Hospitals and the Hospital Teams

There are three main acute hospital sites in Lincolnshire that have hospital social care teams based on site:

• Lincoln County Hospital;
• Boston Pilgrim Hospital;
• Grantham and District Hospital.

The Adult Social Care team based at Lincoln County Hospital is also responsible for supporting the discharge of Lincolnshire residents who are patients within the NHS Humber Health Partnership which comprises of Grimsby, Goole and Scunthorpe, Hull Royal Infirmary and Castle Hill acute hospitals.

As well as the Lincolnshire based acute hospitals, Lincolnshire Adult Care Discharge Teams work closely with North West Anglia Foundation Trust (NWAFT). The hospital social care team that supports with the discharge of patients who are Lincolnshire residents from Peterborough and John Van Geest, Stamford is based either on site at Peterborough Hospital or from Stamford Area Office. In addition, the team also supports discharge of Lincolnshire residents at Queen Elizabeth Hospital at Kings Lynn.

The hospital teams are responsible for managing discharges from these hospitals, ensuring social care needs are addressed and services are in place to facilitate safe discharge and further assessment.

The hospital-based Adult Care teams receive referrals directly from the wards and from the Care Transfer Hubs. The hospital social care teams, wherever possible, have a social care professional aligned to each ward who will attend the daily ward meetings and participate as a member of the multi-disciplinary team. This supports early identification of patients who will require support from social care to ensure a safe discharge, and prevents unnecessary delays.

Where people have an active key worker in the community, following a discussion around the complexity of the case and the level of involvement of the worker between the key worker and the hospital team, it may be appropriate for the key worker to manage the discharge with support from the hospital team. Area key workers are not to close their involvement because an individual has been admitted to hospital without this conversation having been held by them or their Lead Practitioner. 

When the plan is agreed to provide a safe discharge, the individual will leave the hospital to return to their normal place of residence. If, following a proportionate social care assessment of the person’s needs, a return home is not possible, short-term care in a residential care home may be considered to be followed up under the Discharge to Assess process.

As part of the Discharge to Assess process, the hospital teams will commence a needs assessment following discharge within the first two weeks of leaving hospital for those individuals who have been discharged to an Active Recovery Bed, a Community Hospital, a residential short term care bed or with the support of reablement or LCHS Discharge to Assess services. Those discharged with a package of care from a prime provider, new or restarted, to an interim bed, a nursing home or a residential care home placement with a Temporary Nil Request will be transferred on discharge to the Area Team local to their home for ongoing assessment and review.

Lincolnshire has a number of non-acute community hospitals:

• John Coupland Hospital, Gainsborough;
• County Hospital, Louth;
• Johnson Hospital, Spalding;
• Skegness and District General Hospital;
• Lancaster Ward based at Lincoln County Hospital.

Where appropriate, the community hospital teams are responsible for discharges from these hospitals, with the referral route through the relevant Business Support team and managed like any other request for assessment or unscheduled reassessment.

There are key workers linked to each hospital who are part of the hospital Multi-Disciplinary Teams.

In addition, the teams facilitate transfers of care from the Reablement service, the LCHS Discharge to Assess service, active recovery beds and transitional care beds.

Lincolnshire residents admitted to out of county hospitals are managed by the relevant area team for the home address of the person, unless they are from a nominated out of county hospital covered by the in-county hospital teams, which are:

• Lincoln County Hospital – Scunthorpe General, Diana Princess of Wales - Grimsby, Goole Hospital, Castle Hill, Hull Royal Infirmary;
• Grantham Hospital - Nottingham University Hospitals Trust: City Hospital and QMC. Sheffield Teaching Hospitals: Northern General (incl. Princess Royal Spinal Injuries), Royal Hallamshire and Weston Park Hospital. Leicester University Hospitals: Leicester General, Glenfield and Royal Infirmary. Sherwood Forest Hospitals: Kings Mill, Newark & Mansfield Community Hospital, Pinderfields Hospital;
• Peterborough Hospital – Queen Elizabeth Hospital, Kings Lynn Hospital, Papworth Hospital, Addenbrookes Hospital, Wisbech Hospital, Hinchingbrooke Hospital.

The in-county hospital Social Work teams which cover their nominated hospitals have their own referral arrangement with each hospital.

Referrals from all other out of area hospitals and rehabilitation units are received through the Customer Service Centre. Where there is an open key worker involvement, they will be responsible for the assessment. Where there is no key worker, the request will be sent to the appropriate community team to assess and facilitate discharge.