South Tees Hospitals NHS Foundation Trust has over 200 nurses and matrons out in the community within Hambleton and Richmondshire, Middlesbrough and Redcar and Cleveland.
Alongside the core community nursing service, unplanned care is provided as well as fast response and out of hours services to facilitate early discharge from hospital and to prevent hospital admissions.
Each day our community nurses drive
countless miles and tackle unpredictable weather to look after patients in their own homes.
We hit the road with two of our community nurses who are providing very different services in very different locations.
Rebecca Gowling qualified as a nurse 13 years ago and has been a community nurse in Middlesbrough for eight years.
Rebecca carries out a range of duties including insulin management, general wound care and administration of medications.
When asked what she enjoys about her role she said she feels privileged to go into people’s homes.
“I really enjoy working in the community because you get to meet a lot of people,” she said.
Upon arriving for her shift Rebecca already knows which patients she will be seeing that day as she has allocated her and her colleagues’ caseloads in advance, although things often change as patients are discharged and more calls come through.
She has quite a few diabetes patients to see throughout the day that she must visit at certain times to provide insulin management as well as several meetings to attend.
The first patient of the day though is 66-year-old Marie Fields.
Marie broke her femur in September and had an operation on her femur and hip at The James Cook University Hospital.
Since then, she has been less mobile at home and has experienced water fluid build-up and ulcers. Rebecca is visiting Marie to clean her leg ulcers and change her dressing.
“The community nurses are fantastic, they’ve done well for me, they’ve looked after me properly,” Marie said.
Ali helps keep patients out of hospital
As well as a having a district nursing team in Hambleton and Richmondshire, there is a fast response team for patients who need guidance and support in a crisis situation.
The 24-hour service aims to keep patients at home, preventing unnecessary admission to hospital.
It covers an area of approximately 1,000 square miles, often in some of the most rural areas of the trust’s patch.
Referrals are made from health professionals such as GPs and social workers.
Today we’re on the road with district nurse Ali Cummings and support worker Donna Moore.
Ali has worked in the NHS for 42 years and has been out in the community since 2004.
She joined the fast response team in 2015 and hasn’t looked back since.
Patients cared for in their own homes feel safer, more at ease,” she said.
This morning there is a single team (Ali and Donna) in from 7.45am, two further teams will join them from 2pm before the night-time starts after 9pm.
From 6pm the team pickup NHS 111 calls, palliative calls as well as fast response referrals.
Starting her shift Ali logs onto SystemOne – the electronic patient notes system – and has a handover with the late team to gather her caseload for the day before she hits the road just after 8am.
The majority of her patients this morning are palliative care as she’s helping Herriot Hospice Homecare, a charity based in Northallerton.
End of life patients have multiple specialist teams caring for them, working and liaising together to ensure that there are no gaps in care and that they are all aware of any changes in health, medication and care requirements.
First fast response call of the day
Just after 9am Ali receives a fast response call from a GP referring a patient to the service who needs an end-of-life care package putting in place, the fast response team has a two-hour window to call or visit any patients who are referred.
After visiting a patient who needs their wound dressing changed, Ali receives another call – this time it’s a request for a zimmer frame for someone who has just been discharged following an operation.
Ali quickly drops it off in Richmond before heading back to base.
By now it is 2pm and Ali returns to base, adds her patient notes to SystemOne and hands over to the afternoon teams.