This was a detailed project aimed at seeking the views of those patients and their relatives considered to have ‘no right to reside’ in hospital as they had completed their medical treatment and were fit to be discharged. The focus was specifically on the hospitals and community bed-based provision run by Wrightington, Wigan and Leigh NHS Trust.
The Healthwatch Wigan & Leigh team spoke to patients on wards at the Royal Albert Edward Infirmary, Leigh Infirmary and the two-community bed-based services commissioned by Greater Manchester Integrated Care Board, providing Intermediate Care,
Discharge to assess services and stroke rehabilitation. Patients were identified to us from the ‘No right to reside’ list and were able to give their consent to share their story. Patients and relatives told them that the discharge process was complex and confusing. Communication proved to be difficult, and it felt that there was no joined-up working or coordination. Multiple moves around
the hospital and community services led to confusion, miscommunication and lack of any continuity which inevitably led to duplication. In addition, patient and relatives made comments about deconditioning and the impact on mood as patients lack stimulation in the hospital.
Recommendations
- HWWL recommend a review of the number and roles of the teams
currently involved in discharge planning; mapping roles and responsibilities and reducing duplication. - WWL and Wigan Adult Social Services review the current electronic
patient record systems to either align systems or review access to provide appropriate information. This would improve the sharing of information to allow all staff caring for the patient to communicate effectively with the patient and their relatives. - Provide accurate information to patients and relatives about the WWL services available in the community. Provide or update any patient information leaflets relating to Richmond House and Bedford Care Home.
- Explore the possibility of providing rehabilitation/discharge to assess bed-based services in other parts of the borough. The current provision in Leigh has been raised by many patients and their families as a significant challenge for visiting.
- Develop a discharge passport which can be held by the patient and contributed to by staff, patient and family. This would act as an ‘aide memoir’ for:
a. patients who at times may struggle to remember everything they are told.
b. a useful communication tool for relatives who can only visit ‘out of hours’.
c. provide an opportunity for two-way communication with staff. - Utilisation of multidisciplinary meetings especially where there are
differences of opinion between all parties. This is particularly relevant
where patient and families or staff and families have differing views on
discharge plans. This would allow all to air their views and consider
mitigation of risk etc. - Improve involvement of ward staff with discharge plans to aid
communication with families and reduce opportunity for conflict. - Consider a review of the way IDT work with a more patient centred
approach rather than ward allocation. Explore the possibility of linking
staff to patient throughout their journey therefore better supporting
continuity, communication and formation of relationships. - Work with Adult Social Services to review the possibility of identifying
criteria that could trigger an early referral into their services to reduce
length of stay and support more timely discharges. - Discharge of patients from Richmond House and Bedford Care
Home is planned in advance. Therefore, patients awaiting transfer to
these facilities to have their admission planned in accordance with
known upcoming bed availability to better prepare the patient and
their family for the move. - Review the current commissioning of the stroke beds at Richmond
House and consider if there is a more appropriate facility which could
better accommodate these patients to give more frequent and
specialist therapy interventions. - Consider reviewing the current admission criteria for Bedford Care
Home as many of the patients and families we spoke to had considered
that they could be managed at home.