Hospital support

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We have a designated team to support Brent residents to return home following a period of time in hospital. 

The Hospital Discharge Team supports people aged 18 years and over who may be in need of support at the time they are discharged from hospital due to recent illness, disability, old age and frailty.

The team is responsible for facilitating safe and timely discharge from hospital and works closely with hospital staff to make this happen. We support discharge from hospitals for all Brent residents who need support from social care on discharge including:

  • Northwick Park Hospital
  • Central Middlesex Hospital
  • Royal Free, Barnet and Chase Farm Hospitals
  • Imperial Group: St Mary’s Hospital, Charing Cross, and Hammersmith

The team also supports Brent residents who are admitted in acute hospitals that are out of the borough as well as residents receiving inpatient rehabilitation at Willesden Centre for Health and Care.

Services and support

The Hospital Discharge Team carries out social care assessments and sets up appropriate services according to need, to support safe discharges for people when they leave hospital. The range of services that could be set up to support you post discharge include:

  • Reablement Care Packages: up to six weeks at home to enhance recovery where reablement or rehabilitation goals are identified by the therapy staff in hospitals.
  • Long-Term Care Packages: ongoing domiciliary care for people who do not have identified reablement goals.
  • Direct Payments: to provide flexibility, choice and control for people to use to arrange their own support.
  • Step Down: short-term residential/nursing placements, for a maximum of six weeks while waiting for long-term care arrangements.
  • Residential Care: this is a last resort for people whose needs can no longer be supported in the community or Extra Care.
  • Nursing Care: for people with significant nursing needs that cannot be met in the community.
  • Restart of a Care Package: for people who were receiving care before admission and where there are no significant changes to their care needs since being in hospital.

The hospital discharge process

  • Step 1: The hospital staff will complete an assessment notification and send it to Brent Council. When this has been received, the Hospital Discharge Team at Brent Council will arrange for an assessment of the person's needs, living environment and support network, which is done by a social worker. At times this may be done by the hospital staff on behalf of Brent Council if needs are short-term and the appropriate health professional is already involved.
  • Step 2: Medical staff or a consultant will confirm when a person is medically stable and can be discharged from the hospital.
  • Step 3: A hospital therapist will complete an assessment to confirm a person is functionally fit for discharge.
  • Step 4: Hospital staff will send a notification for discharge to Brent Social Services. The Hospital Discharge Team staff complete a Support Plan to meet the identified needs.
  • Step 5: The Hospital Discharge Team staff confirm with the hospital and family that the required services are in place in time for the discharge from the hospital.
  • Step 6: The care plan is monitored by Brent Council and, if necessary, adjusted to meet any change in needs.

For more information on hospital services in Brent, please go to Brent CCG website.

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