Our Aims

We are committed to the following goals for care home residents:

• Improving the experience, quality, and safety of care  for residents, their families, and carers.
• Reducing avoidable ambulance journeys, A&E attendances, and emergency admissions to hospital for care home residents. 
• Optimising medication regimes to ensure that residents are on the safest and most effective treatments.
• Supporting more people living in care homes to die in a place of their choosing, in line with their preferences and care plans.

The People We Will Help

Our care home service is available to all individuals living permanently in care homes, including both residential and nursing homes. This includes residents in homes that provide specialist care, such as those supporting individuals with learning disabilities or dementia. However, it does not include people living in secure mental health units.

How We Provide Care

Under the enhanced primary and community care support model, care homes will be aligned with specific GP practices, Primary Care Networks (PCNs), and Integrated Care Boards (ICBs) This alignment enables structured, multidisciplinary, and personalised support across a range of health needs for each resident.

We believe in a holistic approach, addressing both clinical and non-clinical factors that affect the well-being of care home residents. Strong relationships with local voluntary, community, and civic groups are essential to this work, as well as close collaboration with system public health teams.

What We Offer

Through our integrated care home support service, we provide:

• Comprehensive Health Assessments:
  Regular, proactive health checks and assessments to ensure residents’ health is monitored and any concerns are addressed early.
• Multidisciplinary Team (MDT) Reviews:
  Structured care planning with a team of healthcare professionals, including GPs, nurses, pharmacists, and other specialists. This team works together to create and implement personalised care plans for each resident.
• Medication Reviews:
  Regular medication reviews to ensure that all prescriptions are appropriate and effective, reducing the risk of harmful side effects or drug interactions.
• Community pharmacies
• End-of-Life Care Planning:
  Compassionate and personalised end-of-life care planning to ensure that residents can pass away in their place of choice, surrounded by their loved ones, and according to their wishes.
• Emergency Prevention:
  By focusing on preventive care, we aim to reduce unnecessary ambulance trips, A&E visits, and hospital admissions, allowing residents to receive the care they need in a familiar and comfortable environment.