About the service
The neighbourhood nursing service is essential in preventing unnecessary admission to hospital. Community matrons provide case management for individuals within community settings who have complex long-term conditions requiring support from both health and social care services. Community matrons are responsible for providing service users with an individualised care management plan which helps them to increase their awareness and manage their condition.
District nurses use their skills, knowledge and experience to assess when home-based treatment is the best option for nursing a particular patient.
The neighbourhood nursing service offers the following planned, individualised and patient-centred care:
- Complex long-term conditions management
- Case management
- Assessment and management of complex, chronic and acute nursing needs
- Wound assessment and management
- Acute and chronic disease management
- Health education and promotion
- Palliative care
- Technical nursing interventions
- Referrals from other areas or other district nurses
In the interest of patient care, neighbourhood nurses will use their clinical skill and judgement, be flexible and work with other disciplines and agencies.
All referrals to the neighbourhood nursing service will be treated as new admissions. This means that patients who may have had the care in the past may not necessarily have the same treatment as before.
After treatment, the neighbourhood nursing team will carry out a full assessment of the patient’s nursing needs to determine if further home visits are required.
Why would someone choose the service?
The neighbourhood nursing service is committed to listening to feedback from service users and carers to facilitate change to further improve the way in which the teams work. The service undertakes patient satisfaction surveys every six months that have shown:
- 98% of people felt more able to cope with their medical condition after seeing a district nurse
- 100% felt their privacy and dignity were maintained at all times
- 84 % scored the service as excellent with the remaining 16% scoring it as good.
Staff you may meet
- Administrative staff provide essential support to doctors, nurses and other healthcare professionals. This can be in a variety of different settings, with administrators working as a receptionist in a clinic or a clerk on a ward. They may also be working closely with a consultant as a medical secretary.
- A care navigator provides advice and support to individuals their families or carers during their care. They often make home visits and support hospital discharges. Care navigators can also signpost and refer individuals to the appropriate services or help arrange care based on the individual’s needs.
- Dietitians use the science of food to help people to make good choices about food and lifestyle. Nutrition is an important part of recovery and wellbeing. All service users admitted to a Trust ward have their nutritional state assessed.
- There are more than 60 different specialities that doctors work within the NHS. Each is unique but there are many characteristics which are common. Roles range from working in a hospital to being based in the community as a GP.
- Nurses who choose to specialise in the mental health branch of nursing work with GPs, psychiatrists, psychologists, and others, to help care for patients. Increasingly, care is given in the community, with mental health nurses visiting patients and their families at home, in residential centres, in prisons or in specialist clinics or units.
- Occupational therapy is the assessment and treatment of physical and psychiatric conditions using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life.
- Physiotherapists help people to improve their range of movement in order to promote health and well being. This can help people to live more independently.
- Social workers help, support and protect people who are facing difficulties in their lives. They help people to take positive steps to overcome problems and improve their lives. This could involve assessing and reviewing a service user’s situation, building relationships with service users and their families and agreeing what practical support someone needs.
- Therapy is a broad term and can range from occupational therapists to behavioural therapists. Our therapists are trained in their specialist area and type of therapy to make sure we can offer the very best care.
Why a professional should choose the service
The neighbourhood nursing service will:
- Provide holistic care for all adults referred to the service, designing and delivering tailored care plans that include health promotion and early prevention
- Work in an integrated and partnership way with primary, secondary, social care and the independent and voluntary sector care
- Enable patients with long-term and degenerative conditions to continue to live as independently as possible in their usual place of residence
- Provide excellent anticipatory care to avoid unnecessary/ unplanned A&E and emergency hospital admissions
- Sensitive and timely identification of the end of life, supporting patients in fulfilling their wish of dying in their preferred place of death, maximising their comfort and wellbeing, and supporting the delivery of choice at end of life.
- Health screening
- Onward referral
- Comprehensive and holistic assessment
- Proactive identification of need and integrated care planning
- Nurse prescribing
- Continuing healthcare assessments
- Wound management and tissue viability
- Prevention and treatment of pressure ulcers
- Vaccination and immunisation for housebound patients
- Continence Management
- Aural Care for housebound patients
- Catheter care
- Medication administration until a Medication Usage Review has taken place
- End of life care
- Support patients managing medical equipment at home
- Identification of carers needs and referral for carer’s assessments
- Effective support for carers
- Education, training, and promotion of self-care to support prevention
- Promotion of health and wellbeing to service users, patients and carers
The main outcomes are to:
- Improve patient health and social care outcomes
- Improve productivity and efficiency within secondary care and community services
- Reduce the length of hospital stay
- Reduce growth in unplanned hospital admissions and re-admissions
- Reduce the number of GP home visits
Referrals accepted from:
A & E, AHPs, Carers/family, CMHTs, Consultants, GP staff, GPs, Health visitors, Hospital staff, Housing associations, Local authority staff, Midwives, Other NHS services, Other Trust services, Patients(self-referral), Police
Access to the community nursing service will be via our community nurse referral centre including referrals from other nursing teams, specialist nurses, general practitioners, acute services, social services and self-referral.
- If you do not meet the referral criteria;
- If you are unsuitable for treatment on clinical grounds;
- If you have not consented to treatment
- If your unreasonable behaviour is deemed unacceptable by the provider or service staff