Community services for care homes

Dementia Matrons (SCFT)

The Dementia Matrons sit within the Rapid Assessment and Intervention Team (RAIT) and are focused on helping to reduce avoidable admissions to hospital.

The Dementia Matrons primarily work closely with care homes and care homes with nursing to support patients with either a confirmed diagnosis of dementia or those who present with dementia like symptoms.

They will provide expert support to improve care planning and delivery, provide information and training and will also liaise with other appropriate support services, including dementia services, to ensure there is a coordinated plan in place.

As well as dealing with patients in an acute episode the Dementia Matrons will also work proactively with homes to provide training and information to help improve patient care and reduce the incidence of acute episodes.

The Dementia Matrons will be happy to respond to requests for help but will also contact homes periodically to promote the service and build relationships ahead of when they are needed.

Referral pathway

Referrals can be made via:

Proactive Care (SCFT)

Proactive Care is a multi-disciplinary team (MDT) approach to case management which seeks not only to ensure that planned care is well coordinated and comprehensive but that predictable risks associated with the patient’s wellbeing are identified and planned for. The improved patient experience will include the reduction of unplanned admissions.

The MDT consists of community nursing, social workers, OTs, Physios, Community Pharmacists, Mental Health Nurses and support workers as well as primary care colleagues including the GP.

Patients who are frail or otherwise at risk of deteriorating care and who would benefit from a MDT approach to care planning and delivery can be referred to the Proactive Care Team via OneCall (see below).

Referral pathway

Speech and Language Therapy (SCFT)

Support available includes:

  • Communication or eating and swallowing problems following neurological impairments and degenerative conditions, including stroke, head injury, Parkinson's disease and dementia
  • Head, neck or throat cancer
  • Voice problems
  • Stammering

Referral pathway

Referrals can be made via:

  • Care home staff via post, phone or fax to details below
  • Any other health care professional via post, phone or fax to details below.

SALT service

Please complete a referral form.