CLCH Bedded Rehabilitation
Please see below the criteria for acceptance to Bedded Rehabilitation Services (Athlone, Farm Lane, Alex).
Please note that for all referrals, the following must be included; Referral form, Inter-healthcare infection
prevention form and transfer checklist
EXCLUSION CRITERIA
A client will not be admitted if they:
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if client has had diarrhoea in the last 72 hours they must be 48 hours clear and passing type four
stool
they require respite care or continuing care
they require assistance of 3 or more to transfer
they have moderate or severe dementia unless there is a specific component of care that is being
addressed with a full time non paid carer
they have a level of challenging behaviour that would prevent rehabilitation and require specialist
input from mental health services or require 1:1 care.
they are temporarily non weight bearing and unable to participate in a rehabilitation programme
(eg. whilst waiting for a fracture to heal and wearing a plaster cast). This may be reviewed on a
case by case basis dependent on current admissions to unit (Please refer to interim section below)
INCLUSION CRITERIA
Clients will be considered if they:
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are registered with a GP in CLCH (Westminster, Kensington and Chelsea, Hammersmith and Fulham
boroughs)
are over 18 years of age
are not suitable or safe for discharge home with community services
had a reasonable level of independence prior to their recent acute admission OR need disability
management OR are to be admitted to avoid hospital admission
have identified functional or rehabilitation goals that can be realistically achieved within 1-4 weeks
with inpatient rehabilitation
are motivated and able to participate in a daily rehabilitation programme, with potential for this
having been reflected in the acute services
have consented to admission – they must have mental capacity to give consent or it must be
deemed in their best interests to be admitted with supporting documentation for this
can be medically managed in a community setting - acute conditions must have agreed medical
plans:
Recent history of MRSA must be screened as colonised.
IV lines (incl PICC, Hickman) must have a follow up appointment with the OPAT team.
INRs must be within therapeutic range and stable with client requiring only weekly INR checks. A
plan for dosage should be in place (own GP or anti-coagulation clinic) and client should be
prescribed warfarin for the first week of their rehab admission.
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Oxygen therapy for those needing it will need to be via oxygen concentrator ordered prior to
admission by hospital or GP – ARU only has emergency oxygen on site.
NGT/ PEG/ RIGs must be on a stable care plan and have been referred to the dietician and
equipment supplied prior to admission by hospital or GP.
Pressure dressings must have a care regime in place and suitable dressings provided for 1 week.
Drug and alcohol detox clients must have an allocated community link worker from DAAT arranged
through their GP. A plan for Methadone prescribing must be in place.
have an estimated discharge destination
have potential to be discharged to this destination within 1- 4 weeks following bedded
rehabilitation
have 14 days medication supply (if being admitted from hospital)
have an appropriate walking aid to bring with
have had a screening assessment completed by CLCH staff or in-reach
they have an allocated care manager if they live outside of CLCH local authorities
REASONS FOR CLOSING REFERRALS:
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Clients are unable to demonstrate that they meet the admission criteria
Client would be unable to discharge from bedded rehab services following a maximum of four – six
weeks rehabilitation
Clients become medically unwell
Patient requiring slow stream rehabilitation (please refer to interim bed use)
Incomplete referrals sent / Inaccurate information detailed on referral
Referrer does not make contact with unit regarding outstanding/ requested information after
screening within 24hrs of agreed time.
Expected discharge destination not identified on referral
STROKE PATIENTS
Any acute stroke rehabilitation patient can be admitted to Athlone Rehab Unit. Ideally referrals are
sent via the Badgernet system however for those who do not use Badgernet, a paper referral will be
accepted. Such patients may have the opportunity to stay longer than a four week time frame
where it is deemed to be clinically appropriate and where ongoing therapy will improve functional
independence and care needs.
INTERIM BEDS
Patients who have interim care and/or rehabilitation needs can be referred to Farm Lane. Those
with mild to moderate dementia may be referred and then CLCH staff / Care UK will determine if
this patient can be safely managed. Interim referrers to the following:
1. Patients who are non-weight bearing and are unable to go home safely (they may have potential for
rehabilitation following this time).
2. Patients who require a slow stream approach to rehabilitation in order to achieve functional gains;
therapy input for this patient group will be less intensive.
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3. Patients who are unable to safely return to their previous destination and as such, await social
services identification of a suitable placement based on the recommendations as established at
time of panel reviewing the London Health Needs Assessment (LHNA) / Decision Support Tool (DST);
ie: Interim SOCIAL bed
Care UK provide the nursing care at Farm Lane and complete a face screen of all patients. Please
note that criteria for admission is as above.
REFERRAL PROCESS:
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All patients need to have a completed referral form; stroke referrals are made via Badgernet
system
Referral forms in the tri-borough are sent direct to in-reach via nhs email; in-reach will then
send to SPOR with completed screen (other than stroke; where referrals go via Badgernet)
Referrals from all other sources (eg community, royal free, UCLH, GSTT, GP, private) are to be
sent to CLCH SPOR (other than stroke; where referrals go via Badgernet)
All referrals are to be screened by CLCH teams
Rehab Referrals; CLCH In-reach will screen all referrals made by K+C, H+F, Westminster and
determine outcome. Those rehab patients who are to be admitted to Farm Lane will have an
assessment by Care UK.
Bedded therapists will complete screening of all other referrals for rehabilitation
Interim Referrals; all referrals to go to CLCH SPOR and potentially Care UK at the same time (at
present, the referrals only go to CLCH SPOR; as Care UK do not have direct secure email).
Referrals for an interim ‘SOCIAL’ bed should have a fully completed HNA/DST sent, reflecting
named social worker and contact details.
CLCH In-Reach will screen all interim referrals other than those patients who are awaiting
placement (however they may provide supporting advise if concerns regarding appropriateness
are highlighted) as the supporting LHNA/DST should detail fully patient care needs.
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CONTACT DETAILS:
SPOR CONTACT
Telephone number for paper faxes is 03000083138 EFax is 03000083244
The telephone number for the newly positioned SPOR desk will be 02076414001.
Email: [email protected]
INREACH CONTACT
Westminster
Hammersmith + Fulham
Kensington and Chelsea
[email protected]
[email protected]
[email protected]
MATRON CONTACT
Danielle Nation
Mobile 07931 349802
Email:[email protected] OR [email protected]
CLINICAL LEAD CONTACT
Jenny Phillips
Mobile: 07961 987827
Email:[email protected] OR [email protected]
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