Community Care Home Team Portsmouth

About the service

The Community Care Home Team Portsmouth works with care home providers based in the Portsmouth area.

The team is made up of Mental Health Nurses, Registered Nurses and Occupational Therapists.

Alongside colleagues within care homes, the team provides 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.

What we do

This service endeavours to provide support to care/nursing home residents to remain in their care/nursing home, to avoid them being admitted to hospital unnecessarily. It responds to daily referrals and requests for assessment by care home staff and other professionals through a '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 Community Care Home Team:

• liaises with members of the multi-disciplinary team to ensure those requiring expert specialist care receive it.
• assists in the delivery of that care to deliver the best outcome for the patient.
• works to facilitate the early discharge of patients with complex mental health needs from hospital settings.
• provides follow-up visits, following initial assessment, as well as full support to enable staff to manage residents’ care.
• provides a role in reviewing and monitoring the effects of medication.
• supports delivery of 'End of Life' care in line with local and national guidance.
• carries out formal teaching, along with other specialist colleagues.
• supports Advanced Care Planning in conjunction with the patient, their family, the care home staff and other relevant health or social care professionals.
• supports provision of dementia care in line with local and national objectives.
• supports and encourages staff to be confident in their work and to manage complex patient care.
• works with individual patients during a period of acute illness, or with a trauma of some kind (i.e. falls, pressure ulcers, etc).
• identifies patients with long term conditions and co-morbidities in order to manage the disease process.
• acts as link to other services such as Specialist Palliative Care, Tissue Viability, Diabetes, Falls Prevention and Mental Health.

Accessing the service

Access to the service is via referral only. 

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