Roles and Responsibilities FINAL

Roles and responsibilities for discharge planning
Multi-disciplinary Team MDT. This can refer to:

 the hospital teams involved in the care of the child and who will be involved in any
discharge planning eg hospital therapist, pharmacist, doctors and nurses-
 and the wider discharge MDT which must also include the community based
professionals involved in supporting the family and the child’s ongoing care and
welfare.
Lead professional. The individual based in the community setting who takes the lead in
ensuring the child’s care is well coordinated, the key agencies are involved and contributing
and the child and families wishes are considered. The lead professional will be the person
most appropriate for that child and family so could for example be, the social worker if
involved, GP or children’s community nurse.
Acute Trust/Hospitals
Medical Teams. It is the responsibility of the medical consultant to deem the child or young
person medically fit for discharge. It is their responsibility to ensure this is clearly
documented in the child’s medical notes, and that it is accessible by the entire
multidisciplinary team. The medical team must also prescribe take away medicine (TTA’s)
when patients are nearing their EDD and ensure an accurate and up to date discharge
summary is completed
Ward/Department Manager. Responsible for ensuring the policy is implemented and the
systems and procedures are in place to allow for effective discharge planning. They must
also ensure communication with the patient and their parent/carer regarding the process and
EDD
Registered Ward Nurses. Responsible for early assessment of the need for discharge
planning and implementation of the discharge guidance. They must coordinate the discharge
process and act proactively. They must arrange MDT meetings and ensure actions are
followed up
Community Based Services
Children’s Social Work Teams. Play a key role in assisting, supporting and promoting the
welfare and rights of the child and family. This includes safeguarding assessments; liaison
assessments of the child/family’s needs eg housing referrals adaptations or equipment;
organising and coordinating packages of support once the child is discharged, for example
education support, home care.
Children’s Community Nursing Teams. Provide a range of services to support children

with acute and complex care needs. These children that meet service criteria require skilled
nursing intervention and technical support or advice. The nursing team conducts visits at the
patient’s home, schools, hospitals and community settings.
Children and Adolescent Mental Health Services. CAMHS offers assessment and help to
children, young people and their families with significant emotional, behavioural and mental
health difficulties. The service has specialist clinics that provide support for eating disorders,
self harming behaviours, psychosis, ADHD assessment (all ages) and ASD assessments for
over 13’, crisis care out of hours.
Children’s hospice. Children hospices provide clinical care, short breaks and other
residential services to children and young people aged 0-18 years of age who have life-
limiting, life-threating or complex health conditions and meet the health criteria to be eligible
to use the service. Services are there to support the whole family, from residential clinical
care, to music therapy to enable a child with sensory needs to communicate through sound,
to end of life care with pre and post bereavement support for all the family. Hospices can
also support local professionals with discharge home for end of life care. NEL has two
children’s hospices -Richard House and Haven House
Health visiting and school nursing services. These services are universal public health
services for all children and families and deliver the Healthy Child Programme (HCP). Health
Visitors focus on pre-school aged children providing health interventions, advice and support
during pregnancy, after birth and up until the child is age 5. Specialist health visitors
support families with children with medical needs, physical and/or learning disability.
School nurses provide the HCP to schools and will advise schools on care plans for children
with additional long term medical needs such as asthma, epilepsy, diabetes. Specialist
school nurses support mainstream and special schools on any nursing needs of children
with complex health needs whilst they are in school.
Continuing care. This service is responsible for the assessment, planning, co-ordination
and provision of packages of care for children who meet the continuing care criteria.
Completion of relevant paperwork based on national guidance and presentation of
assessment at appropriate panels in the child’s responsible borough. Liaison with children’s
social care teams to develop joined up assessments and package of care for children.
Includes in house Health Care Support Workers (HCSW) who deliver care within the home
setting or management and liaison with external care providers who deliver managed
packages of care.
Children’s Community Therapists
Physiotherapy. Children Physiotherapy addresses the needs of children and young people
whose gross motor or musculoskeletal development and functioning is being impaired by a
wide range of conditions by providing specialist physical or neuro-developmental
assessment, establishing a clinical diagnosis and providing specific treatment, management
advice and provision of specialist equipment.
Speech and Language Therapy. Children Speech and Language Therapy is a specialist
service for children that assesses and advises on the management of communication and
swallowing disorders and associated difficulties in a range of community and acute settings,
children’s centre’s and schools.
Occupational Therapy. Children’s Occupational therapy is particularly targeted at helping
those with physical or learning disability to develop independence in a range of daily
activities and practical tasks to ensure they can deliver to their full potential. This may
include self-care or participating in education and leisure activities and assistance with
specialist equipment.
Commissioning
Clinical Commissioning Group (CCG) - Children’s Commissioners. Work in partnership

with community and local health stakeholders to understand local health needs in order to
commission and support delivery of high quality services which meet the needs of the local
population. The CCG can also advise on how to complain about or compliment an NHS
service. Responsible for agreeing packages of care for children, including joint packages
with the Local Authority.
Care Education and Treatment Reviews. CETR is a multi agency meeting intended to
support children, young people and adults with a learning disability and/or autism who
display behaviour that could be described as challenging, including those with a mental
health condition. A CETR can be held for a child or young person who is currently in
hospital, to prevent unnecessary admissions into hospital and where people do need to go
into hospital to ensure clearly specified treatment outcomes and a discharge plan. The
family, service or a clinician can request that a CETR takes place if they think the young
person is at risk of admission.

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Roles and responsibilities for discharge planning

Multi-disciplinary Team MDT. This can refer to:

Community Based Services

Children’s Community Nursing Teams. Provide a range of services to support children

Children’s Community Therapists

Clinical Commissioning Group (CCG) - Children’s Commissioners. Work in partnership

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