The District Nursing Service provides high quality nursing care to individuals in their own homes, residential care environments and in the ambulatory care centres across Somerset. The service works in partnership with patients, their family and carers and other health and social care professionals.
The District Nursing teams are each led by a Team Leader and consist of Community Registered Nurses and Community Health Care Assistants. Across Somerset, the District Nursing teams are available 365 days per year throughout the 24hr period
The District Nursing service will triage referrals from anyone who contacts them, such as patients, relatives, carers and other professionals, such as GP's, hospitals, care homes and social services
The service is available to patients over 18 who are housebound and require nursing care or meet one of the following criteria:
- post-operative patients who are temporarily unable to travel
- patients who require end of life care
- people who are neutropenic and undergoing chemotherapy, radiotherapy or whose health condition would lead to travel or attendance at a clinic being detrimental to their treatment or recovery
- those for whom, in the professional opinion of the District Nurse Team Leader, treatment or care would be appropriate to be carried out in the patient's home
- care that can be provided in one of the ambulatory care centres whose clinical treatments are not provided in the GP practice.
Somerset Partnership NHS Foundation Trust has agreed the following definition of housebound:
“A person who is unable to leave their place of residence without the support of an ambulance or where based on clinical judgement, it is jointly agreed with the GP and District Nurse that the individual’s healthcare needs would be more effectively managed in their home environment as opposed to attending a GP surgery or other community service. This includes service users in residential care but does not include the provision of nursing care for service users in a nursing home”
- Urgent: All urgent referrals will be telephoned and discussed with receiving nurse, clinically triaged within 4 hours of documented receipt of referral.
- Non-urgent will be clinically triaged with access to service within 24-48hours of documented receipt of referral.
- Routine will be clinically triaged with access to service with 1-3 days of documented receipt of referral.
- Post-operative Visit access to service on specified date.
- Timed Visits for specified medication requests only.
A Registered Nurse from the District Nursing team will undertake an initial assessment of the patients' needs through discussion with the patient and with the patients, family or carer. A written record of this assessment and plan of care will be provided in the form of a patient held record and entered onto Somerset Partnership NHS Foundation Trust’s electronic clinical record (RiO). Consent will be obtained to share information with other services.
Principles for Practice
Our principles for practice are to:
- provide high quality culturally sensitive nursing care for people in their own homes, community setting or ambulatory care centre
- promote and maintain independent living
- promote a coordinated approach to hospital discharge
- reduce the incidence/frequency of admission and readmission by supporting and educating both patients and carers to seek early intervention for potentially debilitating conditions
- adopt a public health approach to all areas of practice to reduce ill health and promote healthy lifestyles
- promote an evidence-based approach to clinical activities
- promote user involvement in both service planning and delivery.
Provision of Care
The main focus is to provide nursing care to housebound patients in the home or residential care environment and ambulatory care centres. District Nursing offers the following planned, individualised, patient centred care:
- assessment co-ordination and management of complex, chronic and acute nursing needs
- holistic wound assessment and management
- palliative care for those who are terminally ill and care of the dying
- technical nursing interventions, e.g. syringe drivers, central lines, intravenous drugs, etc.
- bereavement support
- promotion of continence and management of incontinence
- assessment of nursing equipment
- nursing procedures
- care management role in nursing homes.
Patients will be discharged from the service when:
- the treatment is completed
- the patient can self-manage safely
- transferred to another more appropriate service, e.g. Social Services,
- patient moves out of area.
Somerset is divided into nine GP Federations which are indicated by the coloured dots on the map. Somerset Partnership NHS Foundation Trust have been working closely with the nine GP Federations to implement a new Federation based model for the District Nursing Service where District Nursing teams are aligned to each GP Federation.
Each District Nursing Federation has a main hub which is the single point of access for referrals and administration for the Federation. Some Federations will also have smaller offices, 'spokes' to enable the nursing teams to effectively cover the very rural county of Somerset. The locations can be seen on the map and you can find the contact details for the District Nursing Hubs by following the link.
Contact details on the page Hubs and Spokes
The District Nursing Federation HUBs operate from 08:00h to 18:00h Monday to Friday
For Out of Hours (evenings, overnight, weekends and bank holidays) please contact 111