*
West Hill, Putney
London SW15 3SW
(
020 8780 4500
Ê 020 8780 4501
:
http://www.rhn.org.uk/
info@rhn.org.uk
The Social Work Department at The Royal Hospital for Neuro-disability has been operational since 1985. The establishment is currently 5.18 wte. The posts are primarily for senior social workers with previous experience in the statutory sector, independent sector or voluntary sectors, healthcare, mental health and experience of adult disability. The Head of Social Work takes almost a full caseload as well as managing the department and undertaking other duties within the hospital and for the profession. The total client case numbers for the department are approximately 94 at any one time (average caseload therefore 18). This includes all rehab beds and 12 long stay beds (sadly the organisation does not chose to recognise that people in long term care have problems and issues that the social work service could address).
The social work service provided is largely for the rehabilitation units at the hospital and is focused on person centred planning and life planning for the future care needs for the clients.
All patients admitted to the rehabilitation units are allocated to a social worker who will work with them and their carers throughout their stay. Permanent staff are allocated to specific units and work closely in association with the range of staff attached to each one.
The social work role includes assessment, psychosocial work with clients and carers, co-ordinating work with a range of stakeholders relevant to each case, membership of the multidisciplinary team, healthcare issues, accessing resources for current and future care needs for clients. The model is one of case management and the overarching description is medical social work.
Because the hospital is a provider organization in the voluntary sector, it means that the role of the social worker is one of close working with primary care trusts and social service departments across the UK but it does not require the direct purchasing of services or statutory assessments for provision of future care needs. The focus therefore remains person-centred and not always resource-led while the person remains within the care of the hospital. The social worker acts as an advocate on behalf of both client and family/carers as necessary.
The Royal Hospital for Neuro-disability is a national medical charity founded in 1854 which currently has 260 beds split between those people being admitted for rehabilitation and the remainder for people who live at the hospital on a long term basis.
The mission statement of the organization is:-
The Royal Hospital for Neuro-disability, as an independent medical charity, is a not-for-profit organisation, which seeks, through research and the provision of specialist services, to meet the needs of people with complex neurological disabilities resulting from damage to the brain or other parts of the nervous system.
Believing that all disabled people should have the opportunity to enjoy an optimal quality of life, it also works with other individuals and organisations to improve professional knowledge and skills and to raise public awareness of disability issues.
People who are sent to use the services at the hospital are profoundly damaged by illness or injury to the brain which results in neurological damage. The needs are often likely to be enduring beyond the rehabilitation period at the hospital, and the disabilities life long. The condition of the people using the service has far reaching effects on all those close to them, family friends, employers, colleagues, communities etc and social work aims to contribute to the adjustments of all those involved and to manage a range of practical issues including accommodation, finance, children needs etc whilst the person is receiving the hospital services.
The social worker is instrumental in co-ordinating on-going care placements in conjunction with the unit team and the external agencies taking on the on-going work after the person leaves. Discharge planning is therefore a key element of the longer term planning needed to be undertaken by the department and one which a student would be expected to take the lead on for any cases being managed by that person. Future plans may be placement in a specialist care resource nearer to the person’s home or a return home to adapted accommodation. The department has built up knowledge of specialist resources but these are subject to change and the knowledge has to be updated on a rolling basis.
Because of the extreme distress created by profound disability and the complexities of the work in the department, support amongst colleagues is deemed to be very important and time given for debriefing as necessary. Years of experience does not reduce the distress of workers in some situations and this is recognized within the department. Each member of the department supports the others informally, over and above any supervision arrangements.
Having a general understanding of community care law is an essential past of the knowledge base of relevant law. Other areas of legislation particularly relevant to the client group are those dealing with mental health and mental capacity, health and social care laws and directives relating to the social care needs of adults, national service frameworks relevant to the client group, civil law relating to personal injury litigation, carers, etc.
Learning within the department is an ongoing process and opportunities are given to attend in house training as necessary and relevant. The organization expects all staff, including those with honorary and student contracts, to participate in an orientation programme when they commence work for the organization and this includes mandatory training for instance in health and safety and moving and handling and an introduction to disability and some of the specific work of the hospital.
Patti Simonson
Head of Social Work
Royal Hospital for Neuro-disability
June 2006
The Social Work Department at the Royal Hospital for Neuro-disability operates within the framework provided by:
·
National Occupational Standards laid down by TOPSS/Skills
for Care.
(reference
http://www.topssengland.net/files/cd/England/Main.htm).
·
General Social Care Council Codes of Practice for
Social Care Workers and Employers.
·
The British Association of Social Workers Code of
Ethics for Social Work.
·
Legislation relevant to the client group.
·
Circulars and guidance information issued by the
Department of Health, Local Authorities and relevant other statutory
bodies.
·
Policies and Procedures laid down by the Royal
Hospital for Neuro-disability.
The Royal Hospital for Neuro-disability is a voluntary organisation and Social Workers employed by the organisation have no statutory powers.
The Social Work Department is part of the Clinical Services Directorate.
All Social Workers must be registered with the General Social Care Council.
The Social Work Department provides an admission to discharge service for all patients admitted to the rehabilitation wards at the hospital. Other patients are seen on a referral basis. The Social Workers provide a case management service as part of their role and are the primary link between the patients and carers, the multidisciplinary team and outside agencies/professionals and other relevant parties in respect of forward planning following rehabilitation. They also have a responsibility to assess and address the psychosocial needs of patients and their carers.
The Social Work task at the Royal Hospital is unique and very specialised. It is an essential service responsible for assessing and negotiating the requirements of clients and carers to a range of individuals and organisations, in order to secure resources to meet their needs following an episode of care for rehabilitation. Only with specialist intervention can appropriate social work assessments and liaisons be undertaken and relevant resources mobilised. Social Workers will take on the role of representative and/or advocate as necessary.
Assessment is provided for all rehabilitation patients, together with an admission to discharge case management service in line with the service level agreement for identified units. Additionally, those with complex discharge arrangements in the Parrington Home will be provided with this service subject to staff availability and negotiation between the social worker and Home Manager. Those patients admitted for respite care are not provided with this service as are some other categories of care specified below.
The Department has responsibilities also for a range of other services to clients and carers including psychosocial support and counselling and is responsible for responding to enquiries for help from personnel in an advisory capacity. Other areas of particular importance are patients finances about which the department should work closely with the Administration Manager who has ultimate responsibility for patient’s monies and manages a patient accounts system.
Monday to Friday 9:00 a.m. – 5:00 p.m. (excluding public holidays).
Time off in lieu arrangements with the agreement with Head of Service for out of hours Social Work requirements.
The Department aims to provide a full admission to discharge case management service including assessment, psychosocial care, practical intervention, forward planning and discharge co-ordination for clients admitted for rehabilitation.
The service incorporates a high level of involvement with carers and involved others, external agencies and professionals in relation to the core service. The role has a large co-ordinating component encompassing both internal and external personnel. Social Workers work proactively in anticipating forward planning requirements and establishing a care pathway for each patient for life planning needs.
There is a very limited Social Work service for residents in the Parrington Home. Referrals should be made to the Home Manager in the first instance on the referral form held on the IT system. Priority is given to complex discharge requirements, and the protection of vulnerable people.
An assessment and case management service as outlined for the Hospital patients is provided for Wolfson Ward for patients on assessment subject to staff availability. Some consultancy is available for the unit as a whole (including Andrew Reed Ward and Coombs Wards) subject to staff availability.
Forward Planning and Co-ordination of Discharges
The
Department is responsible for co-ordinating the discharge process for all
patients leaving the Royal Hospital for Neuro-disability except in the following
circumstances:
·
Clients taking their own discharge against RHN advice.
·
Carers facilitating the discharge of patients against
hospital and /or external agency advice.
·
Discharges for residents admitted for respite care.
·
Situations where funding expires without reasonable
notice (this should be adequate to make a robust and safe discharge)
or is not renewed against hospital recommendation.
·
Transfers to NHS hospital resources, other
institutions referred on to for medical reasons and or/rehabilitation units and
mental health sections to
other mental health resources.
·
Placements arranged against the advice of the
hospital/Social Work Department.
·
Discharges which are deemed unsafe/unsuitable
·
Miscellaneous others as identified by the department
The Department seeks to effect discharge arrangements with reference to the needs of the patients and carers, the views of the multi-inter/disciplinary teams, the outside agencies involved in current and on-going care and other relevant stakeholders.
To diffuse potentially damaging situations with regard to social situations.
To provide a support service for the emotional needs of clients and carers and to implement strategies and interventions relevant to the situation.
To provide and/or facilitate advocacy.
To advise on clients/carers seeking legal advice with regard to matters arising from their predicament .
To identify and advise with regard to suitable community resources for clients in conjunction with the MD team and external stakeholders. For example: care home placement, further education, care packages in the community, housing, care home.
The Department is responsible for making requests for Community Care assessments to Social Service Departments in the Hospital Section.
The Department is responsible for helping to facilitate continuing care assessments in conjunction with both health and social care agencies for patients in the in the Hospital Section.
A range of practical needs can be addressed by the department including accommodation, transport, finance, Court of Protection/Power of Attorney, accommodation for carers etc.
The Department is responsible for setting up and hosting visits by professionals for clients on the caseload from outside agencies and resources, for the purposes of future care planning, these include: care managers, care home managers, housing agents etc.
The Department has a responsibility to visit selected outside resources where this will help to enhance the placement decision, increase knowledge of resources, educate key individuals involved, provide an opportunity to take the client to view the resource, provide support to the client and /or carer etc.
The Department is responsible for arranging review meetings and other meetings with outside agencies, patients and carers and relevant hospital personnel, to further the future care planning and discharge process for the clients on the caseload.
The Department is bound by the Confidentiality Policy of the Hospital, by social work protocols and relevant legislation.
Each client has a case file which is the property of the social work department. Separate files from the clinical records must be maintained by the department. Information is shared for specific purposes on a ‘need to know’ basis in line with guidelines in the statutory sector and hospital policy. Copies of all letters, forms, memos, emails, reports etc., owned and/or produced by the department to be kept on file.
Social workers are expected to keep their files up to date, ensuring that their notes take the form of diarised entries reflecting all actions, telephone calls, conversations decisions etc., about the client and store details of carers and outside agency contact details.
Input into the clinical records is by way of case review notes, clinical reports, case summary notes, discharge summaries and occasional direct entry.
The Department ensures that a social work summary is provided for the internal and external reporting process and final reports of their clients and that appropriate written communication is maintained when necessary, particularly to outside agencies.
As per IT Policy and Procedures.
A record of all formal meetings must be made as per statement by the DCS by the MD team of which the social workers are members.
It is important that social workers are kept abreast of adult social care legislation, guidance and issues, health care initiatives that impinge on social care issues and client work and a range of other related topics relevant to the client groups, for example: housing, finance, health and social care issues, adult disability etc.
Education and training encompass both formal and informal training at various levels. The department seeks to contribute to the teaching offered by the Royal Hospital both internally and externally. Training for statutory requirements is enhanced by close links with Wandsworth Social Services Training Department, Carers UK and other organisations. All training requests will be considered by the staff development department if deemed acceptable by the Head of Service but will be subject to the budgetary limits of the SD and SW Departments and time constraints.
Recognising the highly emotive nature of issues that arise from the needs of those with complex disabilities, the department seeks to prevent or minimise crises in an attempt to support clients and carers constructively and reduce complaints both formal and informal against the hospital.
Refer to hospital policy. Ensure that HOD and/or Home/Hospital Manager is aware of any concerns as soon as possible. Refer also to the risk manager.
The Department can become involved in and/or initiate carers groups initiatives within the Hospital and Home. Plans for cares groups should be discussed with HOD.
Research grants are available through the Research Department. The Department supports research requests and will try to accommodate the need for time out for research.
Placements are offered to social work students intermittently depending on staff time and skills and the availability of suitable students.
These are provided in conjunction with the Administration Manager at the Royal Hospital. The Administration Manager has the overall responsibility for patient monies.
The Department welcomes enquiries and seeks to interact with other organisations to provide a mutually helpful information forum. It will signpost enquirers if necessary.
The Department seeks to collect and store relevant information about various resources and services and acts as a reference point for internal and external enquiries. Such information includes Care Home information, Home Care agencies, Housing Associations, Protection of Property, Specialist Health and Social Care organisations, statutory agencies, accommodation etc.
The Department maintains close links with specialist interest groups for social work and case management for the exchange of information, professional issues, to seek to promote the services of the Royal Hospital, to help to raise professional standards, to make direct contact with colleagues in the field.
Social Workers in a rehabilitation setting at the Royal Hospital for Neuro-disability should have a manageable caseload and the workers are members of the multidisciplinary team on the units/wards. The exact number of cases will relate to the speed of the turnover of beds, the frequency of case review meetings, the issues with regard to both the patients/carers needs, the demands of outside agencies, the staffing arrangements on the Ward/Unit , the operational arrangements of the Ward/Unit, the complexity of onward placement arrangements, the effectiveness and efficiency of inter-agency work, the location of the beds (re: are they in one ward area or more), the focus of the clinical team, the amount of offsite work, other responsibilities such as teaching, management etc. Staffing requirements are submitted to Senior Management at budget setting and as changes occur with service provision or staff changes.
The staffing of the transitional living unit is determined by the requirements of interdisciplinary team working and thus a different patient worker ratio is operational for this unit.
Staffing levels are specified in service level agreements. The approximate staff/client ratio is from 8-20 clients per wte. Social Worker.
This is under regular review and reviewed at IPR.
Social work staff do not rotate through units. Occasionally they may change their area of work in agreement with the Head of Department and other relevant personnel.
All rehabilitation patients assessed subject to staff availability, case managed and appropriate liaison work and discharge work undertaken.
Selected referrals from other areas case managed, prioritising discharge planning, child care, securing of resources, mediation work, protection of finances, advocacy, counselling and support.
· Timely arrangements
· Suitable placements identified and secured
· Funding agreements
· Client/and Carer satisfaction.
· Adequate communication to relevant individuals/organisations
· Management of social care practical problems concerning patients
· The securing of appropriate resources
· Clear representation of the team’s views
· Team work both internal and external
· Appropriate and complete documentation
No formal involvement in admission procedure unless specifically requested on an individual case basis.
Admission may have been previously discussed at admission/discharge meetings or will become apparent by the circulation of admission papers by the operations office.
Ideally the social worker will have spoken to the family prior to or at admission subject to timely information being received, the availability of the appropriate staff member, the correct contact details being issued and the availability of the family.
Specific cases may require social work intervention prior to admission. The Admissions Office, RHN Manager or referring organisation will often be the referral point for early involvement.
After taking preliminary details, these should be put through to the Admissions Office on Ext. 4513 or full number direct dial 0208 780 4513.
The Social Worker is aware of impending admissions in the Hospital Section by attending the relevant Admissions, Discharges and Transfers (ADT) meetings and receiving written admission details from the Admissions Office. Admission information is dispatched to the appropriate social worker by the Administrative Assistant in the department.
The information from the admissions office forms part of the front section of the case file.
The Social Work Department has responsibility for hospital discharges and for some internal transfers for the categories outlined above using information provided by the clinical team. ADT (Admissions, Discharges and Transfers) meetings are held regularly in the Admissions Office to update relevant personnel about the movement of patients.
Refer to separate Hospital Policy and Procedure documents.
The social worker is the link between the Clinical Team, the patient/carers and the outside agencies. The Admissions office is the liaising office between the hospital and current funders with regards to current funding agreements. The social worker will co-ordinate the discharge and refer out to relevant agencies. Transport arrangements are made by the Ward by completion of the appropriate form which is forwarded to the Admissions office. The social worker will inform the Admissions office directly of the patients discharge details and complete the discharge summary section to be included with the discharge report.
How are
the patients and relatives advised?
The social worker is responsible for updating patients/carers/outside agencies,
the multi/inter-disciplinary team, managers and the Admissions Office about
discharges that they are arranging.
The Department is responsible to the Home Manager through the Head of Department.
This is supplied primarily by the part-time social work department Administrative Assistant with support from Clinical Services Secretariat. The Administrative Assistant works in the department weekday afternoons only.
This is sought through the relevant directorates. e.g. Supplies from the Facilities Directorate, maintenance through the maintenance referral system etc.
Hospitality is sometimes requested for specific needs e.g. visits by outside agencies, carers support groups, special interest groups etc.
As per hospital policy. Mandatory training is provided for health and safety and must be updated annually.
As per hospital policy. Mandatory training is provided for moving and handling and must be updated annually.
Risk assessment is continual and social work staff are responsible for risk assessing their areas of work. Referral regarding risk is through the clinical governance structure of the RHN.
As per hospital policy.
Offices must be locked when vacant.
Refer to Social and Recreational Services and Facilities.
The social work department arranges staff meetings approximately once a fortnight for 1 hour subject to staff/time availability. All members meet informally as necessary and seek to exchange information on an on-going basis. IPR’s (Individual Performance Review) are conducted annually.
All documents that are not confidential are circulated around the Department as speedily as possible and feedback sought if necessary.
Resource information is sought and stored in the Department.
Voicemail and answer phone machines record messages when staff are unavailable and responded to as soon as feasible. Staff must take responsibility for their out of office information on computer and telephone voicemail messages and line transfers.
Patti
Simonson
Head of Social Work
Royal Hospital for Neuro-disability
December 2005
Last modified: 25th September 2006Monday, 25 September 2006