Scottish Government

Chapter Five: Care Management Moray

Moray Community Health and Social Care Partnership: Routes to Services: Community Eligibility Criteria

Contents

1. Index
2. Priority

A. Accommodation

• Homelessness
• Social Rented Housing
• Property repair, security and maintenance
• LD Supported Accommodation
• MH Supported Accommodation
• Sheltered Housing
• Very Sheltered Housing
• Care Homes

B. Care at Home

• Home Care
• 28 day care
• High Cost Packages
• Rapid Response
• Meals on Wheels
• Occupational Therapy & Adaptations
• Community Alarm Service
• Phone Installation
• Crossroads
• Marie Curie

C. Respite

• Emergency Support for Carers
• Respite Accommodated
• Respite Non Accommodated

D. Day Care/Hospital

• Older People
• The Oaks
• Moray Resource Centre

E. Transport

• Transport
• Blue Badge Scheme
• MAT
• Scottish Ambulance Service

F. Specialist Teams

• Learning Disability
• Mental Health
• Old Age Psychiatry

G. Health

• Community Nurse
• Health Visitor
• Community Physiotherapy
• Dietician
• Speech and Language
• Podiatrist/Chiropodist
• Community Psychiatric Nurse (Mental Health & Old Age Psychiatry)
• Learning disability

Appendix

1. Framework for the provision of services to people at home
2. Overview of services

Priority

As there is a high demand for Community Care and Health Services in Moray and there are limited resources available in terms of budgets and staff, decisions have to be made in respect of priority of access as well as the level of service provided. The aim of all services is to protect, empower and sustain the most vulnerable people and groups within their own communities.

Emergency

The service user or carer is experiencing problems or difficulties that place them at unacceptable and immediate risk, for example:

• A sudden or severe illness or marked deterioration in their condition
• The sudden illness or absence of the main carers
• Where abuse or neglect has occurred or is likely to occur

Tyical response time one working day

Health and Social Work operate a Rapid Response service designed to prevent an admission to hospital. The criteria for this service is as follows:

• The service user/patient should be able to be cared for safely at home with a package of care usually provided by a number of disciplines.
• Their care needs should be foreseeable with a finite duration of no more than 14 days or £500.

The Rapid Response service will be delivered as an emergency response.

High

Service user or carers feel at serious risk in relation to daily living. For example:

• Where a current situation cannot continue because of serious difficulties.
• When essential daily personal care and nutritional needs are not being met.
• Where the health of the main carer is at immediate risk
• Where service user/patient is in hospital and cannot be discharged until essential services have been arranged.

Typical response time two to fifteen working days

Medium

Where there is moderate risk in relation to daily living. For example:

• Individuals who have some difficulties in carrying out personal care tasks
• The family or care network may require support and/or advice to maintain the situation
• Where rehabilitation services are needed to enable service user/patient to become more independent.

Typical response time fifteen to thirty working days

Low

• Individuals who appear not to be at significant risk but where intervention could improve their basic living standards

Typical response time thirty days or more - assessments done in date order unless relevant change in circumstances

If for any reason the service is unable to meet the typical response time for levels two to four, the service user and the referring agent should be informed of the reasons why and when they can expect an assessment.

Services may use other timeframes - eg housing.

A. Accommodation

Housing

For a comprehensive guide to housing, The Moray Council's 'A Guide to Housing Options in Moray' is available in offices and through the Council's Intranet site.

Homelessness

The homeless service is provided by the Housing Needs Section of the Moray Council's Housing Service. It includes advice, information and assessment, temporary accommodation, tenancy support, education and preventative work.

Eligibility
The service is available to people who are homeless or at risk of homelessness.

Charge
There is no charge for the service apart from the rental for temporary accommodation. Depending on income allowing this, may be paid by Housing Benefit.

Referral Process
Either directly to Housing Needs or by making an application to any of the Moray Council's Housing Area Teams.

Priority
Services available are determined by an individual's personal circumstances and the reason for their homelessness.

Social Rented Housing

Social rented housing is available from the local authority and several housing associations. The type and availability of accommodation varies in each locality.

Eligibility
Anyone over the age of 16 is eligible to apply for social rented housing.

Charge
The charge is the rental cost for which Housing Benefit may be available depending on the applicant's income. In some specialist accommodation, such as sheltered housing, there is an additional means tested charge for housing support.

Referral Process
Through housing application form to provider with any supporting documentation.

Priority
Priority is different between different landlords but is based on housing need.

Points of Note

• Moray Council has nomination rights for housing provided by other social landlords.
• It is helpful if supporting documentation accompanies the application.
• It should be noted that rented accommodation can be accessed through the private sector. The Moray Council can offer advice on this and, in certain circumstances, assistance.

Adapted Properties

There are a variety of adapted social rented housing properties available.

Consideration may be give to adapting a tenant's existing property if this can meet their assessed needs.

Financial help by way of improvement grant may be available from the local authority to adapt private sector houses to meet the needs of persons with disabilities.

Eligibility
Dependant on assessed need
Subject to financial assessment.

Referral Process
Liaison between Housing and Occupational Therapy.

Priority
Applications prioritised High, Medium and Low and dealt with in that order should there be insufficient funds to meet all applications.

Property Repair, Security and Maintenance

Various initiatives are available in Moray helping owner-occupiers and private tenants with advice and help about repairs and improvements to their homes. Voluntary agencies also have schemes for undertaking small repairs, security reviews and fittings.

Eligibility

• Over 60
• Disabled
• Suffering from long term illness

Charge
Charge varies according to service required; the amount charged is for the materials used.

Referral Process
Refer direct to Projects.

Priority
Different for each project and the service required.

Points of Note
Projects available in Moray include:

• Handyman Service
• Care and Repair
• Safe as Houses

Learning Disability Supported Accommodation

Learning Disability Team to be contacted (See Page 24)

Mental Health Supported Accommodation

Mental Health Team to be contacted (See Page 24)

Sheltered Housing

Sheltered Housing is available to persons aged 60 years and over, (some service providers will consider younger persons) who can live fairly independent lives but who have a particular difficulty which may require an emergency response.

The complexes are supported by a warden who contacts each tenant daily. Out of hours the tenants are required to use an emergency call system. Wardens do not carry out nursing, personal or domestic care. The tenant will require assistance from the home care service depending on assessed needs.

Eligibility
Individuals or couples who are eligible for care in supported accommodation, including very sheltered housing, are those who are unable to care for themselves independently, by virtue of their chronic illness, disability or mental health.

Charge
Standard charge in addition to rent for warden services and 24 hour monitoring of personal alarms. Rents vary depending on property.

Referral Process
Completed housing application form ensuring sheltered housing request is specified.

Priority
Points system based on need and disability.

Points of Note

• Moray council sheltered properties are registered for over 60's only.
• Tick box for Housing Association properties completed allows the council to forward a copy of the application form to the other providers in the area.
• Supporting documentation with the application form from GP, District Nurse and OT is required if individual has health or disability needs.

Very Sheltered Housing

Very Sheltered Housing provides the same services and facilities as sheltered housing. However, a greater level of care and support is provided to tenants along with two meals a day, lunch and tea (breakfast is made by the tenant or domiciliary care provider). Staff are available for support on the premises 24 hours a day. The staff do not provide nursing, personal or domestic support.

Eligibility
As for sheltered housing.

Charge
Standard charge made in addition to rent.

Referral Process
Completed application form direct to the service provider.

Priority
Depends on service provider.

Points of Note
Any changes in circumstance should be notified as soon as possible

Care Homes

A Care Home offers accommodation for people no longer able to live in their own home. Care Homes offer both residential and nursing level care depending on the assessed need allowing the service user to remain in the same home when/if their needs change.

Eligibility
Residential - Assessed domiciliary care is no longer meeting their needs and requiring 24 hour care. Nursing - As above and requires care input from trained nursing staff.

Charge
Charges dependent on Financial Assessment, Care Home charges and level of care required.

Referral Process
SSA to Community Care Team or direct contact from individual or carer.

Specialist and Financial Assessment and Request for Funding form completed.

Priority

• Allocations Group meets bi-weekly to discuss priorities for available places across Moray.
• Emergency placements can be decided on an individual basis with the chair of the group as they arise.
• Out of area placements are prioritised by the group against the availability of places in the chosen area.

Points of Note

• Some Care Homes are developing specialist areas of care meeting specific individuals' needs.
• Care Home placement need not be a permanent move. The service user can return home or move to another home.

B. Care at Home

Home Care

Care at home may be provided to assist people with personal care, meal support, housework, shopping, tasks associated with maintaining a tenancy and the maintenance of social and educational activities. (see Appendix 1)

Eligibility

• An individual has care needs they are unable to meet themselves and they do not have adequate support from family, friends, neighbours, other informal carers or the voluntary sector.
• They are unable to make private arrangements to meet their care needs.
• Failure to provide the service would place the individual in a situation of unmanageable or unreasonable risk.

Charge
Age 65 and over requiring personal care - no charge
Over 65 and assessed as requiring care on discharge from hospital - no charge (see 28 days free care below).

Individuals who are under age 65 or those over 65 who require services other than personal care may be liable for a charge for their care, following financial assessment.

Referral Process
GPs, Community Health staff, Hospital Ward staff and Community Care staff refer using Single Shared Assessment
or
Self assessment
or
Direct contact with Community Services via Moray Council local access point.
or
Relative, friend, neighbour, etc.

Specialist and Financial Assessment and Request for Funding form required.

Priority

Emergency
Rapid Response initiated.

High

• An individual who lives alone or with a vulnerable person unable to provide support, and requires significant help with personal care and/or daily living tasks, in an acute situation.

and

• Current family/informal care/private care has broken down.

or

• Acute admission to 23 hour bed.

Medium

• An individual requiring help and support with personal care tasks to maintain independence.
• Requires assistance with essential daily living tasks.
• Could not, without support, maintain living in their own environment.

Low

• An individual who requires support to undertake essential living and domestic tasks.

Points of Note
Individuals can refuse the service.

28 Day Free Care

The service aims to resettle older people into their own homes following NHS care and to encourage their independence.

Eligibility

• Aged over 65
• In hospital over 24 hours or Day Surgery.
• Care provided to be based on assessment of need.

Charge
Free to Client for up to 28 days.

Referral Process
SSA to Community Care Team showing assessed need. Care package availability confirmed to NHS staff. Request for Funding form required.

Priority
High - Medically fit for discharge and assessed as requiring package of care.

Points of Note

• Review 1 week after discharge by highlighted team member. Final review before 28 days. NB - Review can be undertaken by any member of the Multidisciplinary Team.
• Individuals have to claim within 3 days of discharge if not commenced immediately on discharge.
• If family members looking after them for part of the 28 days, the remaining time can still be requested.

High Cost Care Packages

A domicillary care package in excess of £500 per week.

Eligibility

• Terminally ill and have expressed a wish to remain at home
• Where there is a strong view expressed by the service user that it is their choice to remain at home
• Under 65 years old where there is no appropriate local alternative.

Charge
Dependant on service required (If DS1500 complete no charge to service user).

Referral Process
SSA and discussed with Senior Community Care Officer. Specialist and Financial Assessment and Request for Funding form required. Cost over £1000 - referred to Lead System Manager (Social Work) for sanctioning.

Priority
As for home care.

Points of Note

• The care has to have been assessed as essential and benefiting the client, relatives and informal carers, and has been discussed and agreed by the multidisciplinary team.
• To be reviewed every 3 months.

Rapid Response

A joint health and social care provision designed to prevent admission to hospital. The package of care can require input from a number of disciplines.

Eligibility

• Person should be able to be cared for at home with a package of care of limited duration.
• Requires an emergency care home placement for up to one week.

Charge
New or additional care is free up to 14 days or £500.

Referral Process
Telephone to Senior Community Care Officer followed by SSA. Request for Funding form completed

Priority
Emergency

Points of Note

• Services available in each area vary
• Care package to be reviewed in 24 hours then regularly until person's condition improves

or

• Review and ensure care plan for future care in place by end of the 14 days or £500 limit.

Meals on Wheels

The Meals on Wheels Service provides delivery of a hot, two course meal to people in their own homes, three times a week in the middle of the day.

Eligibility
An individual who lives alone or with another vulnerable person and who, for reasons of frailty, disability or cognitive impairment, can no longer wholly maintain adequate levels of nutrition.

Charge
Standard charge made for each meal delivered. There is no charge for the cost of delivery.

Referral Process
SSA to Community Care Team.

Priority

High

• An individual whose nutritional status is compromised

and

• Who is sufficiently independent to receive this service as part of a strategy to address this issue.

Medium

• An individual whose increasingly physical or mental frailty makes it difficult for them to maintain a good standard of nutrition

and

• Who can access other supports on days when meals are not provided.

Occupational Therapy

This service provides information, treatment and professional advice to assist people who are ill, frail or have a disability, to live to their full potential by maximising their level of independence. Some of the services include:

• Working with people with illness, or disability to enable them to undertake everyday tasks safely and with confidence
• Providing equipment to help people maintain or improve a level of independence in everyday tasks.
• Assist individuals to adapt their home environment to meet their needs and to maximise their potential for independence
• To give specialist advice and treatment to those who are ill and disabled in the community

Eligibility
The service is determined by the OT following a specialist OT assessment.

Charge
There is a charge for equipment supplied

Referral process
SSA to service.

Priority

High - within 2 weeks

• People who are terminally ill or who have a progressive and/or a seriously deteriorating disabling condition
• People who have been recently discharged from hospital after major surgery, serious illness or trauma
• People having difficulty with essential daily living tasks e.g. Bed/Dressing/Toilet/Eating.
• People who live alone and are at risk
• A child or adolescent
• Where there has been a dramatic change in the person's condition rendering them incapable of attending to activities of daily living.

Medium - within 8 weeks

• People who have a disabling condition.
• People who have difficulty with some daily living tasks.
• People who have a carer nearby who can give assistance.

Low - within 12 weeks

• People whose condition is caused by the ageing process only and are becoming less able to carry out activities of daily living.
• People who have bathing difficulties only.

Points of Note
Once the assessment is completed a number of services will be offered or managed by the OT Service:

Adaptions to Property and Provision of Equipment

This priority statement is for all provision of equipment and for adaptation work whether in Moray Council or private property.

Eligibility
People who have suffered illness, frailty or disability and who have difficulty carrying out everyday tasks because of the physical environment in which they live.

Charge
Charge dependant on adaptations required

Referral Process
SSA direct to OT service

Priority

High - within 2 weeks

• The adaptation/equipment is essential for the person to be discharged from hospital
• Repairs to existing adaptations/equipment if the service user is unable to manage safely without the work being done
• Adaptations/equipment which, unless carried out or provided, would put the service user/carer safety at extreme risk
• The service user has a terminal illness and the provision of equipment will have a significant impact on quality of life.

Medium - within 8 weeks

• Adaptation/equipment is necessary for hospital discharge or as soon as possible after discharge
• Adaptation/equipment which, unless carried out or provided, would put service user/carer at risk of, e.g. falling, injury
• Adaptation/equipment is required to provide primary access to the house
• Service user/carer is unable to avoid risk
• The service user has a terminal illness and the adaptation would have a significant impact on the quality of life
• The equipment is required for health reasons, e.g. stoma care, dialysis.

Low - within 12 weeks

• Service user/carers who are at low risk until adaptation is carried out or equipment is supplied
• Service user/carer can avoid risk
• Alternatives are available, e.g. wash-down instead of bathing
• Adaptations/equipment which, although will improve independence, are not required for safety, e.g. window openers, additional kitchen cupboards.

Community Alarm Service

An alarm system consisting of a receiver unit and alarm button (worn by service user) which, when activated, alerts staff at a 24-hour manned centre. If assistance is required a nominated person is contacted. The emergency services can also be deployed.

Eligibility

• An individual who lives alone (or is frequently left alone), or with another vulnerable person

and

• for reasons of frailty, disability or personal safety needs may require to summon help.
• All applicants will need to satisfy the criteria and demonstrate that they are able and willing to use the equipment and have suitable contacts.

Charge
No charge

Referral Process
SSA and application form to community care team. Client can complete own application form - return to CCO who would then check if a visit from a CCO is required or whether the form can go straight to the service.

Priority

High

• A person who is at risk because of ill health, restricted mobility or physical frailty and who has a recent history of falls or similar incidents for which it was difficult to summon help

and

• A person who is vulnerable to violence or abuse from someone excluded from their house-hold

Medium

• A person who expresses concern for their safety or well being and who may need to summon help.

Points of note

• The service can be provided on a temporary basis to people recovering from an illness or hospital admission at home, provided that there is an active land telephone line available.
• People who require a service but have no telephone line may seek assistance with the cost of connection if they can demonstrate that they are without means. People seeking support of this kind must be made aware that they will be liable for all rental charges of the telephone line once it is connected.
• Applicants who do not fulfil the criteria but who wish to participate in the scheme may be included provided they purchase their own alarm. No charge will be made for connection and monitoring.
• A leaflet describing the service is available.

Telephone Installation

Assistance with installation of telephone costs can be offered to people who are unable to meet the cost of the installation but are able to budget for line rental and calls.

Eligibility
The individual will need to summon help regularly or frequently as a matter of urgency from someone outwith the household, and has been assessed as being 'at risk' due to their medical condition
or
The individual will either live alone, or be on their own for significant periods of time, or will live with a carer who is unable to leave the individual to summon assistance
or
The individual has been assessed as requiring a Community Alarm.

Charge
Free for installation.
Service user will be required to pay line rental and phone call costs.

Referral Process
SSA and Request for Funding form to Senior OT Practitioner.

Priority
High - within 2 weeks

• The equipment is essential for the person to be discharged from hospital
• If not carried out or provided would put the service user/carer's safety at extreme risk
• The service user has a terminal illness and the provision will have a significant impact on quality of life.

Medium - within 8 weeks

• Equipment is necessary for hospital discharge or as soon as possible after discharge
• If not carried out or provided would put service user/carer at risk of e.g. falling, injury
• Service user/carer is unable to avoid risk
• The equipment is required for health reasons.

Low - within 12 weeks

• Service user/carers who are at low risk until work is carried out or equipment is supplied
• Service user/carer can avoid risk
• Equipment which, although will improve independence, is not required for safety.

Points of Note

• Once approval of funding received, referring worker arranges with British Telecom for installation of line.

Crossroads

Domiciliary respite care service for carers. Care attendants visit the home and relieve the carer for a period of time. Can also be used to access leisure and social activities for the service user.

Eligibility
Any age group who is cared for by an informal carer, and will not require a large amount of personal care during the period of respite.

Charge
Dependant on how service accessed
If accessed through Community Care: service user is financially assessed and may be required to contribute to the cost.
Direct Access: no cost to service user.

Referral Process
Direct to service.
or
Via Community Care - SSA, Specialist and Financial Assessments and Application for Funding required.

Priority
Dependent on availability of suitable carers.

Marie Curie

Provides specialist palliative nursing care to cancer sufferers in their own homes. Care can be provided by trained nurses or untrained auxiliaries as requested. The care can be provided day or night.

Eligibility
Diagnosed with cancer and requiring palliative care.

Charge
Free to service user.

Referral Process
Through District Nurse based on assessed need direct to the service.

Priority
As assessed by District Nurse.

Points of Note
Service user will require nursing care plan.

C. Respite

Respite

Respite Care is any service of limited duration, which benefits a dependent person. The distinctive feature of respite care is that the break should be a positive experience for the cared for person and the carer so as to enhance the quality of their lives and support their relationship.

Emergency Support for Carers (Non - Accommodated)

Emergency domiciliary support or care in the service users home due to the informal carer becoming suddenly unable to continue in the caring role. The care is provided for up to 2 weeks or £500 as Rapid Response.

Eligibility
Users who are cared for mainly by an informal carer.

Charge
No charge for up to 2 weeks or £500 care package as Rapid Response.

Referral Process
SSA to Community Care Team. Specialist Assessment and Request for Funding form required.

Priority
Emergency

Points of Note
It can be difficult to provide 24 hour cover in an emergency due to unavailability of carers.

Emergency Support For Carers (Accommodated)

Emergency care in a care home setting due to the informal carer becoming suddenly unable to continue in the caring role. The care is for one week only as for Rapid Response.

Eligibility
Users who are cared for mainly by an informal carer Care assessed as being able to be met only in a care home.

Charge
No charge for up to one week.

Referral Process
SSA to Community Care Team. Specialist Assessment and Request for Funding form required.

Priority
Emergency.

Points of Note
Can be difficult to provide in the person's home locality due to unavailability of Care Home beds there.

Respite Accommodated

Period of PLANNED care in a care home setting to allow the informal carer a break from the caring role and which will also meet the assessed needs of the service user.

Eligibility

• Person lives permanently with carer.

Charge
There will be a cost to the person with a minimum charge to be paid by all clients. Further charges dependant on financial assessment.

Referral Process
SSA to Community Care Team. Specialist and Financial Assessment and Request for Funding form required.

Priority
Medium

• Where the person being cared for lives permanently with a family or others, who are in need of a break, to help them maintain their caring role.

Points of Note
Maximum of 42 nights a year
Availability of block purchased respite beds must be checked and used as the preferred placement. In the event of there being no block purchased beds available for suitable dates, consideration will be given to an available bed in another Care Home.

Special circumstances could be looked at individually.

Respite Non Accommodated

Period of planned care delivered in the service user's home to allow the informal carer a short break of an hour or for longer periods of time.

Eligibility

• Person lives permanently with carer.

Charge
There may be a cost to the person dependant on age, service required and financial assessment.

Referral Process
SSA to Community Care Team. Specialist and Financial Assessment and Request for Funding form required.

Priority
As for Accommodated.

D. Day Care

Older People

Day Services can be an important element of a care package, which enables an older person to be sustained in the community.

Eligibility
People over pensionable age, who cannot access community social activities unaided because of significant physical or mental health difficulties and those who experience problems managing their personal care.

Charge
For lunch, tea and biscuits only.

Referral Process
SSA to Community Care Team. Specialist and Financial Assessment and Request for Funding form required.

Priority
High

• The person lives alone, is socially isolated and requires emotional support and social contact to prevent a deterioration in their physical and mental health
• The person needs assistance with their personal care that cannot be undertaken at home.
• Where the pressure on the carer is significant and the care arrangements may collapse without the daytime respite.

Medium

• The person lives alone and is socially isolated and requires social contact, but because of their frailty is unable to access resources ordinarily available in the community
• To provide respite on a planned basis as part of the care package to support a carer and this support is not appropriate in the dependent person's own home.

Points of Note

• A person in a care home for respite may be able to continue to go to day care to keep links with the community if this is possible.
• A person waiting for a care home bed as an inpatient can attend day care in the care home one day a week if this is deemed beneficial as part of their planned discharge.
• Transport can be provided to and from day care.

The Oaks - Palliative Care Day Centre

Eligibility
Adult Service. For patients and carers suffering from cancer or a palliative progressive illness.

Referral Process/Cost
Self or health professional referral with key discussion through person's own GP.

Priority
Individual goals and priorities are set by the service user and 12 weekly assessment is carried out thereafter for Day Support users. Goals are then reset or discharge planned.

Points of Note
Services offered:

• Day Support - Tuesday, Wednesday and Thursday
• Information Services Monday - Friday 9.00 am - 4.30 pm
• Look good feel good clinic - second and last Monday of the month.
• Breathlessness programme clinic - 4 week programme on Tuesday afternoons.
• Lymphoedema clinic - Wednesday afternoons.
• Palliative care/symptom management clinic - Thursday mornings
• Complementary Therapy clinic on Fridays - offering Aromatherapy, Reflexology, Reiki, Indian Head Massage, Acupuncture, Art Therapy and Hypnotherapy
• Transport can be arranged.

Moray Resource Centre

Moray Resource Centre offers a specialised service for those with a physical and/or sensory disability, who wish to have the opportunity to develop their chosen skills and aspirations. This includes access to Resource Workers, information on all aspects of disability, and a Disabled Living Centre.

Objectives

• To work in partnership with those with a disability to maximise their independence and develop their chosen skills and aspirations.
• To empower people with disabilities.
• We have a commitment to inform, through our information service, our customers, professionals, carers, disabled people and the general public.
• To provide a barrier free, fully accessible public resource.
• To facilitate training in disability awareness to other professionals, young people, businesses and the general public.
• To provide a focus point for disability groups and services in the area.

All services provided by the Moray Resource Centre are based on the premise that each person is a unique individual who has their own set of needs and that these needs will change over time.

The services are designed in such a way that:

• Every person who uses the service will be appropriately supported to make use of the service to meet their own needs in their own way and in their own time-scale.
• Every person will develop their ability to manage independently to the extent that they will no longer need the support that MRC provides.
• A set of values based upon respect for the individual underpins this approach.

The working method used by the staff of MRC to support this approach is best described as the "stepping-stone" method. This describes an intervention method whereby individual service users work in partnership with staff members to plan a package of support that is 'tailored' to meet their needs. This support is changed, by a process of regular review, as the service user gains confidence and independence.

Charge
Charge for meals.

Referral
Direct to Centre by professionals or individual.
Person is allocated a Key Worker who carries out an assessment of needs. This is then discussed at the next allocation meeting. If appropriate, the person is offered a service or sign posted to more appropriate services.

Priority
Prioritised according to greatest need and availability of places.

Points of Note
See description of service

• Transport can be arranged.

E. Transport

The Moray Transport Group is a joint initiative between Moray Council and Moray Voluntary Services Organisation. The group produce a regularly updated guide which covers all transport services available in Moray and how to access them.

Blue Badge Scheme

The Blue Badge Scheme provides a national arrangement of parking concessions for people with severe walking difficulties and those registered blind who travel either as drivers or passengers.

The scheme allows badge holders to park close to their destination, providing they adhere to the guidelines.

Eligibility

• In receipt of the higher rate of the mobility component of Disability Living Allowance
• In receipt of War Pensioner's Mobility Supplement
• Registered Blind
• Have a permanent and substantial disability, resulting in an inability to walk or have considerable difficulty in walking. A questionaire to be completed in this case.

(Note: children under 2 years of age do not qualify for a badge because they would not normally be expected to walk independently)

Charge
Free to service user
Cost to Council/Health per GP referral form completed

Referral Process
Forms available from: Moray Resource Centre, Moray Council Access Points and Health Professionals.

Priority
All applications dealt with in date order.

Moray Assisted Transport ( MAT)

Set up in consultation with voluntary organisations to provide help with getting about within Moray for individuals who have mobility problems. The scheme is funded and administered by the Council and transport is provided by private taxis who are registered with the MAT scheme. The MAT scheme offers taxi journeys at a 50% reduction up to a maximum limit per single journey. A carer may accompany the person on the journey at no extra cost.

Eligibility

• Live in Moray
• In receipt of Disability Living Allowance - Higher Mobility Component
• A long term disability that seriously impairs the ability to walk and cannot use conventional bus services
• Registered blind
• In receipt of a war pension mobility supplement.

and

• Does not hold a concession card or have a mobility car.

Charge
Annual membership fee and cost of individual journeys as taken.

Referral Process
Contact MAT sheme

Priority
None

Scottish Ambulance Service

All patients requiring non-emergency transport, to and from any part of the NHS, can be transported by ambulance.

Eligibility
Any patient who requires admission or discharge from hospital and no other suitable transport is available.

Charge
No charge.

Referral Process
All requests to be sanctioned by a Doctor, Dentist or Midwife.

Full information to be given on the patient's abilities pertaining to sitting/lying, mobility categories, time of pick up, escorts and any other information required for the journey.

Requests can be telephoned or faxed.

Priority
Ambulance control to receive booking 1 day prior (before 12 noon) to journey.

Points of Note

• Staff to ensure that patient's belongings, drugs and home care are ready before the ambulance arrives.
• Patient should be suitably dressed for the journey.
• Arrangements for access to the destination are in place, and the service is aware of any possible obstacles which are highlighted when ordering e.g large flight of stairs up to property.

F. Specialist Teams

Learning Disability

Community Learning Disability Services includes:

• Community Learning Disability Team
• Day centres
• Day Services
• Supported Accommodation, Residential and Nursing Care
• Respite Care
• Training Facilities

Eligibility
Services are available to adults (16 and over) with a learning disability, e.g., they have a significant, life-long condition that started before adulthood, which affects their development and means they require help to:

• Understand information
• Learn skills
• Live as part of the community
• Enable others to understand their needs

Charge
Day Centres and services are free (although clients are expected to pay for lunch and drinks)

Community Learning Disability Team Assessments/Support are free.
Other services provided are financially assessed.

Referral Process
A Single Shared Assessment should be sent to the team.

Priority
Services are provided, based on individual assessment of need.

Point of Note
The underlying philosophy of all LD Services is that people should access services in their community. Only if their disability prevents them from doing so should they access specialist services.

Mental Health & Old Age Psychiatry

Services include:

• Specialist Nursing, Community Care and Social Work Teams
• Day Hospitals
• Inpatient accommodation
• Supported Accommodation, Specialist Residential and Nursing Care
• Respite Care
• Training Facilities

Eligibility
Services are available to persons with a diagnosed mental health condition.

Charge
Specialist assessments and support are free.
Inpatient care and Day Hospitals free
Other services provided are financially assessed.

Referral Process
All referrals to the Consultant Psychiatrist from a GP or Hospital Doctor
including
A Single Shared Assessment.

Priority
Dependent on medical requirements.

Point of Note
All persons seen by the supporting team have to be assessed by a Consultant prior to referral.

G. Health

Community Nurses

Team of nurses led by a specialist practitioner in community nursing who give nursing care and advice to acute, chronic or terminally ill patients of all age groups. Community nurses will assess, treat and evaluate the patient's nursing needs including the family and specialist services.

Eligibility
Individuals and families requiring support, advice and treatment for a medical condition.

Charge
No charge.

Referral Process
Direct to the service or via the GP.

Priority
Triaged by a senior nurse and priority set based on assessed clinical need.

Points of Note
Community nurses are aligned to service users' GP. All referrals should go to the team which supports the person's own GP.

Health Visitor

Health Visitors promote health and prevention of illness, through assessment and identification of health problems before they become serious or chronic.

Eligibility

• Any age group
• Requiring advice or support to improve wellbeing
• Requiring ongoing assessment and monitoring of health

Charge
No charge.

Referral Process
SSA Direct to Service.

Priority
Based on assessed need.

Points of Note
Health Visitor teams are attached to GP practices.

Community Physiotherapist

Assess, diagnose and treat patients of all ages fitting the eligibility criteria.

Eligibility
Persons requiring physical and functional assessment, mobility aids and treatment of specific conditions such as:

• Acute/Chronic Respiratory conditions
• Neurological conditions
• Musco-skeletal problems
• Fallen and at risk of further falls
• Broken walking aids
• Mobility problems
• Spinal pain limiting function/mobility

Charge
Assessment, treatment and basic equipment supplied as per need with no charge.

If person wishes higher specification equipment this has to be personally funded.

Referral Process
SSA from:

• GP/hospital doctor
• Allied health professional
• Ward nurse/district nurse/health visitor

Referrals can also be taken from

• Relative if patient already known to Therapy Team
• Carer

Priority
Dependent on condition and ability to attend outpatient department. Patients will be triaged to establish priority.

Urgent - next available appointment

• Acute respiratory episode
• Fallen/at risk of further falls
• Broken walking aid and requiring immediate replacement

Semi-urgent - within one working week

• Acute neurological condition
• Acute musculo-skeletal problems limiting function/mobility
• Acute episode spinal pain limiting function/mobility
• Urgent ongoing physiotherapy following hospital discharge
• Moderate risk of falling

Routine

• Neurological condition
• Musculo-skeletal problems
• Mild mobility/fall problems
• Chronic respiratory condition
• Hospital discharge requiring ongoing physiotherapy

Community Dietician

To assess a patient's dietary needs and nutritional status. To provide dietary advice appropriate to medical condition and nutritional needs. Care of tube feeding

Eligibility
Dietetic need identified and patient has consented to referral.

Charge
No charge.

Referral Process
Completed referral form from:

• GP/Hospital Doctor
• Ward Nurse/District Nurse/Health Visitor

Priority
All referrals are clinically prioritised.
High
Seen within 4 weeks or sooner as resources allow
Moderate
Seen within 6 weeks. Prioritised monthly
Low
Seen as service commitments allow

All new tube feeds are made contact with within 24 hours and seen within a week

Points of Note
For patients in hospital dietician to be contacted:

• 5 days prior to discharge with tube feeding
• 2 days prior to discharge for patients on supplements

Speech and Language Therapy

The speech and language therapist aims to provide assessment, diagnosis, management and counselling support to adults referred with swallowing disorders, acquired speech and language disorders, voice disorders, head and neck surgery.

Eligibility
As above.

Charge
No charge for the service.

Referral Process
Direct to the service - by telephone or written
Swallowing assessments require specific referral process.
SSA

Priority
Dependent on condition
Acute swallowing problems seen within 2 days
Communication 1-3 weeks
Outpatients 2-6 weeks

Podiatrist/Chiropodist

Diagnose, prevent and treat ailments of the feet and lower limbs.

Eligibility
Over 65 years

Physically Disabled - registered physically disabled person of any group including registered blind and registered partially sighted person or a person who is substantially and permanently disabled by injury, illness or congenital deformity. This group includes persons suffering from such conditions as chronic arthritis, emphysema, etc.

Learning Disabilities - Registered of any age group.

Expectant Mothers - Treatment may be given from the date of certification of pregnancy and up to 12 months after delivery.

Children - Pre-school and up to the age of 18 years who are in full-time education.

Hospital patients - who are inpatients or attending the outpatient department of a hospital and are under the care of a consultant.

Charge
No charge if meeting the eligibility criteria.

Referral Process
All referrals to be in written format outlining relevant medical history and medication being taken. As much information as possible concerning the individual's foot condition.

If urgent - reason must be given for urgency.

Priority
Urgent requests seen at next available clinic or appointment.

Initial assessment appointment sent based on assessed need and further needs then reviewed.

Points of Note

• Whenever possible podiatry treatment should be provided in outpatient department or GP surgery. If home visit is required this should be noted on the referral
• A nail cutting service is not provided by podiatry.

Community Psychiatric Nurse (Mental Health and Old Age Psychiatry)

Accessed through the specialist team (see page 24)

Learning Disability Nurse

Accessed through the specialist team (see page 24)

Appendix I: Framework for the provision of Services to People at Home

This framework sets out the range of supports, which can be provided to service users at home to ensure that they can continue to live safely and independently in the community. The kind of supports available and the range of tasks undertaken are common to all service providers.

The framework is divided into 3 broad headings, which cover:

• Personal care
• Domestic support including housework
• Social support

The framework may not cover every aspect of an individual's specific care needs. When supports are identified which are not covered in the guide, they should be described in detail in the assessment of need.

There may be a need to charge for any of the services described in the framework. More detailed information is included at the start of each section.

The support required will fit on a continuum.

Personal care

All of the services described in this section may be delivered without charge to:

• People over the age of 65.
• People who are terminally ill and who meet the DS 1500 rules.
• Children.

Personal care tasks are those which relate to an individual's need to maintain:

• Personal hygiene.
• Physical health.
• Mobility within the home.

Personal hygiene

Domestic Support

The services described in this section may be delivered without charge to:

• People over the age of 65 for up to 28 days following discharge from Hospital
• People who are terminally ill and who meet the DS 1500 rules.
• Children.

Housework - rooms in daily use

Social Supports

The services described in this section may be delivered without charge to:

• People over the age of 65 for up to 28 days following discharge from Hospital
• People who are terminally ill and who meet the DS 1500 rules.
• Children.