Discharge of Leeds Children with Complex Needs - Care Pathway

Publication: 28/02/2007  
Next review: 03/07/2023  
Care Pathway
ID: 1108 
Approved By: Leeds PCT 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Care Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Care Pathway for Discharge of Leeds Children with Complex Needs


The Purpose of this pathway is to facilitate the safe, coordinated and effective discharge of children from hospital to the community.

Discharge planning is the process by which the hospital team considers what support might be required by the patient in the community, refers the patient to these services, and then liaises with these services to manage the patient’s discharge. Poor discharge planning can lead to poor patient outcomes and delayed discharge planning can cause patients to remain in hospital longer than necessary, taking up valuable inpatient beds when they could be more easily and comfortably cared for in the community.

Effective discharge planning is crucial to ensure timely discharge and continuity of care.

Since the introduction of the Care Pathway for Discharge of Leeds Children with Complex Needs, there have been many changes. In 2018, LTHT employed a discharge coordinator who is responsible for coordinating the discharge of children from the hospital to the community. Specialist nurses have also developed care pathways for discharge of children in their area of expertise for example, long term ventilation and tracheostomy pathways. The liaison and communication between community services and the hospital has improved. As a result this care pathway has been refreshed to highlight key principles of the discharge process.

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Care Pathway For Discharge Of Leeds Children With Complex Needs

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Community Support

The following support is available in the community:

Support from Leeds Children’s Social Work Services (LCSWS) including support for care in the home.

For advice and referrals to social care:

Regional Specialist Team Telephone: 0113 5351504
CHAD West North West Team Telephone:

0113 3784068
CHAD South Team Telephone: 0113 3784915
CHAD East North East Telephone: 0113 3785140


Information on Early Help Support


Information on Special Education Needs and Disability (SEND)


Helpline on 0113 3951200 or send an email to: sendiass@leeds.gov.uk

Community Nursing Services

Leeds Children’s Nursing and Butterfly Team
The team provides a service for children with a whole range of nursing needs, from 0-18th birthday and until 19th birthday if they attend a an inclusion school, who are registered with a Leeds GP, or live within the Leeds geographical boundary, but are not registered with a GP.

The team:

  • Provides follow up for children and babies who have had complex or day surgery.
  • Works with other professionals to ensure the needs of the children and families are met.
  • Is predominantly a nursing service and provides advice and support over 7 days with a reduced service at the weekend.
  • Have a play worker and other team members who work with children who have life-limiting/life threatening conditions and their families.

There is an open referral system by a written faxed referral to Fax: 0113 2711638
Contact Details: Telephone: 0113 2761294 (24 hour answer machine)

Leeds Children’s Continuing Care and Health Short Breaks Team
The team provides a package of care to children or young people with multiple, complex and enduring health care needs due to disability, accident, life limiting or sudden illness. The team operates 24 hours a day 365 days a year and also provides palliative and end of life care for children at home. The team consists of a skill mixed team of children’s and learning disability nurses and support staff. The team offers a service to those who meet the health short breaks criteria and those who meet the criteria for continuing care.

Health Short Breaks (Home based and residential including Hannah house).
The service is for children and young people age 0 up to their 18th birthday.
The majority of short breaks allocation will be delivered within the home environment.
The Health Short Breaks Team offers a limited number of hours to children who meet the criteria.

These hours are:
Pre-school (0-4 years): 3 hours per week and 5 hours a fortnight.
School age: 5 hours a fortnight and in addition 3 hours per week in school holidays.
Both elements of the service are provided by a team of carers.

To refer to Children’s Health Short Breaks a child needs:

  • Electronic referral form which includes a nursing assessment.
  • Early help assessment, a child and family assessment or/and Educational health care plan.

Contact Details: Telephone: 0113 2728644 or email community.childrensnursing@nhs.net

Hannah House Health Respite Unit
Hannah House is a purpose built self-contained residential facility providing planned or emergency short break care for children with complex health needs.

Hannah House is located in Rothwell and is accessible to children and young people aged 3–18 years who have been assessed and meet the criteria.
3-5 years can access for day respite and 5 and above for overnight stays. They must be registered with a Leeds GP, or live within the Leeds geographical boundary, but are not registered with a GP.
Hannah House is open 24 hours a day 365 days a year and has a skill mix team.

A charitable donation from a parent (Hannah’s mum) provided the initial funding for the building and Leeds Community Health Care NHS Trust fund the ongoing running costs.

Children’s Continuing Care
Children’s continuing care provides support to the most complex children in Leeds. i.e. children who are ventilated or who require complex nursing interventions and those who require end of life care.
The Children’s Continuing Care Team delivers the package of care that has been agreed by the Children’s Continuing Care Panel.

The assessment and agreement for continuing care is carried out by the Children’s Case Management Service (CCMS) within Leeds CCG. If you think that a child has high level complex health needs you need to contact the CCMS to discuss the case and invite them to the discharge planning meetings.

They can be contacted on:
Fatima Patel : 07702 117331
Office contact: 0113 8431717

Martin House Children’s Hospice
Martin House is a purpose-built, 15-bed hospice for children and young people with life-limiting and life-threatening conditions, between birth and 25 years old. Children do not need a diagnosis to be referred.

Care is divided into two buildings on the same site:

  • Martin House: a nine-bed hospice for babies can children between the ages of birth and 13, where whole families can stay,
  • Whitby Lodge: a six-bed hospice for young people over the age of 13 years.
  • Community care is also offered to families on the caseload.

Martin House cares for children across West, North and East Yorkshire. Referrals can be made by anyone, using the form on the website, or by telephoning the team. The hospice will seek confirmation of the child’s life limiting condition from the professionals involved in their care.

The hospice:

  • Offers a combination of planned short breaks, with three beds reserved for emergency short breaks, symptom control and end of life care. In addition, there are three cool rooms used to care for children and young people after death.
  • Have nurses on duty 24 hours a day, seven days a week.
  • Provides community-based care seven days a week.
  • Has access to a doctor 24 hours a day. The hospice has a range of therapists available, including a clinical psychologist, music therapists, counsellors, artists and musicians.
  • Cares for the whole family – offering stays for families of children up to 13 years in Martin House.
  • Enables young people staying in Whitby Lodge to bring someone with them, usually a friend or sibling.
  • Offers families between 10 and 16 nights of planned care per year, with additional nights for symptom management, as required.

Contact Details: Telephone: 01937 845045

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Record: 1108
Clinical condition:

Discharge of Leeds children with complex needs

Target patient group: Children with complex needs
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Clinical Physiologists
Health Visitors
Primary Care Doctors
Adapted from:

Evidence base

Not supplied

Approved By

Leeds PCT

Document history

LHP version 1.0

Related information

Not supplied