The PCN Integrated Care Home Team re a service that provide assessment, guidance and support for both individuals living in a care home, their families and staff.

The team will discuss personal wishes and explore care needs.  This includes decisions regarding future planning and wishes regarding treatment.  The team can offer clinical support, guidance, signposting and referral to other services if appropriate.  The team work very closely with care home staff and other key services within health and social care and the voluntary sector.

Our nurses and paramedic works closely with the GP’s and other medical colleagues and are competent in performing physical health assessment with the aim of diagnosing and prescribing medications if required.

The team also work collaboratively with the PCN Pharmacy Team to ensure there is an integrated approach to medicines management and Personalised Care Planning.

What do they do?

• Undertake regular care home ward rounds for all care homes within the Primary Care Network.
• Provide education for the individuals and the care home staff about conditions and how to recognise and manage symptoms.
• Develops and reviews a Personalised Care Plan with individuals, their relatives and care home staff.
• Liaises with GPs and other health and social care staff to ensure they understand the support an individual needs
• Supports, or makes referrals to any services that may benefit the individual.

What is a Care Plan?

Care Plans are personalised plans developed by the Care Home Nurse and the individual.  Family members and care home staff may also be involved in these discussions.

A Care Plan will contain relevant health information that will help other health professionals to understand individual needs and wishes.

In communicating information through a Care Plan other services are better able to understand and recognise personal health and care needs holistically and assist the individual in meeting these needs.