Our Care Homes Service supports people with mental health problems who live in care homes across Leeds. It is split into two teams.
Firstly, there is a team working with people with longer term mental health needs, including people with dementia. This is to ensure these people receive the same level of service they could expect if they were living at home – where they would be under the care of a Community Mental Health Team for example.
Secondly, there is an intensive care homes team who work with people in the shorter term. They help people living in care homes to avoid hospital admissions and to support faster discharge from hospital back to care homes.
The service aims to be an integral part of how local NHS services support the care home sector to provide person-centred care for the most vulnerable older people, with complex needs and frailty. We want to improve the capability and confidence of the local care home sector to understand and meet emotional, psychological and mental health needs of their residents.
The team also offers short-term, personalised and intensive mental health intervention for newly placed, complex care home residents. This is to support care home staff to manage potentially complex and volatile settling-in periods for residents whose behaviour and individual care needs require specialist skills and practical advice following a stay in hospital or inpatient facility.
We support care homes to respond to mental health and dementia needs where the person, other residents and staff are at risk; including working with colleagues in LYPFT to ensure the quality of response out-of-hours.
We support care home staff to respond to behaviours that they perceive as challenging and develop care plans that promote medical responses only where appropriate.
We develop care plans that offer meaningful activity and occupation and address concerns such as disturbed sleep pattern, unsafe behaviour, aggressive behaviour, withdrawn behaviour and loss of appetite. This includes assessing the extent to which presenting need and behaviour is related to mental health.
We work in partnership with colleagues including GPs, primary and community care staff, social work teams and continuing healthcare to assess needs and develop interventions.
We provide a responsive service for people with complex mental health needs which may include Behavioural and Psychological Symptoms of Dementia (BPSD), to enable discharge from a hospital or inpatient facility to the most appropriate place of residence to meet the individual’s care needs.
We support service users during the transitional period between hospital discharge and settling into a new care home setting.
We provide reassurance to care home providers that complex needs may be a shared responsibility with advice, support and clinical intervention provided in a timely manner.
We prevent avoidable hospital admission by offering intensive support
We consider requests for training of care home staff where there are clear benefits to quality of care.
This section is for health and care professionals looking to make a referral to the Care Homes Team.
All referrals to the Care Homes Team are processed via our Single Point of Access (SPA), where they will be directed to the Care Home Service duty desk for initial triage and allocation.
The duty desk will be staffed seven days a week, 365 days a year. The duty person will telephone the care home staff/referrer to assess the risk and how this is currently being managed following this conversation will form the start of the initial assessment.
Criteria for referrals
People aged 65 and over with mental health and dementia related needs living permanently in care homes (nursing or residential), or when a move to a care home is being planned and prepared from The Mount.
Younger people whose primary diagnosis is Dementia and who are living in a care home.
The service user is registered with a Leeds GP.
The service user has been assessed and subsequently identified as a delayed discharge within LTHT and LYPFT inpatient wards
The service user has been described or perceived as requiring complex care within the care home environment
The service user is an older person with complex dementia and/or mental health needs
If there is potential to avoid admission to The Mount
Who we accept referrals from
Externally (via the SPA) from:
Leeds Teaching Hospitals if deemed as a delayed transfer of care via the LYPFT Care Navigator
GP practices i.e. GPs and other primary care clinicians for example INTs
Care home managers / care home staff in management roles
Community health staff eg. Community matrons, continuing health care team.
Social work staff
Other LYPFT services such as:
The Mount wards/Care Navigator
Intensive Home Treatment Team
Older People’s Services (OPS) Community Mental Health Teams
Crisis Resolution Intensive Support Service (for out of hours referrals)
The Care Home Service works citywide but staff align themselves to our three community localities in order to build relationships with care homes, GP practices and community mental health team colleagues.
The city-wide team operates between 8am and 5pm, five days per week, and between 10am and 6pm on weekends and bank holidays, 365 days per year.
The Intensive Care Home Treatment Team operates from 8am to 8.30pm, Monday to Friday and provides weekend cover, 7 days per week.
In between the hours of 9pm-8am referrals will be managed by our CRISS service and any urgent assessments between these hours carried out by CRISS.
If a health professional has given you a specific phone number to call when you are concerned about your condition or that of a loved one, please continue to use that number.
We recommend the following places where you can find helpful and reliable information with links to further help and support.
MindWell is the single ‘go to’ website for information about mental health in Leeds. It includes advice on practical help with things like housing, benefits or money problems.
The National NHS website
The national NHS website (formerly known as NHS Choices) is the official website of the National Health Service in England. It provides a comprehensive health information service helping you to make the best choices about your health and lifestyle, but also about making the most of NHS and social care services in England.
NHS 111 service
You can call the NHS 111 service 24 hours a day, 365 days a year, if:
you need medical help fast but it’s not a 999 emergency
you think you need to go to A&E or need another NHS urgent care service
you don’t know who to call or you don’t have a GP to call
you need health information or reassurance about what to do next
For less urgent health needs, you should contact your GP or a local pharmacist in the usual way. For immediate, life-threatening emergencies, always call 999.
Please note this is not comprehensive list of services but a few suggestions of how to get started finding help and information.