Care Homes Team

Here’s a summary of what to expect from our team:

• 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activity and occupation and address concerns such as disturbed sleep pattern, unsafe behaviour, aggressive behaviour, withdrawn behaviour and loss of appetite.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)
• Liaison Psychiatry for OPS
• Memory Services
• Dementia and Mental Health Liaison Practitioners

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 website

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.

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.

The Care Homes Team is based at:

The Mount

44 Hyde Terrace

Leeds

LS2 9LN

Telephone: 0113 8555363

Switchboard: 01138555000