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The aim of our service is to support children with complex medical continuing healthcare needs to live within their family home and fulfil their potential as individuals. This includes supporting them in a variety of settings in the community for example, schools and nurseries. Without the support of the team many families would find it impossible to continue to care for their child at home.
The Children’s Intermediate Care Service consists of a multi-disciplinary team comprising of a number of specialists working together to provide a co-ordinated approach to meeting the needs of children and young people with complex health needs in the community. The team include the following:
•Children’s Community Nurses;
•Children’s Continuing Care;
•Children’s Respiratory Nurse;
•Paediatric Continence Adviser;
•Special Needs Nurses and Nursery Nurses;
•Child Development Centre Nursing Team;
•Early Support Manager.
The team also works in partnership with the Local Authorities to ensure a holistic approach to meeting the health and social care needs of children and young people by focussing on the individual rather than specific needs.
This service operates a case management approach to care, co-ordinating service provision and resource allocation based on clinical assessment of health need. The service aims to reduce hospital attendance and admission by doing short term acute assessment and treatment at the child’s home and by offering advice to other professionals, allocation to support robust community packages of care, in partnership with wider Children’s services to ensure that specialist health needs are met wherever the placement.
The Children’s Nursing Team at the Child Development Centre (CDC) co-ordinates and supports paediatric clinics for children and their families. Working in partnership with paediatricians and families while waiting for, or following, diagnosis, supporting families at this often difficult time working to support transition into education and universal services.
We provide nursing advice and health promotion and safeguard and promote the welfare of children accessing the service.
The Nursing Team also oversee the Information Room which provides resources regarding specific conditions, support groups and a number of other topics related to special needs for children, young people and their families.
The Special Needs Nursing team are part of the wider Intermediate Care Team, thereby providing a co-ordinated specialist service.
The Special Needs Nursing team support children and young people aged 3-19 years old, with learning disabilities and associated additional health care needs within the special school setting. The service is provided by a multi-skilled team of registered nurses and specialist nursery nurses.
The team work in partnership with parents and carers, education teams, children’s community nurses, continuing care, social care and the wider multi-professional team to enable children and young people to access the curriculum.
The service provides:
The team develop individual care plans to meet the health care needs of children and young people through a process of assessment, planning, implementing care and evaluation of outcomes. The team co-ordinate pre and post-operative planning in order to ensure all services are in place to promote a timely return to school following surgery. The team take an active role in transition planning to promote effective transition from children’s to adult services.
The team provides training to parents, carers, education staff, respite provision and voluntary agencies in a variety of clinical interventions specific to individual care plans, to include, administration of medicines, enteral feeding, rescue medication (buccal midazolam/rectal diazepam), epilepsy awareness, oxygen therapy, suction, and the management of anaphylaxis (Anapen/Epipen).
The team work in partnership with the multi-professional team to co-ordinate health care clinics held within the special school setting in order to ensure that children and young people spend as little time as possible attending appointments outside the school setting. Clinics provided are:
•Medical reviews (led by Community Consultant Paediatrician)
•Immunisations (planned and provided by the special needs nursing team)
The nursing team work in partnership with the education staff in the planning and delivery of health promotion to include healthy eating, sexual health, drug awareness and other government initiatives.
The special needs nursing team act as an advocate and provide advice and support to families meeting their children’s health care needs. The team are responsible for sign-posting to and referring to specialist services as necessary, sourcing relevant information, liaising with and when appropriate taking the Lead Professional role in conjunction with the family and other health care professionals.
CHUMS offers four services in Bedford Borough which are aimed at children, young people and their families.
Bereavement Service - any child or young person who has been bereaved is able to access bereavement support which may be in the form of individual or group support. Group support includes parents/carers. Ongoing support is also available for parents and teenagers on a monthly basis with other events such as a Remembrance Service and Family Day being offered during the year.
Trauma Service – offers support to children and young people who have been bereaved in traumatic circumstances such as murder, suicide, road traffic collision as well as those showing signs and symptoms of post traumatic stress disorder (PTSD). The service is also able to support children and young people affected by other traumas such as sexual abuse, witness to domestic violence or witness to another traumatic event.
Emotional Wellbeing Service - short term support for children and young people presenting with a mild to moderate mental health difficulty. Presenting issues include anxiety, relationship difficulties, low mood and low self esteem. Group support is offered to those with anxiety and we offer a group programme for children and young people who have an ASD diagnosis. Parents/carers are included in our group programmes.
Recreational Therapeutic Service - this service is offered to young people who have found it difficult to engage with traditional therapies and/or are finding it hard to engage with education; they may be at risk of exclusion or have been excluded. Support is offered by activity based programmes including football or music as a tool for engagement.
The Community Eye Service cares for children from 0 - 16 years of age with strabismus, lazy eye (amblyopia) and vision defects. If a child/young person has special needs they can be seen until the age of 19 if they remain in education. The team comprises of orthoptists, orthoptic support workers, community ophthalmologists and specialist paediatric optometrists.
The Orthoptic support workers screen the vision of all children attending mainstream lower/primary schools between the age of 4-5 years.
To develop good eyesight, it is important that eye problems are identified and treated at an early age, as defects which may cause squints or strabismus- (where one eye turns in/out), often run in families or are associated with other special needs. The term lazy eye is often used to describe one eye that is not developing good vision, this is also known as Amblyopia.
Following referral, we will offer your child an initial assessment and, together, we will plan your child’s on going eye care. The treatment plan will then be reviewed regularly to improve your child’s eyes as much as possible. After your first visit to see the orthoptist your child will probably have a further appointment to see the ophthalmologist or optometrist. For this next check eye drops may be needed to enlarge the pupils. The ophthalmologist will examine the eyes to ensure they are healthy and prescribe glasses, if required. Each eye is checked to see if it is healthy and to see if your child needs glasses to correct long/short sight or astigmatism, the children’s glasses prescription voucher (HESP) will be issued.
The orthoptist will monitor the child’s eye problem, offering advice and non-surgical treatment, in order to maximise your child’s visual development. Where a child has a condition where the vision cannot be improved the team will work with other professionals to ensure the child visual capabilities are understood. The Community Eye service orthoptists work closely with the ophthalmologists and optometrists in the Community eye Service and at the Moorfields at Bedford Paediatric Eye Clinic.
The Heart Failure Nurse Service aims to enhance the care of patients with a diagnosis of heart failure, improving quality of life and ultimately preventing avoidable admissions to the acute sector. This is achieved by focusing on improving patient self-management, through education and support, also offering educational sessions to staff in primary care.
The service provides both on-going clinical management of the condition by nurse prescribing, self-management advice and support components and actively encourages the involvement of the family and carers. The service enhances primary care through independent nurse prescribing.
The service comprises of Community Matrons with advanced clinical and diagnostic skills who are responsible for the case management of those with complex long term conditions. As well as case management, the Community Matron is responsible for providing treatment for their patients (except when treatment needs to be provided by a specialist provider).
Each patient will have a personalised health plan offered and a Community Matron will oversee the care co-ordination and joined up services across health and social care. Telehealth monitoring is also available for patients with COPD and heart failure.
Patients accepted onto a Community Matron caseload are frequent users of healthcare services and will have a complex, long-term condition. Each Community Matron will be aligned to a Locality Team, and their patient caseload will be taken from the population served by that team and group of GP practices.
The Community Matron service incorporates:
•carrying out advanced clinical assessment;
•the development of care plans;
•the case management and care co-ordination of the patient’s care across various organisational boundaries;
•facilitating self care: educating patients, families and carers on how to move towards self management;
•Medication management including non medical independent prescribing to avert hospital admission;
•managing unplanned episodes within the Community Matron’s case load- assessing, providing / organising treatment at home or appropriate place of care;
•liaising with secondary care to facilitate safe, early discharge of patients on the Community Matron caseload;
•liaising with a range of specialist nurses and other primary, community and social care teams, to ensure quality palliative and end of life care is available to all patients and their carers;
•liaising with GP practices and primary care staff regarding assessments and care plans put in place;
•maintaining effective communication with GPs and practice teams throughout care delivery.;
•telehealth monitoring and triaging.
Occupational Therapists (OT) help children who have difficulties with activities of daily living
skills (eg washing, dressing, eating, toileting; play and leisure; ability to participate in
school lessons or move around the school building).
This may be achieved through individual advice, treatment and recommendation of specialist equipment within the school environment
Contact a Family is a national charity for families with disabled children
We provide information, advice and support. We bring families together so they can support each other. We campaign to improve their circumstances, and for their right to be included and equal in society.
Please click the link to open to the Contact A Family website