Community Care Home Team

The Portsmouth Care Home Team is based at St Marys Community Health Campus, working with the Care Home providers based in the Portsmouth area.

Our team is made up of:
• Mental Health Nurses
• Registered Nurses
• Occupational Therapists

Alongside our colleagues within the care homes, we provide additional nursing expertise and clinical leadership to support residential and nursing home providers in Portsmouth City to maintain the health of their residents.
This includes the support and assessment of patients, as well as treatment planning, whilst working alongside Urgent Community Response colleagues supporting providers.

Referral criteria

Referral Eligibility

Patients must be registered with a Portsmouth City GP, and be a resident within care homes / nursing homes within the local area to be referred to the Care Home Team.

Referral Process

Providers will refer an individual to our team via Single Point of Access, there are multiple reasons this could happen. Some of the most common reasons for this include:

• Tissue viability
• Mental Health
• Treatment escalation plan
• Occupational Therapy input
• Other appropriate physical health complaints

The Care Home Team will offer a Multi-disciplinary meeting on a 5 week rolling rota. The Multi-disciplinary Team will consist of:

• GP (Portsmouth primary care alliance)
• Registered Nurse / Registered Mental Health Nurse
• Pharmacist (Medicine Optimisation Team)
• A nominated member of the care home staff

Individuals will be identified for the Multi-disciplinary Team 48 hours prior by the care home, with the support from the Care Home Team nurses. This should include any new patients recently admitted or those returning to the home from an admission. An individual will be discharged from our care when the support is no longer is required, as the concern is now manageable or has been resolved.

Health Professional?

Full service description

This service endeavours to provide support to care / nursing home residents to remain in their care / nursing home to avoid their being admitted to hospital unnecessarily. It responds to daily referrals and requests for assessment by care home staff and other professionals through Single Point of Access.

Residents at risk of deterioration are identified through referral from other professionals and also when the care home team are visiting care homes or nursing homes to conduct clinics.

The Care Home Team :-

liaise with members of the multi-disciplinary team to ensure those requiring expert specialist care receive it.
assist in the delivery of that care to deliver the best outcome for the patient.
work to facilitate the early discharge of patients with complex mental health needs from hospital settings
provide follow-up visits following initial assessment are provided as is full support to enable staff to manage residents’ care.
provide a role in reviewing and monitoring the effects of medication.
- Support delivery of sound End of Life care in line with local and national guidance.
Carry out formal teaching, along with other specialist colleagues
Support Advanced Care Planning in conjunction with the patient, their family, the care home staff and other relevant health or social care professionals.
Support provision of sound Dementia care in line with local and national objectives.
Support and encourage staff to be confident in their work and to manage complex patient care
Working with individual patients during a period of acute illness, or with a trauma of some kind. Falls, pressure ulcer, etc.