Working in Community Response

Gracy's Story

Interview with Gracy, Discharge to Assess

Name and title?

Gracy. Senior Community Staff Nurse with the Discharge to Assess team.


How long have you been here for?

I’ve been here for over three and a half years and I really enjoy the role. It was a privilege to be involved with the early stages of the DTA (Discharge to Assess) and to be part of the creation of support workers as new roles.

I was working as a pathway link role nurse between the acute hospitals, which is mainly Trafford and Wythenshawe, just getting them to know what the DTA is and what we support. And we created such a beautiful rapport as they’ve been shadowing us here, so they get the opportunity to know what is out in the community and what the risks are.

This relationship helps the hospital with key information that can help to keep people safe in the community. It all works in the best interest of the patient.

I think that’s what I like about Discharge to Access.  We work together under Community Response and we work in very close relation with the crisis team and home pathway as well.

We can always get additional advice and support to ensure a patient is safe.

Because if a patient comes home, if they’re unwell, say they’re dehydrated, then transport can be delayed. It’s nothing new. People can be reluctant to drink, because they are anxious or worried – especially elderly or frail people.

So, when we go to see them in the house, they may be a bit unwell. Fortunately, the way this service works is that we can get additional advice and support from the crisis team to keep them safe.

Worst-case scenario, they have to go back to hospital or they could be fine in the morning, but people could rapidly deteriorate. So we work in a close collaboration with the crisis and also go over to the home pathway, which is really great.


What is it like being in a community-based setting?

Sometimes we have a very challenging environment. Everybody, every individual is different and they have their own unique perception, and their own lifestyle. So you may come across challenges. Sometimes people are reluctant to accept help and they’re a bit worried about asking for help.

This is a part of the role I really enjoy though. Helping people to engage with the services and encouraging people to accept help when they need it. It’s about letting some people know that this isn’t forever, often just for a short period. Working in close relation with reablement helps with the care course too.


Why do you think people would want to join this service?

From my background as a nurse, I can say that it’s different to see people in a hospital setting because they are in a safe environment. You can get help on the end of the button.

In a community that is not the reality. You have to deal with the situation. So you need to anticipate things ahead and you really need to assess the patient. In a simple way, we are a safety net for people in their homes. Everybody prefers to be in their own homes don’t they? Because for most, it isn’t nice being in the hospital.

It is an interesting challenge for us as professionals, because no hospital has the space to keep everyone there. We have to make a home environment the best place to be and there are great services to assist us, like the TEC (technology assisted care) team for example. It’s great to draw upon knowledge and make people aware that home can be the best place.

Helping people to enjoy their lives — this is why people should join this team. We support students too. Our future is training students to be lead nurses across Manchester.