Bedfordshire Community Therapy Services

We provide therapy services to residents registered to a Bedfordshire GP across the county of Bedfordshire, inclusive of Luton. 
The county is split into three localities: North, Mid and South and each have their own main base: 

Primary Care at Home North 
Twinwoods, Milton Road, Clapham, 
Bedford, MK41 6AT

Primary Care at Home Mid 
Shefford Health Centre, Robert Lucas Drive, Shefford, SG17 5FS

Primary Care at Home South 
Queensborough House, Friars Walk, 
Dunstable, LU6 3JA 

• To provide the population of Bedfordshire with appropriate therapy services with the main aim of supporting people to remain at home with independence and a better quality of life
• We aim to encourage and promote an individual’s functional ability at home
• We provide support to the Multi-Disciplinary Team (MDT) to prevent unnecessary admissions to acute hospital or nursing/residential care services
• We coordinate with acute care providers to facilitate timely discharges from hospital
• We provide holistic assessments, treatment, advice and support with the focus to remain at home following illness injury or disability
• We work with patients, other professionals, carers and families to set realistic and achievable person-centred goals and care plans with a focus on maximizing independence and reducing reliance on care packages
• We advise other professionals and care staff on methods of improving the function and independence of patients
• We provide specialist knowledge of equipment and resources available to enable patients to manage their conditions
• To provide nursing home patients with one off specialist rehabilitation/equipment and Advice
• We identify the need and facilitate the provision of minor equipment and adaptations on a short term loan basis. Equipment is provided via Millbrook HealthCare. See ELFT Equipment Provision for more details.

Option 1:

Call Single Point of Access (SPoA): 0345 602 4064

Referrals are received 24 hours a day, seven days a week via the Single Point of Access (SPoA) Service, and will include the date and time referral was made, patient demographics, GP surgery, referrer details and a brief synopsis of requirement. 

You will receive a telephone call from a member of the therapy team to triage and gain further details regarding your referral. 

Note: Self-referrals cannot be made for the rehabilitation Bedded Units.

Option 2:

Electronic Referral 

This will produce a referral through to SPoA, who will then verify the details received to ensure it is legitimate and complies with service criteria.

Once this process is completed, SPoA will register the referral and direct onto the required service. 
 

The Transfer of Care Team operate seven days a week (8am-9pm)

The service provides short term (up to a maximum of six weeks*) therapeutic rehabilitation to support a patient’s recovery and independence post hospital admission or to support the prevention of avoidable admissions into hospital.

It is the aim that within a couple of weeks of intervention, there will be progress made and independence regained. At this point, a discussion will be had and a discharge date from the service agreed. 

All rehabilitation plans will be individualised, patient-centred and goal orientated around the following Activities of Daily Living (ADLs):

• Personal Care
• Self-confidence with medication administration
• Meal Preparation
• Transfers, Mobility, balance and muscle strengthening

*If it is identified at an early stage that rehabilitation is either inappropriate or limited, we will support a referral to a more appropriate service at the earliest convenience of the service. We will actively involve you and your NOK (when requested) to signpost and support you towards other organisations or professionals. In the interim, you may be transferred to the Home Recovery Service to provide you with the required support of your care needs."

Supporting hospital discharges

The service supports the Discharge to Assess model in the Bedfordshire hospitals to support with the quicker identification and assessment of patients that are medically optimised and appropriate for pathway 1.

This is with the aim to provide a streamlined and rapid facilitation of discharge, ultimately supporting the prevention of hospital delays, deconditioning of the patient and the risk of acquiring Health Care Acquired Infections (HCAI’s). 

In some cases, patients may require support from the Local Authority with the provision of a Package of Care, which if identified the team will refer into with your consent. 

Bedfordshire Community Health Services (BCHS): Transfer of Care Team are working with Central Bedfordshire and two commissioned Domiciliary Care provider services to support patients with their care needs at home (that are tax payers to Central Bedfordshire).  This is an essential service, and without it the rate of acute discharges and the volume of care delivered by BCHS could not occur.

Patients will receive day to day support by the care provider whilst remaining under the care of BCHS.

This interim service is provided for up to 4 weeks whilst the patients long-term care needs are assessed for and a package of care is sourced. There are daily MDT meetings between BCHS and the care provider where the patient care needs are discussed. If it is identified that they would benefit from a long term package of care, a referral will be made with the patients consent to the Local Authority for an assessment.

Depending on the outcome of the assessment, it will be identified if the patient may be required to self-fund the package of care. Any patients identified as a self-funder will be given 1 week to source a permanent care package. Support to source a package of care is available at a cost from the Local Authority
Supporting the prevention of avoidable hospital admissions:

The service also supports the Urgent Care Response (UCR) Team in Bedfordshire by providing a responsive assessment of patients that are at risk of being hospitalised without the appropriate support being provided in the home environment. 

It will either be a Nurse/Matron or Therapist that responds to the urgent referral, depending on the primary need identified at triage. Should it be identified that short term support or equipment would promote independence/regained confidence of the patient, then this can be provided from our Equipment Provider: Millbrook Healthcare.

Who can refer to the Transfer of Care service:

• Hospital Discharge Teams 
• GPs
• Health Professionals
• Social Workers

Leaflets

• Transfer
• Home Recovery Service (APT- South Bedfordshire)
• Home Recovery Service (Mega Care- Mid and North Bedfordshire)

The Community Occupational Therapy service operates seven days a week (8am-5pm)

The team provide assessments for those who require health-related minor works equipment, support or advice. 

This service follows the national guidance of assessments occurring within 18 weeks from the point of referral. 

The service provides:

• Comprehensive moving and handling assessments 
• Postural Seating Assessments
• Assessments for equipment with demonstrations and advice to patients and carers
• Equipment that supports safety and independence. Please note that all equipment items we supply has criteria which needs to be met for it to be prescribed. There may be times when equipment is wanted by a patient, but if they do not meet the criteria, we will not be able to provide it. In which case, it will need to be purchased privately
• The service refers to and liaises with Social Service’s Occupational Therapy service regarding major adaptation needs, identified on assessment. 

The service does not provide: *this list is not exclusive:

• Reimbursement for privately funded equipment
• Housing support letters
• Supporting letters for new windows or aids to facilitate the lights to be turned on and off
• Garden sheds for mobility scooters 
• Small aids such as kettle tippers, jar/tin opening aids, cutlery, light switches etc. These will need to be privately purchased

Who can refer to the service:

• GPs
• Health Professionals
• Social Services
• Acute Hospitals
• Self-referrals/relatives
• Carers
• Voluntary Services

Leaflets

• Community therapies
• Seating advice

The Community Physiotherapy service operates 7seven days a week (8am-5pm)

This service is for patients who are housebound, unable to attend a physiotherapy outpatient appointment or there is a clear benefit/justification to a physiotherapy assessment taking place in the patient’s home environment who would benefit from a period of rehabilitation to improve their strength, stamina and/or mobility.

This may include provision of basic equipment to support your identified and agreed rehabilitation goals.
If the patient is not housebound, the referral will be passed to the GP or referring consultant to request an outpatient’s appointment to be arranged.

This service follows the national guidance of assessments occurring within 18 weeks from the point of referral. 

The service provides:

• Mobility assessment and provision of walking aids
• Gait assessment and mobility progression
• Stair assessments
• Transfer assessments and provision of equipment
• Minor Physiotherapy aids
• Personalised Rehab/Exercise Plans
• Falls assessment/advice/exercises

The service does not provide for: *this list is not exclusive:

• Patients that can attend an outpatients’ appointment
• Patients that have active private physiotherapy involvement

Who can refer to the service:

• GPs
• Health Professionals
• Social Services
• Acute Hospitals
• Self referrals/relatives
• Carers
• Voluntary Services

Leaflets

• Community therapies
   

Rehab Bedded Units therapy input occurs Monday-Friday 8am-4pm

The bedded units are at either: Taymer located in Silsoe or Kimbolton Lodge in Bedford. However, there are also a small number of Integrated Care Board (ICB) purchased beds dotted across the county of Bedfordshire.

The community therapy services will visit those in a bed to provide appropriate therapeutic intervention, they are not based onsite. We work alongside the staff within the homes to ensure there is a continuation of your therapy input when we are not present.

Rehabilitation Beds: Can be occupied for a maximum of four weeks
These beds are for those that have been identified as requiring physical rehabilitation, following either an acute illness or a deterioration of a long term condition. Referrals into these beds will either be to facilitate an earlier discharge from the acute setting or to prevent a hospital admission from the community.

What to expect from therapy when in a bedded unit:

We provide short term therapeutic rehabilitation for a period of up to 4 weeks. During your stay, you will be seen by a member of the team who will complete a holistic assessment with you, which will aid in identifying your personal goals and what is the safest way for you to achieve these in a timely manner.

A safe and graded rehabilitation plan will then be agreed with yourself and drawn up. The plan will be provided to therapy staff as well as on-site staff who will then work alongside you to support you in achieving your goals.
Within the first week, the therapy team will start to discuss what will be required for your discharge, this may include equipment needs, longer-term support or potentially a discussion about whether returning home is the most suitable option or not.

Whilst this may seem early to start these discussions, when the input of other services are required, such as those of the Local Authority e.g. Social Services then a timely referral is required. There may also be the need for the team to discuss the discharge plans with your Next of Kin or other professionals and services which may also require time to arrange. 

Although our main aim is for you to return to your home environment, safely and independently at the end of your stay, the therapy team will be able to identify fairly early on if within the four weeks you will be able to meet your desired/required goals. If it is unlikely that your goals are achievable and you are likely to be unsafe at home, then the following options will be discussed with you to ensure you are discharged with the appropriate support:

• Return to your home environment but with a continuation of therapeutic interventions at home with the ToC Team
• Short term (up to four weeks) domiciliary care provision whilst Social Services are assessing and organising a long term package of care
• Return home with an immediate long term package of care provided by the Local Authority. Please note, you will be financially assessed for this
• A permanent placement within a care provision setting organised by Social Services. Please note, you will be financially assessed for this.

Leaflets

• Rehab Bed Units
• Rehab Beds - Access Visits explained

The Community Equipment Service in Bedfordshire is currently provided by Millbrook Healthcare.  

If it is felt that an item of equipment is required to meet your needs, it will be provided to you free of charge on a short-term loan basis.  However, the equipment remains the property of Millbrook Healthcare and should be returned when no longer required.

Millbrook also offer an online self-assessment service, where you will be asked a number of simple questions which will identify suitable equipment to meet your needs.  This assessment can be completed by a member of your family or carer with your consent and means that you can gain the equipment in a timely manner without the need for a formal assessment of a Therapist.  

However, if the assessment identifies that you would benefit from a full assessment by a Therapist, contact details of the relevant services will be made available to you.  

Returning Equipment:
Should you wish to return equipment, please call Millbrook on 0333 003 8074 to advise of the specific equipment items that are no longer required and a convenient collection date will be arranged with you. However, please be aware that it is not viable for the Community Equipment Service to collect small single items of equipment (such as walking sticks).

Local Authority Service Provision:

Equipment Provision
Where equipment needs are identified outside of the standard stock provided by Millbrook HealthCare, we will work alongside external, reputable companies for specialist equipment if it meets the clinical need.

Technology Enabled Care (TEC):
We can support with the assessment and provision of Technology Enabled Care for Central Bedfordshire Residents only. Please note: we will only assess and prescribe TEC equipment if there is a need for other equipment provision as well. If the need is solely for TEC equipment only, then this is to be provided directly from Central Bedfordshire Council.

Equipment: Major Adaptations:
Where appropriate, we will refer onto the Local Authority Occupational Therapy Service for any recommended major adaptations required to the home environment, such as: Stair lifts, Level Access Shower rooms and through floor lifts etc

• Central Bedfordshire Council
• Bedford Borough Council

Details of Longer Term Care Provision:

• Bedford Borough Council
• Central Bedfordshire Council

We are always keen to hear the views of our service users/relatives/carers, so we actively encourage people participation to continually improve the therapy services we provide. Please see the link below for further information to see how you can become involved. 

People Participation is an opportunity for service users and carers to become involved in many aspects of East London Foundation Trust’s work (ELFT).  

You will be able to access a range of opportunities where you can meet like-minded individuals, have your voice be heard and see how your opinion and lived experiences can make a difference.  

Many individuals involved in People Participation are working on their own skills and changes in health and/or circumstances

You can help encourage positive change and development within services, helping us to improve and ensure everyone receives the best care.  

You can feel positive and content knowing you are helping others and that your contribution could be life changing to someone else accessing either the same or a different ELFT service within your community.  

People Participation is for:  

• Any service user who is currently accessing ELFT services, or has recently accessed ELFT services (within the last 12 months)
• Any carer who is supporting someone who is currently accessing ELFT services, or has recently accessed ELFT services (within the last 12 months)
• If you have been discharged from an ELFT service, you can continue to access People Participation for a further 12 months.

Some people worry that they need certain experience or qualifications to become involved in People Participation. This is absolutely not the case! Your lived experience of using our services or looking after someone that uses our services is all the experience you need to get involved. Your unique perspective will help staff understand how we need to improve.   

If you have other skills and experience that you would like to bring to People Participation (PP), then of course your People Participation Lead (PPL) should help shape your PP journey in a way that enables you to use and develop these skills.  

Equally – if you are getting involved with People Participation because you are hoping to learn and develop new skills, then your PPL will be able to direct you to training and opportunities which will allow you to do this.  

Leaflet:

• People Participation