West Suffolk Hospital is part of West Suffolk NHS Foundation Trust, which provides both hospital and community services across West Suffolk. That gives its discharge arrangements a particularly joined-up structure, with community teams able to take over support when someone leaves hospital.
For people leaving hospital on Pathway 1, the aim is to get them home once they are medically stable and assess and arrange the support they need in their own home. It means several different professionals or services may become involved during the first days and weeks at home, depending on the person's needs. Therapists, reablement and community nursing each have their own role, and other services may also become involved as the person's long-term needs are established.
This guide follows that process from the ward through to the first days and weeks at home, and explains exactly where A Class Care fits alongside NHS and community services.
On the Ward: What a Pathway 1 Discharge Means at West Suffolk
A Pathway 1 discharge at West Suffolk Hospital means that a person can return home once they are medically ready to leave acute care. Any immediate support is arranged before discharge, whilst further assessment of their longer term needs takes place at home rather than in hospital.
Pathway 1 as a different way of working for health and social care professionals. The key principle is that discharge is based on whether the person still needs an acute hospital bed, rather than waiting until every aspect of their longer-term care has been decided. It is the first of Suffolk's three discharge pathways and is used for people who are expected to return to their own home.
What Happens Before Discharge
The planning involves more than the professionals a family may see on the ward. Depending on the person's needs, this can involve:
- The medical team
- Ward nurses
- Occupational therapy
- Physiotherapy
- Social care
- Reablement
- Discharge coordinators
- Community health teams
- Equipment services
- Independent care providers
They all work together through the transfer of care hub.
The focus is on three things: what the person could do before admission, what they can do now, and what support they are likely to need when they first get home. That final assessment helps determine what needs to be in place for a safe discharge and what the initial care package should look like.
One qualification applies to residents of Cambridgeshire treated at West Suffolk, typically from Newmarket and the villages towards Cambridge. For them the onward social care is arranged by Cambridgeshire's Transfer of Care Team rather than Suffolk's, because the council for the area where the person lives holds the case whichever hospital they are in.
The First Hours at Home: Who Arrives and Why it is Quick
Under Pathway 1, the person’s assessment continues at home from day one of discharge. Community health and Home First teams become involved quickly after discharge, assessing how the person manages in their own surroundings and identifying what support, equipment or reablement is needed. West Suffolk’s Pathway 1 model is specifically designed around assessment in the home rather than keeping someone in hospital whilst every longer-term need is worked out.
That first assessment can settle practical questions that are difficult to answer accurately on a hospital ward: can the person manage the step at the back door, get safely from their own armchair, use the bathroom or move around their home with the equipment available? The answers help determine what support is needed next.
Someone should be at home for the initial visit where the service has arranged one. The person should not be left without the support specified in the discharge plan and families should pay close attention to the advice given about equipment, mobility and reablement because it can shape the care that follows.
Leaving the hospital
For transport, the arrangements depend on eligibility and the person’s circumstances. Where a family member is able to take the person home themselves, this can give them greater control over the timing of the journey. The hospital does offer non-emergency transport which is discussed later in this guide.
Support to Go Home: The Hospital’s Own Bridge When the Care Package is Not Ready
Support to Go Home is a short-term care service at West Suffolk Hospital and runs in partnership with Suffolk County Council. It supports people at home from the day they leave the hospital until their council-funded care package is ready to begin.
Its purpose is to bridge a very specific gap: the person is medically fit to leave hospital, the council has agreed that care should be provided, but the carers who will deliver the longer-term package have not yet started.
What the Service Provides
The team includes an occupational therapist, care coordinator and support workers. Once the person is home, support is practical and focused on helping them manage safely whilst the longer-term arrangement is put in place.
This can include help with washing, dressing and preparing meals, alongside follow-up visits and referrals to other services where needed.
It is a partnership service, combining occupational therapy from the hospital with care provided through the council. This allows the different elements to work together as one short-term service rather than the family having to coordinate separate visits.
Who is Eligible?
The eligibility criteria are quite specific. The person must:
- Be aged 18 or over
- Be registered with a West Suffolk GP
- Have been medically discharged from hospital
- Be waiting for a care package to begin
Where the care package is being funded by the council, Support to go home is free.
The service is intended for people whose care is being arranged through the council. Families who choose to arrange care privately from the outset may not need to use Support to Go Home. Instead, private care can often be arranged more quickly from the initial enquiry, allowing support to start as soon as the person is ready to return home and reducing the need for interim or bridging care.
When Home First Takes Over and Where A Class Care Fits
Home First is Suffolk County Council’s reablement service and at West Suffolk hospital, it can often be a part of the initial support to go home period. Reablement is designed to help a person regain independence and do as much as possible for themselves, rather than simply providing ongoing care on their behalf. It can run for up to six weeks, or until the person’s goals have been met, whichever comes first.
The service itself is part of Suffolk’s wider Home First model, but what is particularly important at West Suffolk is how the different stages can follow one another. A person discharged on Pathway 1 may move through several teams in a relatively short period: first the interim support to go home service, then home first reablement and, where longer term care is still needed, a permanent care provider arranged through the council.
A Class Care fits into this process in two different ways.
Where the family wants private care from the outset, we can provide support alongside the NHS and council discharge arrangements rather than waiting for reablement to finish. This can be particularly useful where the person needs hands on care that goes beyond what reablement is intended to provide, or where the family wants greater continuity from the first day home, such as live-in or overnight care.
Alternatively, where home first establishes that the person will continue to need care after their period of reablement, A Class Care can be considered as the longer-term provider. A council-arranged package can be commissioned from us, subject to assessment and availability.
The key distinction is that Home First is focused on helping the person recover independence, whilst A Class Care provides the ongoing care and practical support they may still need. The two can therefore work alongside each other rather than being competing services.
Planning longer-term care during reablement
Families do not need to wait until the six-week reablement period has finished before thinking about ongoing care. If it is already clear that the person is likely to need substantial support at home, discussions about longer-term care can begin earlier. This helps ensure that short-term reablement and ongoing practical care connect smoothly, without leaving the person or family facing a gap in support.
The Safety Net After Discharge: The Early Intervention Team
The Early Intervention team is West Suffolk’s community service for helping people stay well at home and avoid an unnecessary return to hospital. After discharge, it can provide follow-up, equipment, urgent nursing input and other community support where needed.
It is a multidisciplinary team that includes community nurses, social workers, occupational therapists, physiotherapists, specialist paramedics and reablement support workers. Its work ranges from same-day mobility assessments and equipment provision to urgent nursing care and rapid-response visits.
If you would like to make a referral to the early intervention team or have a query, you can contact them by calling 0300 123 2425 (open 24 hours, 7 days a week).
The Early Intervention Team provides clinical, therapeutic and community support. It is not a substitute for ongoing personal care.
That distinction matters after discharge. The NHS teams can assess, treat, monitor and arrange support, but they do not provide the regular hands-on care that may be needed with washing, dressing, meals, medication prompts, mobility or overnight supervision.
That is where A Class Care Fits in. We can provide the practical, day-to-day care that sits alongside these NHS services, whether that means additional support during recovery, overnight care, or a longer-term package once it is clear that ongoing help is needed.
How Quickly Can A Class Care Start?
Once a person is clinically fit to leave hospital, care from A Class Care can normally begin within 24 hours to three days, depending on the complexity of the package.
A single-carer package built around personal care, medication and meals, using standard equipment, will usually sit at the faster end of that range. A double-handed package requiring specialist equipment and carers with the appropriate competency to use it will usually take longer because the priority is to make sure the care is safe and properly staffed before it begins.
Planning Ahead Can Remove the Gap
Where a family follows the NHS and council route, Support to Go Home can cover the period between discharge and the start of the longer-term care package, so the family does not normally have to arrange private care simply because the permanent package is not ready yet.
Where a family chooses private care from the outset, the process is different. The earlier the assessment is completed, the more that can be prepared before discharge. Staff, equipment and the care plan can be organised in advance, so that when the person is clinically ready to leave the hospital, their private care is ready to start at home rather than having to begin the planning process from scratch after discharge.
Frequently Asked Questions
What is a Pathway 1 discharge?
A pathway 1 discharge means the person can return home once they are medically ready to leave hospital, with immediate support arranged and their longer-term needs assessed at home rather than on the ward.
Who visits in the first hours after discharge?
Under pathway 1, community teams become involved from the start of the person’s time at home. This can include a Community Health therapist and a Home First risk assessor, who assess how the person is managing in their own environment and what support or equipment is needed.
Where the council-funded care package is not yet ready, Support to Go Home can provide interim care whilst that package is being put in place.
Is Support to Go Home the same as Home First?
No they have different roles. Support to Go Home is an interim service for people who are medically ready to leave hospital but are waiting for their longer-term care package to start. It provides short-term practical support at home during that gap.
Home First is Suffolk County Council’s reablement service. Its purpose is to help the person regain independence and do more for themselves. Reablement can run for up to six weeks, or until the person’s goals have been met.
Who should we call if something is wrong in the first week?
The Care Coordination Centre on 0300 123 2425 is staffed 24 hours a day and is the main route for community support when something has changed or there is a concern that is not an emergency. For a medical emergency, you must call 999.
Who deals with a concern about the discharge itself?
For concerns about the discharge process, contact West Suffolk Hospital PALS on 01284 712555 or PALS@wsh.nhs.uk.
PALS is available Monday to Friday, 9am to 12pm and 2pm to 4pm, from the office in the main entrance foyer opposite the information desk.
