Here you’ll find a variety of resources that can be used to support people living with frailty to maximise and maintain health, wellbeing and independence and prevent unnecessary admissions to hospital.
The following resources are aimed at professionals. For public information, please read and watch the video Staying healthier in older age.
Click on the categories below to access further resources:
Frailty resources: The NHS resources on frailty
End of life care in frailty: Resources from the British Geriatrics Society.
Keeping older people safe and well at home: Aimed at supporting older people to stay well.
Home/Community support: Support available in the community.
Nursing resources: Information from the Royal College of Nursing to support those working with older people
Clinical Frailty Scale (CFS) App: The App for frontline colleagues to download and use to undertake clinical frailty scoring with patients in real time.
Fire & Rescue Service Safe and Well Visits:
• Surrey
Video to watch
Useful links
Please click on the links below for more information:
Keeping active and healthy | The Chartered Society of Physiotherapy
Avoiding trips and falls at home | The Chartered Society of Physiotherapy
Useful links
Click on the links below for more information:
Welcome to Health Innovation Wessex
Nutrition: Older People's Essential Nutrition (OPEN)
Implementing nutrition screening in community care for older people | Bournemouth University
Urgent Community Response Service
If you suddenly become unwell your GP or health or social care professional could refer you to the Urgent Community Response (UCR) service.
The UCR aims to avoid an unplanned hospital stay when you have an urgent healthcare need by supporting you at home.
We can be with you within 2 hours of a referral.
UCR in your home or care home
We can visit you wherever you live, either in your own home or a care home.
We provide assessment and short-term intervention, usually one day. If you need further care, we can refer you to our Virtual Ward or signpost you to other health or social care services. We can also recommend adaptations to your home or request equipment to help you maintain your independence.
If you live in a care home, we will work closely with care home staff until your condition is stable.
You remain under the care of your GP.
Depending on your needs, staff from our team may visit and help you get back to being able to carry out your usual daily tasks.
Specialists that may visit you, could include:
- Nurse and Paramedic Practitioners, to carry out assessments such as blood pressure, temperature and pulse checks
- Health Care Assistants, to take blood or other tests
- Occupational Therapist, to see if you’re able to do everyday tasks, such as washing, dressing and cooking, and whether you need equipment to help you
- Physiotherapists, to look at how you’re walking and getting out of your bed and chair and suggesting exercises to help with your strength and balance
- Therapy Assistants, to complete a home exercise programme with you, or to support you with daily tasks if you live in your own home
- Carers, to assist with daily living tasks such as helping with washing and dressing (this does not include domestic tasks such as shopping or laundry)
- A Geriatrician to review and advise on your medical needs
We may also provide equipment and guide you to other support services if we think it will help you.
When will we contact you
After we have received your referral from your GP, health or care professional, or through NHS111, we aim to at your home within 2 hours.
Your care and support plan
We will find out more about the difficulties you are experiencing and create a care and support plan with you.
We’ll contact your GP to let them know we’re helping you.
Depending on your needs, after you have been seen by the UCR Team you may be discharged or referred for longer term careill
Virtual wards prevent hospital admissions by supporting you in your home or care home if you suddenly become unwell.
Our service gives you the same level of high-quality patient care, with access to all the same investigations and treatment you would receive in hospital, without needing to be admitted.
While you’re Virtual Ward patient, you will be under the care of a consultant geriatrician and can expect to be seen by a healthcare professional in your own home every day.
We will carry out an urgent assessment and put in short-term intervention(s). These can include IV antibiotics and fluids or physiotherapy, including equipment.
You could be under the care of the Virtual Ward for up to 5 days, but this can vary depending on your needs. In most cases you won’t have to go into hospital at all and will be able to remain at home for your treatment.
When your treatment is completed, you will then be discharged back to the care of your GP. We may also refer you to other community services or carer support providers as necessary.
Referrals
The UCR is only available via a referral from your GP, a health care or social care professional, or NHS 111 or 999. They will contact our Integrated Hub which manages all referrals for our community services.
Out of hours, and urgent help
Call NHS 111 if you have any concerns about your health.
Call 999 in an emergency.
We are open every day, including bank holidays, during the times below.
Day of week and time
Monday to Sunday 8am – 8pm.
You can also find more information on the Berkshire Healthcare NHS Foundation Trust website.
If you are a GP, work in a care home, are part of the NHS111 or 999 service, or work as a paramedic or community nurse you can refer to the UCR team.
For patients registered in the South, which covers Surrey Heath, North East Hampshire and Farnham, please call 0300 614 9000.
North which covers Bracknell, Royal Borough of Windsor and Maidenhead and Slough, please call The Hub on 0300 365 1234.
You can also call these numbers to informally discuss a referral or its suitability for the UCR.
Referrals to the UCR can only be made by health or social care professionals. We do not accept patient self-referrals. Please speak to your health or social care professional if you feel the UCR is suitable for your needs and they can refer on your behalf, if appropriate.