Publicly funded NHS & social care services
Publicly funded NHS & social care services

Community Rehabilitation, Reablement and Recovery Beds – Discharge to Assess

Leaflet URN 002

Discharge to Assess

Information for you, your relatives and carers regarding support for you to return home safely.

Why am I moving to a Community Rehabilitation, Reablement and Recovery Bed?

Your medical team feel that you no longer need a hospital stay but would benefit from extra support to get you ready to go home.

It may be your independence has temporarily reduced after a fall, or operation or you are covering after an infection leaving you unable to care for yourself.

We will work with you to help you with your rehabilitation and recovery.

You will be transferred to a community bed where we will help you receive additional support to aid your recovery.

What is different about the Community Beds?

These are beds for short-term stays in your community, particularly after a spell in hospital, and any medical needs you may have can be safely met by a GP in the community. Some of the beds are in a private room with en suite facilities whilst others are in bays with a small number of beds.

How long will I be there?

Rehabilitation and recovery is an individual and personal process. Timescales can vary from person to person.

Your progress will be reviewed regularly and on an individual basis as we know you will be keen to go home and while we want to help you achieve that goal but want to make sure that it is done safely.

What will happen next?

You will be transferred from the hospital to the community bed where you will be welcomed by the staff who will provide the majority of your care and support. They will address any nursing needs you may have.

Our therapy team will work with you to identify the things that you need to be able to do or may need help with before you go home – this may be practising walking up and down stairs, personal care or food preparation.

To get the best possible benefit and to help you get home more quickly, it’s important that you actively participate to the best of your capabilities in your rehabilitation. The nursing team, with the support of GPs when needed, will continue to care for you to make sure you remain as well as possible.

What will happen when I’m ready to go home?

We will discuss and plan this with you, your family and/or carers. Sometimes it takes time to organise as we want to make sure you have all the support you need before returning home. You may need a home assessment or support from other community teams or agencies and we will help to arrange this. Your GP will be informed when you go home.

What do I need to do?

We would like you to agree to take part in a rehabilitation programme. Your family and carers are welcome to be involved too and can be present with you during sessions.

We would like you to be as involved as you can and participate as actively as you are able.

If necessary we will need to visit your home to assess it for hazards which will help us to plan your discharge – we would encourage a member of your family to be present for this. This will be discussed fully with you before it takes place.

Is there a cost?

No – it is NHS care and therefore it is free.

Once you no longer need one of these beds, your ongoing needs will be assessed and addressed.

However, if it is identified that you require on- going care provided through Social Services once you are well enough to go home, you will be financially assessed and may be charged via your local authority.

I have a question not addressed here.

If you, your family or carers have any worries, questions or concerns at any time please do not hesitate to talk to any member of staff as they will be able to help you, or find someone who can, and are available at any time.

If you have a more general question, or would like to give us feedback about your experience, please call the team on 0117 414 1181 – Monday to Saturday – or email sghospitaldischargeteam@nhs.net

And when you’re getting ready to go home, please let a member of the team know if you have any question or worries about issues relating to going home or moving to a different type of care setting.