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Community and mental health services for Southampton, Portsmouth and parts of Hampshire and the Isle of Wight.


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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.

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.


  • Identifying patients with long term conditions and co-morbidities in order to manage the disease process


  • act as link to other services such as Specialist Palliative care, Tissue viability, Diabetes, Falls Prevention and Mental Health

Contact Information

Care Home Team

0300 300 2012

023 92 340240

Civic Offices, 3rd Floor, 1 Guildhall Square, Portsmouth, PO1 2GJ

Opening hours

  • Monday: 8:30 am - 5:00 pm
  • Tuesday: 8:30 am - 5:00 pm
  • Wednesday: 8:30 am - 5:00 pm
  • Thursday: 8:30 am - 5:00 pm
  • Friday: 8:30 am - 5:00 pm

Patient Advice and Liaison Service (PALS)

Please visit our services page for specific services and contact details. Alternatively, contact our Patient Advice and Liaison Service by emailing or calling the number below. You can also give us feedback, make a complaint or share a compliment.

0800 013 2319

*Lines are open Monday to Friday 10am – 4pm.

The Freedom of Information (FOI) Act was passed on 30 November 2000. It gives a general right of access to all types of recorded information held by public authorities, with full access granted in January 2005.

The Act sets out exemptions to that right and places certain obligations on public authorities.


Phone: 0300 123 3919

*Subject to any exemptions which apply, we are obliged to provide the information requested please note that requests for Personal Information is not covered under this Act and should be applied for through the Data Protection Act 1998.

Our administrative and managerial centre is based in Southampton.

While our services can be found around various NHS locations in Southampton and Portsmouth (and surrounding districts), our administrative and managerial centre is based in Southampton at:

Highpoint Venue
Bursledon Road
SO19 8BR

If you require a printable version of how to find us including bus times, car access and bike info please download our leaflet. (Copyright of Highpoint Venue).

Central office phone: 0300 123 3390

*Lines open Monday to Friday 9am to 5pm.

If you are a journalist with a media enquiry, please contact the Communications Team at:

0300 123 4156 or 02381 031076

The Communications Office is open Monday to Friday 9am to 5pm.