Older People's Community Services

About the service

Our Care Homes Teams supports people with mental health problems who live in care homes across Leeds.

This service consists of four teams offering care home-based support to older people experiencing complex, severe, and long-term mental health problems including mood disorders, psychosis, and dementia. The four care home teams 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.

What to expect from our service

We work together with service users, carers, and families help them reach their potential, and we support people to enjoy a valued, satisfying, and meaningful life.

The aims of our service are:

  • To offer a full professional assessment of people’s mental health needs
  • To work with service users and carers to provide a detailed care plan and crisis plan
  • To provide a service for people with complex mental health needs, who can be safely supported in their current residence
  • To ensure services are accessible to all sections of the Leeds population within each locality, in line with our principles of equality and diversity
  • To provide a joined up approach to care, working with other mental health, physical health and social care services across Leeds

What to expect

  • 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 across the Trust 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activity and occupation and address concerns such as disturbed sleep pattern, unsafe behaviour, aggressive behaviour, withdrawn behaviour, and loss of appetite.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 can 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 consider requests for training of care home staff where there are clear benefits to quality of care.

How we can help

These are examples of the kinds of things we might do to help:

  • A review of prescriptions and medicines
  • A range of specialist occupational therapy interventions – including improving functional ability and social participation
  • Support with diet and nutrition
  • Physical health support including treating any immediate physical health risks
  • Advice on support to improve lifestyle such as physical and social activity

Referral information

Referral criteria

  • 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, our Inpatient Service.
  • Younger people whose primary diagnosis is Dementia and who are living in a care home.
  • They service user must be registered with a GP in Leeds.
  • The service user has been assessed and subsequently identified as a delayed discharge within Leeds Teaching Hospitals NHS Trust and Leeds and York Partnership NHS Foundation Trust’s 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, our inpatient service.

Who we accept referrals from

Referrals can be made from colleagues external to the Trust including:

  • Leeds Teaching Hospitals if deemed as a delayed transfer of care via the Trust’s Care Navigator.
  • GP Practices, including GPs and other primary care clinicians, for example from Integrated Neighbourhood Teams.
  • Care home managers / care home staff in management roles.
  • Community health staff, for example: community matrons, continuing health care teams.
  • Social work staff

Please download the single point of access form from the referrals the mental health services page.

Our Trust staff can also refer into the service, including:

  • The Mount inpatient wards
  • Intensive Home Treatment Team
  • Older People’s Services (OPS) Community Mental Health Teams
  • Liaison Psychiatry for OPS
  • Memory Services
  • Dementia and Mental Health Liaison Practitioners

Please complete referrals through CareDirector.

How to contact the service

The Care Homes Teams’ operate across Leeds and are aligned to our four Older People’s community localities in order to build relationships with care homes, GP practices, and Community Mental Health Team colleagues.

The Teams operates between 8am and 5pm, Monday to Friday, excluding bank holidays.

Care Home Team South, Southeast Leeds

Aire Court Community Unit
Lingwell Grove
Middleton
Leeds
LS10 4BS
Tel: 0113 8555363 / 0113 8550673

Care Home Team East, Northeast Leeds

North Wing
St Mary’s House
St Martin’s View
Leeds
LS7 3LA
Tel: 0113 8555363 / 0113 8558877

Care Home Team West Leeds

St Mary’s Hospital
Green Hill Road
Leeds
LS12 3QE
Tel: 0113 8555363/ 0113 8550547
Switchboard: 01138555000

Care Home Team North Leeds

Millfield House
Kirk Lane
Yeadon
Leeds
LS19 7LX
Tel: 0113 8555363 / 0113 85 59350

Other advice and support

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
  • The NHS UK website
  • 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.

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Page last updated: 24th Mar 2026 2:53pm