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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

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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.

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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.

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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

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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.

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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

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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.

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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.

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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.

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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

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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.

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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.