Community Support Team

Our Community Support Team is based at our Tibshelf site but provides support to patients from across our practice area.  It’s purpose is to provide care for patients to avoid unnecessary admissions to hospital and prevent extended lengths of stay, ensuring people can be cared for in the most appropriate setting.

The Community Support Team helps patients:

  • Become more confident in looking after themselves
  • Have a better understanding of their condition(s)
  • Feel less lonely/isolated
  • Have increased involvement in their care and future care planning
  • Access other services, e.g. benefits,  homecare
  • Understand their medicines and the benefits of taking it correctly
  • Have less need to call a doctor when the surgery is closed

Patients are referred into the Community Support Team by other members of staff, hospital staff or adult social care.

Community Support Team Members

All of the of the members of the team have specialist qualifications and training that have enabled them to undertake their role.

Care Coordinator

Karen Gammon works Monday to Friday 8.30am – 4.30pm and oversees all of the administration of the Community Support Team, organising the team meetings, inputting data onto patient records and acting as the central point of liaison between all the team members.  She undertakes work to identify patients at risk of hospital admission and brings this to the attention of the practice team.  The Care Coordinator is also the point of contact for the patient to answer questions, pass on messages or information and help them to access services.

To speak to our Care Coordinator Karen please telephone: 01773 309010

GPs

GPs are there to help with and monitor all of the patients medical needs and provide a medical overview to the team. They give advice on medical care and support to the other members of the team and liaise with the consultants at the hospital as necessary.  The GP liaises with the Care Coordinator regarding patients identified as being at risk of hospital admission and reviews with the team any interventions it is thought may be beneficial.

Community Matron

Liz Millington works similarly to the GP and has advanced training in looking after people with multiple long-term conditions.  She will try to manage the patient’s condition, alongside them, to enable them to remain at home and avoid any unplanned, unnecessary hospital admissions.  The Community Matron will help patients to access appropriate health and social services, as well as prescribing and optimising medications and agreeing care plans.

District Nurses

The District Nurse team work alongside the other members of the Community Support Team in helping to look after housebound patients.  Some of their duties include dressings and pressure ulcers/wound assessments; continence care; taking bloods and monitoring long-term conditions; and they have much involvement in palliative care.  They have links with hospital discharge teams and will help patients to access any specialist services you may require.

Social Worker

The social worker will liaise with members of the Community Support Team and provide information to them on a range of issues impacting on adult care relevant to care planning and supporting individuals.  The Social Worker may undertake an assessment of need, if required, in accordance with self-directed support and the allocation of personal budgets, taking into account individuals’ views and wishes and focusing on individuals’ strengths, abilities and choices and what they wish to achieve.