The Trust

Community Nursing

Aims of the service:

We 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

We aim to improve quality of life, maximise independence and, wherever possible, prevent inappropriate admission to and facilitate safe and timely discharge from hospital.

We aim to facilitate the co-ordination of care for adults with complex multiple co-morbidities who are very high intensity service users of health services.

We aim to improve patient outcomes whilst also reducing unnecessary hospital admissions and supporting early discharge.

October 2016 update - services in South Cheshire and Vale Royal

Please note - community health services in the South Cheshire and Vale Royal commissioning areas are now being delivered by Central Cheshire Integrated Care Partnership, which took over the services in October 2016.

Please see this letter for further information.

Our service

The community nursing service is a core service and is the main provider of domiciliary nursing care for adults who have complex and palliative care needs in collaboration with key partners within primary care and social care. The service is delivered across the footprint by East Cheshire NHS Trust.

Community nurses work within skill mix teams in which patients are case managed within a defined co-ordinated caseload by a qualified district nurse at Band 6 or 7 who provide team leadership to support patients in the management of their care at home or a community matron.

District nurses have additional knowledge and skills in the management of patients with a palliative diagnosis, coordinating packages of care and actively participating in multi-agency care planning to meet the preferred priorities of care and all end-of-life pathways.

District nurses have skills in the assessment, diagnosis and treatment of leg ulcers and all aspects of wound care.

District nurses provide assessment for continuing healthcare, when required for housebound patients on their caseload and liaise with health and social care to ensure prompt assessment of at-risk patients that require long term nursing or residential care.

The district nursing service offers opportunistic health promotion at each patient contact to patients and carers in respect of healthy eating, exercise, smoking, alcohol, mental well-being and falls prevention etc. and signpost to appropriate services

The district nursing service also offers up-to-date and evidenced-based care for patients with indwelling catheters, continence issues, gastrostomy tubes and patient specific clinical procedures, review of patients with ongoing nursing requirements and are also responsible for recognising at risk patients through assessment.

Community matrons are clinicians with both advanced clinical skills and case management skills enabling them to care for patients with multiple complex long term conditions, who are at high risk of hospital admissions and readmissions. The application of a holistic, person-centred approach to care, promotes self-care, self-management of long term conditions and facilitates the reduction of crises which lead to hospital admissions. The service delivers prompt assessment, diagnosis and treatment of this group of patients in their home, when they may otherwise have been admitted to hospital.

Who will we see?

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.

The community matron service will accept referrals for patients over the age of 65 years who have complex health needs and with two or more long term conditions.

All patients must consent to accept the service.

Referral route into service

Referrals may be made by the following:-

Patients themselves, carers and families, GPs and other members of the primary healthcare team, social services, NHS and private hospitals, intermediate care, hospice, residential homes.

Location of service delivery

This service will be offered in patients’ own home or place of residence including residential homes and residential beds in nursing homes

Opening times

The service is accessible 365 days a year, 24 hours a day, 7 days a week.

Routine care will be provided wherever possible during the day whereas the evening and night-time service will be more focused on urgent access to nursing assessment and management, as well as patients requiring routine nursing care out of hours.

Our teams are in various bases across the footprint of East Cheshire Trust

Waters Green Team 1 – covers Park Green, Park Lane and Broken Cross practices - 01625 264090 / 01625 264080

Waters Green Team 2 – covers Cumberland House, South Park practices - 01625 501922

Wilmslow – 01625 441196

Handforth – 01625 441995

Alderley Edge – 01625 865639

Poynton – 01625 870693

Bollington – community matrons only – 01625 264080

Riverside, Congleton – 01260 371064

Holmes Chapel – 01477 535014

Knutsford Hospital 01565 757233



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