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This service supports older people to enable a timely return home from the Tunbridge Wells, Maidstone and Kent Community Hospitals and to prevent readmission.

Woman at home drinking tea with carer

About this service

Age UK East Sussex works closely with the Tunbridge Wells, Maidstone and Kent Community Hospitals, to enable older people to be discharged from hospital and return home in a safe and timely manner. The service ensures patients are accompanied home, safely settled in and comfortable.

The service has a particular emphasis on supporting those who live alone, who are carers, or who have had a fall.  Patients are referred from the Hospital Intervention Teams or from wards. Self-referrals may also be accepted with prior agreement from the Hospital Intervention Teams.

A day in the life of a Take Home and Settle worker

“The day normally starts by picking up a patient at one of the community hospitals at about 11am. On average, I take home about four patients a day. Sometimes, I will be asked to drop-off their additional equipment from the hospital and help set it up if the ambulance has already taken them home.

I work very closely with the discharge teams at the hospitals and they are fantastic. They will call me if things go wrong or are delayed and are really supportive.

On arrival at the patient’s home, I will consider their individual circumstances and carry out a risk assessment for their safety, signposting to other services if needed. If a patient comes with the ‘Home First’ home care package, we need to make sure that someone will come and assess them.

Once the patient is settled, I might make them a cup of tea or a snack and will make sure they have basic essentials at home, such as food and heating. If needed, I will help with small household tasks, like changing the bed linin and I often clear out their fridge, put out the rubbish and go and do a small food shop for them.

If they are living by themselves then before I leave I will check whether there is someone that can keep an eye on them - either a member of the family, friends or a neighbour.”

Case Study: Helping Betty return home

Betty, 80, had been in hospital for some time as result of flu and other healthcare issues. Betty is asthmatic and was anxious upon leaving hospital. She needed reassurance and support to help her settle back in at home. Take Home and Settle (THS) was called from the ward to collect her.

Betty lives in a ground floor flat. On arrival home, the THS worker found that her flat was very cold as the heating was not working. Betty naturally became worried and breathless.  THS contacted the landlord of the property, who then gave them a number for the heating company. THS spoke to the heating company, emphasising how this was a priority, and arranged for an engineer to be sent out within two hours.

While waiting for the engineer, THS spent some time talking to Betty. They found out how Betty lives alone after separating from her partner. Betty said that most days she takes the bus into town and heads for the library. She also goes to church on Sundays but that her life is sometimes challenging. THS found some information on lunch clubs, organised by the Salvation Army and the Baptist Church, which Betty found very appealing.

A few hours later, an engineer turned up, fixed Betty’s heating and left their contact details in case she had any further problems.

Betty was very happy with all the support she had been given by THS. Not only had they helped arrange for her heating to be fixed, but she is now looking forward to going out and about, particularly to try out her newly found interest – lunch clubs.

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