period will be assessed when planning care.
o
Where an individual patient requires a care management plan it will include, crisis
management plan, which is agreed by the patient and their family/carer. Patients and carers
will be encouraged to be self-managing and the district nurses will provide the appropriate
training and education to enable this; this information will include health promotion advice on
healthy lifestyles.
o
It is anticipated that should an assessment identify needs that the District Nursing team cannot
meet, then referral to a suitable service should be made. e.g. referral for specialist equipment.
o
All information provided to patients and carers can be made available in accessible formats.
3. Applicable Service Standards
3.1 Applicable national standards.
As noted in Section 1. this list of evidence is not exhaustive, so it is expected that the service
will take account of all national and Local sources of Guidance and examples of Best practice
(both existing and new) apply it to the local service, thereby enhancing the quality and
effectiveness of care provided.
National Clinical Guidance












NICE Quality Standards
The Care Quality Commission Report: Dignity and Nutrition for Older People
No Health without Mental Health DOH
Carers Strategy DOH
End of Life Strategy
NICE Guidelines for Improving Supportive and Palliative Care for Adults with Cancer
Royal Marsden Clinical Guidelines
NSF for Older People
NSF Long Term Conditions
NSF Diabetes
National Dementia Strategy
Dudley Community Services Policies
Professional Guidance/Standards and Legislation





Nursing and Midwifery Council Professional Code of Conduct and Clinical Guidelines
Essence of Care – Updated 2010
Principles of District Nursing expressed by NMC, CPHVA and RCN
Listening and Learning the Health Ombudsman Report
Standards for Better Health and any successor guidance to be published by Care Quality
Commission
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
3.2 Applicable National and Local standards
National, Regional and Local Priorities/Commissioning Intentions



The Operating Framework for the NHS in England 2012-2013
The NHS Outcomes Framework 2011-2012
NHS High Quality Care for All – 2008 and subsequent review documentation – Our Journey
so far 2009
NHS Health & Well-being Improvement Framework
Regional Commissioning Framework
Dudley Clinical Commissioning Group & Dudley Primary Care Trust: Commissioning
Intentions 2012/2013



4. Key Service Outcomes
This revised Service Specification for the District Nursing Service will contribute to the recently stated
Local Commissioning Intentions for 2012 –20132 and help attain National Priorities3. This achievement
will facilitate the maintenance and improvement of the quality of care provided, whilst delivering
transformational change and conserving financial stability. This change to be achieved by:

Providing a service that delivers high quality, improved outcomes, patient choice and offers
Value for Money

Raising the quality and safety of patient services

Supporting the Commissioning Frameworks for Urgent, Planned and Long Term Conditions

Provides a service that meets both National and Local Targets, guidelines and policies

Becoming a reconfigured service that supports best practice and makes maximum use of local
resource
5. Location of Provider Premises/Service availability
5.1 Location of Service Delivery
The service will be delivered from the following locations:
o
o
o
Patient homes
Residential homes
A range of primary care/community settings across Dudley, including practices, Primary Care
Centres, health centres and District Nurse Community Clinic settings
5.2 Service Availability
The service will be available seven days a week – twenty-four hours a day. It will be provided
to ensure continuity of provision with a seamless transition of care from the Day services to the
2
Dudley Clinical Commissioning Group & Dudley Primary Care Trust: Commissioning Intentions 2012/2013.
3
DOH-The Operating Framework for the NHS in England 2012/13
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
District Nursing Evening service (one team); based in Brierley Hill Health & Social Care Centre
and the district-wide Night service which is based at Russells Hall Hospital.
To ensure an effective communication of patient conditions and care requirements between the
three elements of service a robust handover system will be in place at the beginning of each
shift.

Shift patterns in place over a twenty-four hour period:
 Day Service
 Evening Service
 Night Service
0.800 – 18.00
17.30 – 23.00
22.30 – 08.15
6. Quality and Performance Standards
6.1 National/Local Targets and Standards











National Service Frameworks: Older People, Diabetes and Long Term Conditions
NICE (2004) Guidelines for Improving Supportive and Palliative Care for Adults with Cancer
NICE Quality Standards
National Dementia Strategy 2008
NHS High Quality Care for All 2008
No Health Without Mental Health
Carers Strategy DOH
Royal Marsden Clinical Guidelines
Dudley Community Services Policies
Common Core Competencies and principles for health and social care workers working with
adults at the End of Life
Health and Social Care Act 2008, Code of Practice of the NHS on the Prevention and Control
of Healthcare associated infections and related guidance
6.2 Service User Experience
As part of the Providers Quality and Performance Standards it is expected that the Provider will
undertake as a minimum, an annual patient survey. The Provider is expected to share the findings of
the survey with Commissioners.
The provider will ensure, consistent with CQUIN targets for Making Every Contact Count (MECC) that
all front line staff receive training to provide Brief Opportunistic Advice (BOA) and signposting to
lifestyle services for smoking, alcohol and obesity.
As per CQUIN the targets for this are


No of staff trained in MECC - 90% of staff trained
No of BOA delivered - 80% of contacts offered BOA
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
6.2.1 Improving Service Users and Carers Experience
The provider should have systems, procedures and policies in place to respond to service user and
carer feedback. Commissioners will expect the Provider to be able to demonstrate evidence of action
taken and improvements made as a consequence of service and user feedback.
Quality indicator
Improving
Service Users &
Carers
Experience
(continued)
Quality Performance
Indicator
Increased
carer
support, linked to
Local
Authority
Carers Strategy
Threshold
Target: 95% of carers
offered a place on or
signposted to a support
programme.
This
opportunity
to
be
recorded
Random sample of carers
offered accept a place on
a support programme. (5
case notes per month)
Refusal
should
documented in
patient’s notes.
be
the
Method
of
Measurement
Measured
through
Annual Patient & Carer
Satisfaction Surveys
Consequence
Breach
of
Patients and Carers
record ‘satisfied’ rating
on returned survey
forms
Withheld
reports
together with action
plans will instigate a
Commissioner review.
Number of carers:
(1) identified
(2) Assessed using
Carer Strain Index
(3) Offered place on or
signposted to a support
programme (total and
as % of all carers)
(4) Accepted place on
support
programme
weave in use of CSI
As per CQUIN the targets for this are


No of staff trained in MECC - 90% of staff trained
No of BOA delivered - 80% of contacts offered BOA
6.2.2 Improving Customer Experience
The provider should have systems in place to ascertain customer feedback (in this instance the
customer will be all Dudley Registered General Practitioners).

ACTION: The Provider will undertake an Annual survey of all General Practitioners to
understand the level of satisfaction of services provided and importantly allow the opportunity
for general practitioners and primary care colleagues to register any issues relating to service
delivery thus creating the opportunity for change/improvement. It is expected that the survey
will concentrate the following areas:
o
o
o
Levels of satisfaction with the delivery of service against the backdrop of the new service
specification
Any continuing care/quality issues with the service
Examples of where the service is working well
Commissioners will expect the Provider to be able to demonstrate evidence of action taken and
improvements made as a consequence of customer feedback and report these findings back to all
practices through attendances at Locality Forums .
Method of Reviews –Contract Monitoring Meeting –Quarterly and Annual Review
(The completion of GP Survey also noted for input of the District Nursing Steering Group)
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
6.3 Reducing Inequalities
The Provider should have systems, procedures and policies in place to demonstrate evidence of
action taken in-year to ensure the District Nursing service is accessible to all vulnerable groups.
It is accepted that health inequalities as a whole can only be reduced locally if a partnership approach
is taken to confront all the determinants. The district nursing service will help work towards the
reduction of the inequalities noted below:



The wider determinants of health such as employment, education, housing and environment
Lifestyles of health behaviours such as smoking, drinking and poor dietary habits
Access to services such as health and social care.
Secondary prevention meaning early identification and prompt treatment to cure, reduce harm from or
slow down progress of condition e.g. heart disease or cancer
Method of Review – Contract Monitoring Meeting – Quarterly/Annual Reviews
6.4 Improving Productivity
The service will monitor and collate failed visit activity and redesign the service to try and reduce all
failed visits. The Provider should have arrangements in place to manage failed visit information to the
Commissioner.
It is accepted that during periods of inclement weather that this target maybe compromised. This
however, is only accepted for patients requiring routine procedures; every effort should be made to
ensure the continuity of service for those patients requiring urgent nursing care. e.g. those patients
requiring daily Insulin Injections, on IV Anti-biotic therapy, EOL requiring palliative care and those
patients needing urgent re-catheterisation.
Quality
indicator
Quality Performance
Indicator
Threshold
Method
Measurement
Improving
productivity
Reporting
the
number of failed
visits
(excluding
those failed due to
inclement weather).
Target: No greater
than 10% failed
visits
Baseline No. of failed
visits recorded during
2011/12
of
Consequence of Breach
More than 10% attainment
and/or withheld reports will
instigate a Commissioner
review.
Method of Review – Monthly Contract Monitoring Meeting
It is acknowledged that there are other global Quality and Performance Standards which are relevant
to the District Nursing Service, some are embedded in to the main body of this service specification
document, but others will be contained within main contract documentation, Local Quality
requirements and CQUIN targets.
27
FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
APPENDIX 1
Dudley GP Practices by Locality – April 2012
0
2.831
kilometers
Scale: 1:70,760
Dudley & Netherton


30
30
Halesowen & Quarry Bank
47
47


Kingswinford, Amblecote & Brierley Hill
Sedgley, Coseley & Gornal
19
19
43
43
A Roads
66
Railway




55
32
32
20b
20b
39a
39a




25

25


31
31
8a
8a

 99




8b
8b




24
24
51
51


 
28

28
21c

21c
49
49


41
41
40
40
17
17



10a
10a
22


27
27
20a
20a
10c
10c
Woodlands




4a
4a




34

34
29
29
52
52


4b
4b
Lake
48
54
54 48




38

37
37 38
23
23





15
22
22 15
42
42


Populated areas
39b
39b



 
 77


16
16


Minor Roads
11
11
13
13
33
B Roads






Motorway
35
35


36
36
10b
10b
Dudley Boundary



14
14


Stourbridge, Wollescote & Lye
Key:


26
26





46
46


21b
21b
45
45






18b
18b




44
44
50b
50b
21a
21a


18a
18a

11

12
12




50a
50a
33
33
Map Created by Public Health Intelligence, Dudley Public Health
Topographic Data © Crown copyright and database rights 2011 Ordnance Survey 100050565
28
FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
Dudley & Netherton
Map No.
5
15
22
23
25
29
32
34
37
38
39a
39b
48
51
54
Practice
Number
M87006
M87017
M87025
M87026
M87028
M87036
M87601
M87605
M87612
M87614
M87617
M87617
M87634
Y02212
Y02955
Practice Name
Eve Hill Medical Practice
Steppingstones Medical Practice
Cross Street Health Centre
St James Medical Practice (White)
Netherton Health Centre
Bean Road Surgery
Keelinge House Surgery
Central Clinic
St James Medical Practice (Porter)
Tinchbourne Street Surgery
Netherton Surgery
7 Hazel Road
St Thomas's Medical Centre
Dudley Partnership for Health (Quarry Road)
Kates Hill Surgery
Halesowen & Quarry Bank
Map No.
1
12
18a
18b
24
28
33
41
44
45
49
50a
50b
Practice
Number
M87001
M87014
M87020
M87020
M87027
M87034
M87602
M87619
M87623
M87625
M87638
Y01756
Y01756
Practice Name
Meadowbrook Road Surgery
Lapal Medical Practice
Feldon Lane Surgery
6 Hawne Lane
Quarry Bank Surgery
Clement Road Medical Centre
Halesowen Medical Practice
Coombs Road Surgery
Alexandra Medical Centre
Crestfield Surgery
Thorns Road Surgery
Halesowen Health Centre
3 Tenlands Road
Kingswinford, Amblecote & Brierley Hill
Map No.
3
4a
4b
7
8a
8b
9
16
20a
20b
27
31
40
52
Practice
Number
M87003
M87005
M87005
M87008
M87009
M87009
M87010
M87018
M87023
M87023
M87032
M87041
M87618
Y02653
Practice Name
Moss Grove Surgery
Three Villages Medical Practice
80 Bridgnorth Road
Kingswinford Health Centre
AW Surgeries
AW Surgeries
The Waterfront Surgery
Summerhill Surgery
Wordsley Green Health Centre
84 Market Street
Brierley Hill Health & Social Care Centre
Rangeways Road Surgery
Quincey Rise Surgery
High Oak Surgery
29
FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
Sedgley, Coseley & Gornal
Map No.
6
11
13
14
19
30
35
36
42
43
47
Practice
Number
M87007
M87012
M87015
M87016
M87021
M87037
M87606
M87610
M87620
M87621
M87629
Practice Name
The Ridgeway Surgery
The Greens Health Centre
Lower Gornal Medical Practice
Woodsetton Medical Centre
Coseley Medical Centre
Northway Medical Centre
Bayer Hall Surgery
Masefield Road Surgery
Castle Meadows Surgery
Bath Street Surgery
Bilston Street Surgery
Stourbridge, Wollescote & Lye
Map No.
2
10a
10b
10c
17
21a
21b
21c
26
46
Practice
Number
M87002
M87011
M87011
M87011
M87019
M87024
M87024
M87024
M87030
M87628
Practice Name
Norton Medical Practice
Worcester Street Surgery
Meriden Avenue Surgery
Greenfield Avenue Surgery
The Limes Surgery
Wychbury Medical Group
Chapel House Surgery
62 Cradley Road
Pedmore Medical Practice
Chapel Street Surgery
30
FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012
APPENDIX 2
HYPERLINKS TO PATHWAYS
COPIES OF POLICY/PATHS FOR THE FOLLOWING ARE STILL OUTSTANDING. THE
APPENDIX DOCUMENT WILL BE UPDATED AS AND WHEN THEY BECOME
AVAILABLE:
1)
2)
3)
4)
5)
FALLS Pathway link – to be confirmed
IV DIURETICS Pathway/protocol link – available End of May 2012
DIABETES AND FOOT CARE Pathway link – available April/May 2012
DEMENTIA Pathway link – to be confirmed
IV CELLULITIS Pathway link – to be confirmed
ATRIAL FIBRILLATION (AF) PRIMARY CARE DIAGNOSIS AND MANAGEMENT
PATHWAY - http://pctnet.dudley.nhs.uk/documents/cms/528-2010-3-29-5049621.pdf
Clinical Pathway for the Management of Cardiovascular Risk http://pctnet.dudley.nhs.uk/documents/cms/528-2010-7-20-5782276.pdf
Chronic Kidney Disease Pathway - http://pctnet.dudley.nhs.uk/documents/cms/5282010-7-20-5784456.pdf
NHS Health Check: Dudley Pathway Vascular Risk Assessment and Management http://pctnet.dudley.nhs.uk/documents/cms/528-2010-7-27-3365514.pdf
Primary Care: Stroke and TIA Pathway http://pctnet.dudley.nhs.uk/documents/cms/528-2011-1-13-2941124.pdf
Asthma Treatment Guidelines http://joint.dudley.nhs.uk/cmsextra/documents/cms/586-2010-5-11-5531807.pdf
Guidelines for the Diagnosis, Management & Treatment of Chronic Obstructive
Pulmonary Disease (COPD) in Dudley http://joint.dudley.nhs.uk/cmsextra/documents/cms/586-2010-12-7-3727752.pdf
Diabetes guidelines – currently ratified on intranet
- http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-4-27-5504077.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3870563.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3896806.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3900833.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3905425.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3908760.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3919369.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3922363.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3927186.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3927186.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3930005.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3945141.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-11-13-3962667.pdf
http://joint.dudley.nhs.uk/cmsextra/documents/cms/195-2007-5-1-5989992.pdf
Liverpool Care pathway - http://joint.dudley.nhs.uk/cmsextra/documents/cms/191-2011-614-3070702.pdf
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FINAL DOCUMENT FOLLOWING CONSULTATION PROCESS – 27 APRIL 2012