Welcome to the knowledge zone for health professionals. Please click on the tabs below to find referral information and useful resources.
Advanced Care Planning
All residents of care homes in North Shropshire are invited to take part in an advanced care planning process which records their wishes and preferences for care in a Personalised Care and Support Plan. Completing a ReSPECT form is part of a wider advanced care planning process and focuses on the resident’s preferences for care in an emergency.
If a resident lacks mental capacity to carry out advance care planning then discussion with their family, Lasting Power of Attorney (LPA), GP, nurse or social worker can help determine what measures are in their ‘Best Interests’.
Resources
- Advance care planning | Gold Standard Framework | Marie Curie – useful website for families and carers to understand what advanced care planning is.
- Gold Standards Framework | Advance Care Planning – the 5 simple steps to advanced care planning.
- ReSPECT resources | Resuscitation Council UK – link to patient information leaflets explaining the ReSPECT process
- Macmillan Cancer Support | Preferred priorities for care document – Printable PDF that can be used by care home staff to document patients wishes and priorities for care.
- Advance Care Plan Day
Continence
Residents who are experiencing bladder or bowel problems can be referred to the Continence service.
How to refer
The service accepts referrals from GP’s, Nursing and residential home staff, social services and patients themselves. Details are in the link below.
Bladder and bowel continence services | Shropshire Community Health NHS Trust
Dementia
The Dementia Assessment and Support Service (DASS) provides specialist assessment and support for people who are presenting with possible onset of Dementia or who have a diagnosis of Dementia.
Dementia Assessment and Support Service (DASS) (PDF)
How to refer
Referrals for new and existing patients are made via the GP
For residents already known to the service, care home staff may call DASS direct on 0300 303 3426 (9am-5pm)
Resources
District Nursing
District Nursing Role in Residential and Nursing Homes (NE & NW Shropshire)
The District Nursing teams provide nursing support for adults with complex health needs living in residential homes. We do not see patients who are under nursing in the homes, this is because the funding is provided for the patients nursing needs.
Our role includes:
- Wound care including complex wound care.
- Pressure area management and equipment provision.
- Catheter care, TWOCs, bladder washouts and nephrostomy bag changes.
- Continence assessment for conveen or incontinence pads.
- Palliative and end‑of‑life care.
- Support with long‑term condition monitoring.
- Injectable medication administration (Insulin, anticoagulation, B12, hormone injections).
- Fastrack assessments for patients EOL.
- Dopplers and hosiery.
- Bowel care (Digital rectal examination, enema, suppository & manual evacuation).
- Clinical assessments, holistic assessments and ongoing review.
- Collaborative working with the wider MDT to support safe and effective care.
Patients must be registered with one of the local GP surgeries in our catchment area. This helps prevent delays in treatment and avoids issues arising from out‑of‑area referrals.
How to refer
- NE team: Phone 01630 650734 or email shropcom.neidt@nhs.net
- NW team: Phone 01691 663609 or email shropcom.nwosidt@nhs.net
Triage service between 9am – 5pm, 7 days a week. Health professionals can also refer via Single Point of Referral 0333 358 4584 or shropcom.singlepointofreferral@nhs.net.
Information required
- Patient demographics and contact details
- Reason for referral and urgency
- Clinical history and any other relevant information that can assist in patient care
Falls/Mobility
North Shropshire care home residents can receive physiotherapy and occupational therapy from the North East and North West community therapy teams.
Referral criteria
- Falls/reduced mobility
- Equipment and seating advice
- Progression following hospital admission/positioning
- Transition from care home to home
How to refer
Referrals are accepted from care home nurse in charge, GP or other members of the MDT.
Please complete a community referral form (on EMIS) including the following information: Patient details, Reason for contact and desired outcome of therapy, Mobility and transfer status, including history of condition. Forms are triaged so please provide as much detail as possible.
- North East: email form to shropcom.neics@nhs.net or phone the team 01948 509250
- North West: email form to shropcom.nwics@nhs.net or phone the team 01691 663609
Resources: Safe manual handling techniques
- Encourage the resident to use arms to push up rather than pulling up (no under axilla assistance from carers)
- Encourage independent movement rather than dependence on carers
- In-house moving and handling advisor to assess patient in first instance.
Resources: Falls
- An accurate history of the fall is helpful to determine the reasons.
- Check lying/standing or sitting BP if any dizziness or falls on standing or night time falls.
- Home | Falls Assistant Comprehensive toolkit for use by patients, care home staff or family members to check risk of falls and promote exercise and activity.
Medicines
PCN pharmacists working in North Shropshire GP Practices carry out Structured Medication Reviews for care home patients annually. These will be arranged by the pharmacist contacting the care home.
The medicines management team at Shropshire and Telford ICB also support care homes with any issues relating to medication and can provide training on:
- Self-care medicines
- Medicines Management in Care
- Error Workshop
- Care Home Medicines Ordering Cycle
- Personalised Medication
The team have also produced a self-audit tool for care home settings which aims to support care settings to assess their own standards in line with the regulations and contractual requirements.
Please contact stw.carehomeenquiries@nhs.net for more information.
Resources
Clicking on the Care Settings tab in the link below brings up all the prescribing policies relevant to care homes, including homely remedies guidance.
Mental Health
Midlands Partnership Foundation Trust (MPFT) provides community mental health services via the North Shropshire Community Mental health service.
How to refer
Referrals can be made by GPs, Care Home staff or residents themselves via the Access team: 0808 196 4501 or email access.shropshire@mpft.nhs.uk.
Nutrition
Think Food First
Think Food Approach in Care Homes | A practical guide for the treatment of malnutrition (PDF)
Think Food First resource is a comprehensive local guideline for the recognition and management of malnutrition in care homes, using MUST score to stratify risk and a food fortification approach combined with oral nutritional supplements when appropriate. The guideline also sets out when and how to refer for Dietician input.
Managing Malnutrition
Managing Malnutrition | Care Homes | Making Malnutrition Matter
The Managing Malnutrition website provides information leaflets for patients and relatives, a downloadable MUST score poster, Top Tips for care homes on identifying and managing malnutrition.
Resources specific to patients with Dementia
The Eating and Drinking Well with Dementia Toolkit | Bournemouth University
Resources for Care home residents at End of Life
- Marie Curie | Eating-Drinking-Dementia – Marie Curie resource aimed at patients/relatives
- Hydration and nutrition | Information for professionals | Marie Curie
- BDA | End-of-life-nutrition (PDF) – simple and clear information
Training resources for Care Home managers and staff
Swallowing
Residents who are experiencing difficulties with eating, drinking and swallowing may need to be assessed by the speech and language team. However please check the guidance below prior to a referral
How to refer
Nursing homes can refer directly after following the safe swallowing guidelines.
Residential homes can discuss concerns with the GP, after following the safe swallowing guidelines. GP’s can then make a referral if appropriate.
Dysphagia Resources
Communication Resources
Urgent Care
In an emergency dial 999.
For urgent care in core hours (8am – 6.30pm) contact residents GP surgery, 111, or Urgent Community Response team.
For urgent care out of core hours contact 111 or Urgent Community Response team (8am – 11pm).
Urgent Community Response
The Urgent Community Response (UCR) service provides a 2-hour response across Shropshire, Telford and Wrekin. It operates 7 days a week, 365 days a year, including bank holidays, from 8am to midnight (last referral received at 11pm).
The service is designed to deliver a two-hour response to prevent hospital admission in the event of clinical deterioration. The aim is to assess and stabilise patients in their own home/care home when they experience a change in health status affected by a clinical condition such as Falls, Decompensation of Frailty, Reduced Function/Deconditioning, Palliative/End-of-Life Crisis, Urgent Equipment Needs, Confusion/Delirium, Urgent Catheter Care, Urgent Diabetes Support.
How to refer
Referrals are accepted from care home staff, GP’s and NHS 111: 0333 358 458 4, option 1.