Community Care Home Team

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