The Community Nursing Service provides nursing care for adults who have complex and palliative care needs, in their own homes.
The Community Nursing team supports patients to manage their care at home.
The Community Nursing team aim to provide professional nursing care, advice and support to housebound patients who have acute, chronic and terminal conditions, by agreeing an individualised plan of care with the patient. The goal is to maximise the patient's independence and, wherever possible, prevent inappropriate admission to, and facilitate safe and timely discharge from, hospital.
The team aims to facilitate the co-ordination of care for adults with complex multiple co-morbidities, in order to improve patient outcomes whilst also reducing unnecessary hospital admissions and supporting early discharge.
The service is accessible 365 days a year, 24 hours a day, 7 days a week.
Routine care is provided wherever possible during the day, whereas the evening and night-time service is focused on urgent access to nursing assessment and management, as well as patients requiring routine nursing care out of hours.
Community Nurses work within skill mix teams, and are experienced in the management of:
- Patients with a palliative diagnosis.
- The assessment, diagnosis and treatment of leg ulcers and all aspects of wound care.
- Assessment for Continuing Healthcare when required for housebound patients on their caseload, and liaisons with health and social care to ensure prompt assessment of at-risk patients that require long term nursing or residential care.
- Indwelling catheters, continence issues, gastrostomy tubes and patient-specific clinical procedures.
- Patients with ongoing nursing requirements (and recognising at risk patients through assessment).
- Advice around healthy eating, exercise, smoking, alcohol, mental well-being and falls prevention, etc. and signposting to appropriate services.
The Community Nursing Service is available to patients above 18 years of age who are housebound or their care is more appropriately delivered in the home setting.
Our Complex Care Practitioners will accept referrals for patients over the age of 65 years who have complex health needs and two or more long term conditions.
All patients must consent to accept the service.
Patients can refer themselves to this service, and be referred by: carers and families, GPs and other members of the Primary Healthcare Team, Social Services, NHS and private hospitals, Intermediate Care, Hospice, & Residential Homes.
The Community Nursing Service is provided in patients’ own homes or places of residence, including residential homes and residential beds in nursing homes.