Make a referral for a complex care placement

On referral, one of our clinicians carries out an initial assessment.

If we determine we can meet the individual’s needs, we proceed with a comprehensive clinical assessment, with input from our clinical experts.

We also carry out a community fit assessment to make sure the person is a good fit for our existing communities.

The detailed costing report outlines the care we’ll provide to support the individual to achieve their goals.

We aim to deliver this report within five working days of the assessment. However, sometimes this may take longer due to the complexity of care needs.

Our priority is always to provide a thorough assessment to reduce the risk of placement failure.

During the assessment, we evaluate 16 areas of care and support, based on the ‘NHS continuing healthcare decision support tool’.

These are:

• Behaviour

• Cognition

• Psychological and emotional needs

• Communication

• Mobility

• Nutrition

• Continence

• Skin and tissue viability

• Breathing

• Drug therapies

• Altered state of consciousness

• Professional intervention

• Clinical support

• Social support

• Hygiene

• Other significant needs

For each area, we address required interventions (and their duration and frequency), and the type and number of staff needed to support this individual (including nursing, care, and therapy staff).

We also listen to the views of the individual, their family, and relevant professionals from the current placement.

With increasing pressure on local health and care systems, we can work with local stakeholders to do an assessment within 24-48 hours for emergency and urgent admissions, where it’s suitable to do so and in exceptional circumstances, such as if a placement is closing down or if notice has been served.

Please note, due to the complexity of the people we support, this can often take longer.

However, we’ll make every effort to ensure people can access the care they need, as quickly as possible.

Our detailed assessment identifies all the care and support needed to meet someone’s complex and holistic needs.

This makes sure they receive the right care, from the right team, from the start - reducing the risk of the placement failing.

The weekly fee reflects all care, support, and interventions required based on our assessment.

It would only be possible to reduce the fee if we also reduce care needs. However, our priority is always to provide the necessary - and person-centred - support to make sure the placement is stable and successful.

We review all placement costings six weeks after admission, allowing for a ‘settling in’ period to ensure stability for the individual.

Then, we carry out further reviews annually, or whenever care needs change.

If the reviews show change in care needs or costing, we’ll share this with you as soon as possible.

Our care and nursing teams are continually monitoring the care they provide.

The allocated Nurse completes a formal monthly review of each individual’s care profile.

If this review identifies a change in care needs, we also review the weekly care cost.

During reassessments, we keep the original assessment information in the report. This allows you to clearly track changes and progress.