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1
NHS Standard Contract for Community Services
SERVICE SPECIFICATION
Service
Community-based Nursing Service
Commissioner Lead
David Slack
Contract Manager Community Commissioning Manager
Provider Lead
Period
April 2012 to April 2013
1. Purpose
1.1 Aims
To support adults who are housebound and who require nursing care to address or
minimise their healthcare problems and lead as fulfilling, pain-free and independent
lives as possible.
This specification incorporates two previously separate service specifications for
District Nursing and Community Matrons.
In the context of this Service Specification, and to promote the self-care model
described in Section 3.1, the term ‘service users’ is used to describe people accessing
this service or where relevant their family or carers.
The term ‘housebound’ means an adult who is unable to leave their place of residence
without the support of an ambulance or where for particular reasons their healthcare
needs are considered to be managed more effectively in their home environment as
opposed to attending a GP surgery or other community facility.
1.2 Evidence Base
The service will be provided in line with all related guidelines and standards detailed
in the main body of the contract. This includes but is not limited to:
Department of Health ( 2001) The National Service Framework for Older
People. London, DH Publications
Department of Health ( 2001) No Secrets Guidance on protecting vulnerable
adults from abuse
Department of Health (March 2005) The National Service Framework for Long
term Conditions, London, DH Publications
The National Institute for Clinical Excellence (November 2004) The
assessment and prevention of falls in older people, London, Oaktree Press Ltd.
Department of Health (December 2007) The National Stroke Strategy, London,
DH Publications.
Intercollegiate Stroke Working Party (2008) National Clinical Guideline for
Stroke, third edition, Royal College of Physicians
2
Department of Health (2007) Cancer Reform Strategy. London; Department of
Health
Marie Currie (2008) Liverpool Care Pathway: Promoting best practice for the
care of the dying. Care of the dying patient (ICP) (Hospital). Available at: http://www.mcpcil.org.uk/files/LCPHOSPITALVERSIONprintableversion.pdf
Department of Health (2007) National Framework for NHS funded Continuing
Healthcare and NHS funded Nursing Care
Department of Health (2008) National End of Life Care Strategy
Department of Health (2009) National Dementia Strategy
Department of Health (2003) National Service Framework for Diabetes.
London: Department of Health.
Department of Health (2001) Valuing people a new strategy for learning
disability for the 21st century a white paper. London: Department of Health
Local Government Ombudsman (2009) Six Lives: the provision of public
services to people with learning disabilities. Part one: Overview and Summary
of investigation reports. London: Department of Health
1.3 General
Overview
To provide a service to housebound adults who require nursing care incorporating the
following aspects:
Assess and diagnose health-related problems and other relevant associated
medical or non-medical problems being experienced by the individual which
are contributing to the service user being housebound.
Undertake the single assessment process in partnership with social care and
Somerset Partnership NHS Foundation Trust, as appropriate, for service users
who require additional NHS-funded packages of care in accordance with the
National Framework for NHS funded Continuing Healthcare and NHS funded
Nursing Care (DH 2007). Act as care managers for additional care packages
and for NHS funded Nursing Care once agreed. (As per DH Guidance).
Conduct risk assessments of service the user’s domiciliary environment to
inform ongoing delivery of the service or services provided by other healthcare
organizations. Working with service users wherever possible to minimize risks
and where risks can not be reduced to a satisfactory level agree alternative
options for the delivery of the service or inform other agencies where required.
Draw up an agreed treatment or support plan which addresses the individual’s
healthcare problems identified at assessment.
Provide advice and information relevant to the individual’s problems. This
includes the training of other staff, individuals or their family members and
carers in the management or self-management of their condition, wherever
appropriate and safe to do so.
Provide treatment for a range of healthcare problems as detailed in Section 1.6
and which lie within the scope of individual practitioners in terms of their own
professional codes of registration.
Providing equipment, aides or devices to service users which help eliminate or
reduce their healthcare problems or their symptoms or consequences.
3
Referring service users on to other professionals and organisations where their
problems lie outside the scope of the service.
Signposting service users, family members of carers to other services where the
individual’s problems lie outside of the scope of the service.
Teaching and mentoring pre and post registration students.
Identify vulnerable adults at risk of abuse and act in accordance with the
Somerset Multi agency Safeguarding Adults Policy to safeguard vulnerable
adults from harm.
1.4 Objectives
The main objectives of the service are to:
Provide safe, high quality evidence based care to service users
Assess healthcare needs and develop a care plan in partnership with the service
user to meet their needs with clear timescales for review of the care plan.
Promote service users’ understanding of their healthcare problems.
Promote service users’ own contribution to reducing their problems and
minimising the likelihood of their reoccurrence or exacerbation.
Promote service users’ ownership of their treatment or support plan and ensure
this is reviewed on a regular basis.
Facilitate high quality end of life care at home
To eliminate or minimise service users’ healthcare problems
To optimise service users’ independence, comfort and wellbeing.
To ensure relevant others are kept informed as is appropriate and as agreed
with the service user
To positively promote the reputation of Somerset Community Health and the
wider NHS
To safeguard vulnerable adults from risk of abuse.
1.5 Expected
Outcomes
The main outcomes of the service are:
The service responded to the service user promptly.
The service user felt that they had been listened to, treated with respect and that
their problems had been taken seriously.
The service user has a reasonable understanding of their healthcare problems in
terms of: how the problems may have occurred, the likely consequences of the
problems, what they can do to support themselves and the support and
treatment options available to them.
The service user felt that they had contributed to decisions about the support
and treatment they would receive.
The service user’s healthcare problems were resolved.#
o Or
The service user’s healthcare problems were minimised and their
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independence, comfort and wellbeing optimised.
The service user was referred onto other staff or organisations where his or her
problems were agreed to lie outside the scope of the service, in line with agreed
care pathways and or NICE guidance. Adequate information was exchanged,
with the service user’s consent, as part of the process.
Other individuals (professionals or family members and carers) were kept
informed of relevant information, in accordance with the service user’s
informed consent.
Contribute to a reduction in acute hospital admissions for those patients with
complex long term conditions, as identified by using the RISK tool.
1.6 Service users’
problems and
needs in more
detail
The service is commissioned to respond to a range of difficulties experienced by
patients who are housebound, for example:
Patients with terminal or life limiting conditions, in particular patients in the
last 6 months of their life.
Patients with long term conditions for example diabetes, Chronic Obstructive
Airways Disease, Heart Failure, Multiple Sclerosis.
Patients with wounds (post operative, or leg ulcers) and or infections
Patients who are bed bound or whom have limited mobility
Patients who require additional services to commissioned NHS services and
who need to be assessed for NHS funded Continuing Healthcare or NHS
funded Nursing Care.
Patients in needs of specialist equipment for example hoists, beds, catheters.
Patients whose carers require training in providing care to them
Patients who require multi-agency support for example joint working with
adult social care teams and or community mental health or learning disability
teams.
5
1.7 Standard
procedures
In terms of the provision of treatment, the service will provide range of a
interconnected standard procedures including, but not limited to:
Palliative care – provided in accordance with the Gold Standard Framework ,
and Liverpool Care Pathway for service users in the last 6 months of their life.
This includes building an appropriate therapeutic relationships, emotional and
spiritual care, symptom control and pain relief, pressure-sore relief, and
coordination of care which may include fast track applications for NHS funded
Continuing Healthcare, Somerset Palliative Care Partnership service or Marie
Curie Nursing Service.
Chemotherapy support – for example the management of symptoms like
nausea, the need for suppositories, management of thrush, anorexia and
emotional support.
Syringe driver and Central Line management
Gastrostomy care – (PEG feeding) – service users who are unable to swallow
are fed by a tube directly into their stomach. Including training for carers where
necessary
Tracheotomy Care – for service users who breathe through a tube inserted into
the throat. Including training for carers where necessary
Provision of intravenous therapies for example antibiotics
Cannulation
Venepuncture and submission of samples to pathology services.
Venepunture to obtain blood samples for International Normalisation Ratio
(INR) monitoring to inform optimal warfarin management.
Catheterisation for men and women including the management of suprapubic
catheters following insertion within an acute hospital setting.
Bowel and stoma care – including management of constipation, provision of
suppositories, stoma care for patients with colostomy
Ear and eye care – administration eye drops and teaching of eye drop
instillation to carers for example following cataract removal.
Provision of Flu and Pneumonia vaccines to housebound patients in their own
private homes
Prescribing of drugs, equipment or devices either by nurse prescribers or
independent prescribers.
Wound and pressure area care in accordance with the Somerset wound
formulary and clinical policy.
Administration of Zoladex – an injection containing slow release medication
used in the treatment of prostate cancer.
Doppler Assessments – assessment of blood flow through a limb to assist in
6
the differential diagnosis of leg ulcer.
Lymphoedema management including the management of compression
garments, and skin care.
Assessment of service user’s requirements for equipment for example hoists,
beds and pressure relieving equipment or aides to daily living for example
commodes, perching stools , bed rests.
Undertake the single assessment process in partnership with social care, for
service users who require additional NHS-funded packages of care in
accordance with the National Framework for NHS funded Continuing
Healthcare and NHS funded Nursing Care (DH 2009).
Working towards the completion of assessments and the National Decision
Support Tool for applications for Continuing Healthcare within 14 days of
completion of the national screening checklist.
Commencement of assessments for NHS funded Nursing Care within 14 days
of admission of the resident to a nursing home.
Act as care managers for additional NHS funded Continuing Healthcare
packages and for NHS funded Nursing Care once agreed. (As per DH
Guidance DH 2009).
Health Education and promotion in accordance with the service user’s care
plan and to promote independence, self care and health lifestyle.
Community Matrons will identify high intensity users of secondary and
primary care using the predictive RISC tool to identify individuals in the top
(tier 3) of the Keiserpermante and implement escalation /care management
plans for specific episodes of care where required.
2. Scope
2.1 Service
Description
As described above.
2.2
Accessibility/accep
tability
The service is available to adults, 18 yrs and over, who are housebound and registered
with a Somerset GP and eligible for NHS treatment. The service is also available to
adults registered with non-Somerset PCT or those foreign nationals provided the
relevant cross-charging mechanisms are put in place.
On occasions the service will be made available to adults who are not housebound if it
is considered clinically appropriate.
2.3 Whole System
Relationships
The service will work collaboratively and or jointly with a range of other health and
social care staff and organisations where this is likely to optimise positive outcomes
for the service user, their family members or carers and to maximise the use of the
services resources.
7
2.4
Interdependencies
The service will maintain and develop constructive working relationships with a range
of relevant staff and organisations. In particular:
GPs
Providers of adult social care
Providers of specialist mental health services
Providers of learning disability services
Providers of specialist palliative care services
Other services provided by Somerset Community health including:
Rehabilitation, Continence, Tissue Viability and Speech and Language
Services.
2.5 Relevant
networks and
screening
programmes
The service does not currently contribute to any particular local networks or screening
programmes.
The service accords with the principles and rules of registration of staff as defined
within the Nursing and Midwifery Council’s Code of Conduct. Available on the web
on 16th
February 2008 at: http://www.nmc-uk.org/aSection.aspx?SectionID=45
2.6 Sub-
contractors
The service contributes to a countywide fund used to purchase equipment, aides and
devices. This is currently provided by Medequip.
3. Service Delivery
3.1 Service model
The service reflects a stepped-care multi-disciplinary approach which aims to promote
the service user’s self care management and maximise independence, resulting in
effective use of staff time, expertise and the resources of the service.
Stepped care in this context is considered to mean that service users are supported to
receive the minimum interventions or level of support required to resolve their
problems or optimise their movement and independence.
The service is delivered in both one-to-one and group settings in a variety of hospital,
domiciliary and community facilities.
The current staff team consists of the following:
Team Leaders: 45.12 WTE
Senior District Nurses (Band 7): 13.1 WTE
Matrons: 16.15 WTE
Professionally registered nursing staff (Band 5): 145.80
Non registered Health Care Assistants & Administrators 45.3 WTE
3.2 Care Pathways
The main, generalised stages of the care pathway are detailed below:
Individual’s healthcare problems identified by self or professional
Contact made with the service via telephone or referral received.
Service user sent or provided with information as it appropriate at any stage of
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the pathway.
Initial appointment, usually within the service user’s home, discussed and
agreed with service user.
Assessment/s conducted with service user as required.
Treatment or support plan agreed and drawn up with service user. Where
required this is undertaken collaboratively with staff from other services or
from adult social care.
Treatment or support provided. Again provided collaboratively with other
organisations where required.
Treatment or support plan reviewed as is appropriate.
Service user discharged from service or referred on to other staff / organisation
as appropriate.
Discharge information, as appropriate, sent to referrer with copy sent to service
user.
Information shared with other professionals or relevant others as is required.
4. Referral, Access and Acceptance Criteria
4.1 Geographic
coverage/boundari
es
The service is to be provided across the county of Somerset.
4.2 Location(s) of
Service Delivery
In the main the service will be provided within service users’ own homes, however
staff will be based in a variety of settings which facilitate good communication with
general practitioners.
All General Practitioners will be informed of the community nursing staff designated
to support the practice.
The service will be located and available at times and places which reflect the relative
population demographics and anticipated needs of a particular geographical area.
4.3 Days/Hours of
operation
The service is to be provided 24 hours a day, 365 days per year.
In general the service will be operated at times which optimise the service user’s
ability to attend and minimise disruption to their personal commitments or those of
their carers or family members. The operating times should reflect and accommodate
wherever possible service user’s personal circumstances and commitments and their
choice of venue and time of appointment.
At the time of writing the hours of operation were subject to a review but were
currently offered as follows:
Standard hours: 8am to 5pm
Twilight hours: 5pm to 10pm
Overnight hours: 10 – 8 provided through a mix of waking night and on call
staff.
4.4 Referral
criteria & sources
The service will accept self referrals as well as referrals from other professionals most
commonly General Practitioners, Acute Hospitals and the Somerset Primary Link
Service. Criteria as per section 2.2
9
4.5 Referral route
The service will receive referrals from General Practitioners directly to the
Community Nursing Staff assigned to the GP Practice. Referrals are also received
from Acute Hospitals, Hospices and Adult Social Care teams.
Telephone: under review.
Fax: under review.
Electronic mail: under review.
Referral form sent to: under review.
It is intended that unless unusual circumstances are identified, each service provided
by Somerset Community Health will be move to a position whereby all referrals are
received via a central point of contact and all appointments booked through a central
booking service. Furthermore that maximum use is made of the Somerset Choose and
Book system. A timeframe for achieving this will be agreed between commissioners
and Somerset Community Health for each service area.
4.6 Exclusion
criteria
Generally the service is not available to children or service users whose needs are
assessed as sitting outside of the scope of the service, except in exceptional
circumstances or for young people approaching adulthood where this is their choice.
Where the individual’s healthcare needs present complications or risks which require
more specialised services or expertise from specialist teams.
The service is generally not available to service users who are not housebound.
In terms of Nursing Homes, where direct nursing care is already provided, the service
provides a care management role only.
4.7 Response time
& detail and
prioritisation
The service’s anticipated response times are:
Urgent –access within 4 hours:
Non–urgent – Access within 24–48 hours
Routine – Access within 10 working days of receipt of referral
Service users should be seen in priority order in relation to their assessed clinical
risk.
Referrals to first appointment for service users with urgent problems that are
not considered to require emergency services is 24 hours but is generally
same day.
Referral to first appointment for all other service users is 48 hrs including
weekends.
10
5. Discharge Criteria & Planning
Discharge
planning
Discussions about the anticipated length of time service users will be supported by the service
should be conducted during the initial stages of their engagement with the service. Discharge
plans should be clarified at the latest when drawing together the treatment or care plan.
[For inpatient services, the discharge date is expected to be agreed with the service user within
24 hours of admission].
Discharge
procedure
All service users discharged or referred on will receive a copy of the discharge letter. This
will incorporate the national standards concerning discharge as detailed in the main body of
the contract. In particular the letter will provide a summary of:
their main problems relating to the service
the treatment and support they have received
the progress made to date
the agree next steps including onward referral to other professionals or organisations
how to contact the service if their problems were to reoccur.
Discharge letters should be sent to the referrer and copied to the individual service user within
the nationally defined expectations detailed in the main body of the contract.
6. Self-Care and Service user and Carer Information
All individuals receiving the service will be:
offered clear and concise verbal or written information to support their understanding
of their condition and how they can contribute to resolving or minimising future
problems.
given a copy of their treatment or support plan – care plan is left in the patients home
and accessed by the nurses when giving care
offered information which positively promotes the image and reputation of the service.
11
7. Quality and Performance Standards
Consequences of breaches, as per mandated template to be agreed and confirmed during 2009/10.
Quality
Performance
Indicator
Threshold Method of
measurement
Report Due
Infection Control
The service to be provided in accordance with
all relevant national or local infection control
procedures. In particular the application of:
Department of Health (2009). The Health and
Social Care Act 2008: Code of Practice for the
NHS on the prevention and control of
healthcare associated infections and related
guidance. London: Department of Health.
Annual audit or
as agreed.
Annual
Service User
Experience
As per Schedule 3 Part 3 of the contract. Various
Annual patient
feedback
questionnaire
to identified
group of
service users.
Annual review
of complaints,
commendations
and PALS
Various
Annual
Improving Service
Users & Carers
Experience
As per Schedule 3 Part 3 of the contract. Various Various
Unplanned
admissions
The service will contribute to reducing
unplanned hospital admissions by:
Providing prompt diagnosis and
treatment of healthcare problems.
Supporting service users to maintain
optimal health.
Referring service user on to other
professionals when other problems
outside the scope of the service have
been identified.
Coordinating provision of additional
healthcare and carer support in the home
when required
Audit if
required.
Various
Reducing
inequalities
The service will contribute to reducing
inequalities by:
Providing a welcoming responsive
service to all.
Evaluating service user’s perceptions of
the service as detailed in Schedule 3 Part
3 of the contract and ensuring these are
used to inform service developments.
Offering service information in a range
% service users
engaging with
the service by
age, ethnicity
and disability
and areas of
residence and
the extent to
which this
reflect the
Annual
assessment.
12
of formats and languages.
Promoting the use of interpreting
services where required.
Undertaking with commissioners
mapping exercises to monitor the
demography of service users, where the
service is delivered and the degree to
which particular groups of service users
are engaging or not engaging with the
service.
Undertaking targeted promotional
campaigns to service user groups not
considered to be engaging with the
service.
Ethnic monitoring of all service users
population of
Somerset.
Audit as
required.
Reducing barriers
In addition to the requirements within the main
body of the contract, the service will contribute
to reducing barriers to access by:
Ensuring service user’s personal
circumstances are taken into
consideration when arranging
appointments.
Ensuring premises from which the
service is offered is compliant with
disability discrimination law.
Ensuring that all service users receive a
welcoming friendly reception on
attending the service.
Audit as
required
Annual
Improving
productivity
The service will achieve a Did Not Attend Rate
of 10% or less for all appointments. Would this
need to include a no access rate? And contacts?
Access
The service’s anticipated response times are:
Urgent –access within 4 hours:
Non–urgent – Access within 24–48
hours
Routine – Access within 10 working
days of receipt of referral
Monthly
monitoring.
Report
provided.
Care Management
100% of service users who receive interventions
on a one-to-one basis will have a personalised
care or treatment plan
Audit Annual
End of Life Care Contribute to achieving a 10 % increase in the
number of people who die at home each year for
2010 -11, 2011 – 12, 2012 -13
Quarterly
monitoring
information
Outcomes
Work towards assessments for NHS funded
Continuing Healthcare to be completed within
14 days of completion of the national screening
checklist
Commencement of assessments for NHS funded
Nursing Care to be completed within 14 days of
admission to a nursing home.
Monthly
monitoring of
timescales for
completion of
assessments.
Additional
Measures for Block
Not applicable
13
Contracts:-
Staff turnover rates
15%
Sickness levels
3%
Agency and bank
spend
Advice currently being sought from HR
Directorate. Plus Finance Department being
asked for baseline activity.
Contacts per FTE
See Section 8 – activity.
8. Activity
Activity Performance
Indicators
Threshold Method of
measurement
Consequence of
breach
Report Due
Thresholds (targets and anticipated volumes) to be confirmed and agreed for each service specification,
during 2009/10
In order to ensure baseline activity is available for each service the following will be required during
2009/10 on a quarterly basis. These are in addition to the reporting of national and service standards reported
for the whole service as part of the quarterly contract monitoring meetings.
Baseline activity Quarter 1 Quarter 1 Quarter 3 Quarter 4
Referrals received
Appointment attended
Appointments DNAs
Proportion of service
users meeting waiting
time target
Number of active cases
at end or reporting
period*
Optimal caseload for
team
Number active service
users with care /
treatment plan
Number discharged
Staff wte funded
Staff wte in post
9. Continual Service Improvement Plan
The service will identify areas for development and improvement as part of the Somerset Community
Health’s annual audit against Standards of Better Health and implement them as part of the Somerset
Community Health’s Quality Improvement Plan. These will include service reviews, audits, pilot schemes
and other initiatives to improve service quality. The community nursing service will have in place an agreed
annual clinical audit plan which may include national priorities and or NICE guidance and record keeping.
14
10. Prices & Costs
These sections are being drawn up by the Finance Directorate.
10.1 Price
Basis of Contract Unit of
Measurement
Price Thresholds Expected Annual
Contract Value
For 2009/10 the service will be paid for under block contract arrangements. Price and currency options will
be reviewed during 2009/10 and where agreed to be changed a contract variation will be drawn up.
Block element £
Pay
Non-pay
Central charges
Deductions for cross charging
Total
10.2 Cost of Service by commissioner
Total Cost of
Service
Co-ordinating
PCT Total
Associate PCT
Total
Associate PCT
Total
Associate PCT
Total
Total Annual
Expected Cost
Co-ordinating commissioning arrangements will not apply in 2009/10.