Community Health and Social Care encompasses multi-disciplinary teams including, nursing, occupational therapy, social care, and social work. Their aim is to help people maintain the best possible quality of life and independence in their own home.
Service users and their carers are encouraged to participate in planning, implementation and evaluation of care where appropriate, whilst respecting individual's personal choices.
The community teams provide care and support in the service user's home, enabling people to live in their own homes for as long as possible. They work closely with other Health and Social Care professionals and allied services, to deliver integrated, evidence-based care.
For more information about the Lifeline Telephone Service, Meal on Wheels, or the Voluntary Car Service, please read the drop down menu item below called "Support Services".
Referral Route
The teams have an open referral system. Health and Social Care professionals, potential service users, their relatives or carers and staff from other agencies can make direct contact, with the exception of the Rapid Response Team.
Referrals will be accepted for adults in Guernsey and Alderney provided they fit the criteria outlined in the information below.
For further information please contact Adult Community Services on Tel: 01481 223900
Out of hours, bank holidays and weekends, please contact us through the PEH switchboard Tel: 01481 220000
For information on community based mental health services and adult disability services please see the links at the bottom of the page.
Social Care
- Community Carers
- Community Carers provide support with personal care such as washing, dressing, preparation of drinks and light meals, or prompting of medication. They will provide assistance as necessary but also encourage independence.
- By the provision of social care support in the community, this helps service users who need assistance with the activities of living, to live as independent a life as possible, whilst remaining in their own home. The amount of help required will depend on the needs of the service user, who is encouraged to remain as active as possible. An assessment of care needs will be undertaken by the most relevant professional, and the service user or family member, so that a care plan can then be provided for care staff to follow.
- Home Help Service
- The Home Help service will help with basic domestic and household tasks if the person is unable to access conventional cleaning services due to financial position, frailty or because they require additional considerations that would fall outside of a private cleaner.
- Shopping Service
- The shopping service provides assistance to service users who are, for reasons of ill health or frailty, unable to perform this task themselves. This will include providing shopping service support when the main carer is unable to carry out this activity due to ill health.
- Prescriptions are also collected for service users on the shopping day and personal items that service users may need from St John Healthcare store.
- This service is for people who have no other way of accessing shopping or family/friend support to assist with this.
- Bathing Service
- This service is to assist people to have a bath in their own home. Referrals for specialist equipment may be required, and will be discussed during the assessment process.
- Contact details - Community Services. Tel: 01481 223900
Community Nursing Team
- The Community Nursing Team is made up of Community Specialist Nurses, Staff Nurses and Nursing Assistants/Support Workers. The team delivers individualised assessment and nursing care to service users, and support to carers, in the home environment. The Community Nursing Team operates a 7 day a week, 24 hours a day service.
- To access this service:
- The service user is unable or has difficulty, due to ill health, disability, fragility, to attend a surgery or clinic
- The service user has a health problem, which requires skilled nursing intervention to ensure effective care in the home
- The service user is in the palliative phase of their illness and requires nursing care/advice/support to enable them to remain at home for as long as they, their family or carer so wish, or condition allows
- The service user is already receiving care from other services, which requires community nursing input and a collaborative/shared care basis
- Skilled nursing assistance is needed to support service users/carers using technical equipment to manage their health condition at home
- The service user has continuing health care needs requiring frequent or regular nursing input
- Contact details - Community Services. Tel: 01481 223900
Extra Care Housing
- What is Extra Care Housing?
- Extra Care Housing is designed to help people live as independently as possible, with the confidence of being in a safe environment with a flexible, tailored package of care and support offered by trained staff.
- There are three Extra Care Housing schemes and if you would like more information about a specific scheme or are interested in an informal viewing, you can contact a Care Manager or Duty Manager using the numbers below:
- La Nouvelle Maraitaine, Vale Tel: 223736
- Le Grand Courtil, St Martin Tel: 223998
- Rosaire Court, St Peter Port Tel: 720232
- For more general queries about the extra care housing schemes and further information on how to apply, please contact the Housing Department on 226540 or email HousingAllocations@gov.gg or download our Extra Care Housing leaflet.
Community Specialist Disability Team
- A specialist team of individual professionals providing assessments, advice and intervention for adults with a complex physical, neurological or sensory disability.
- The team consists of:
- Disability Lead Nurse - provides holistic assessment of need, complex case management, specialist advice to individuals with complex health needs and carer assessment and support.
- Specialist Support Worker - provides specialist support to service users under direction of the team. Implements short term interventions to enable and empower independence towards specific agreed goals.
- Specialist Disability Social Worker - provides advice and support, including carer assessment and support, specialist assessment of social needs, including housing, benefits, finances and employment and complex case management.
- Two Clinical Nurse Specialists MS/Parkinson's/MND - provides specialist advice to individuals who have been diagnosed with MS, Parkinson's and MND with regards to their diagnosis, symptom management, medication monitoring and treatment protocols.
- Advanced Disability Occupational Therapist - provides holistic assessment to people with long term, progressive neurological conditions including Motor Neurone Disease, Multiple Sclerosis, Parkinson's, Huntington's and Ataxia to maintain personal independence with daily routines, specialist equipment, major adaptations and environmental advice and recommendations.
- Referrals can be made directly to the Community Referral Coordinator Tel: 01481 223904 or email: hscresource.referralsacs@gov.gg
- Contact details - Community Services. Tel: 01481 223900
Rapid Response and Reablement Team
- The Rapid Response Pathway is multi-disciplinary, aiming to prevent avoidable emergency admissions to hospital, residential and nursing homes. Endeavouring to maintain service users in their own homes during a period of crisis, which can be resolved with additional short-term nursing/social/therapy support. The service is available 7 days per week from 07.30am - 8.30pm, for a maximum of 14 days.
- To access this service:
- The service user and/or primary carer accept the service
- The service user has a medical condition or situation that can be improved by this short-term intervention
- When the service user would otherwise have to be admitted to hospital, nursing or residential home
- When a Carer needs unplanned and rapid support short-term
- The Reablement Pathway may be offered to patients following support from Rapid Response nurses and support workers. The team is staffed by an occupational therapist, physiotherapist, social worker, and a team of support workers.
- You might be referred to Reablement following a stay in hospital, a period of illness at home or following an accident, and you might need time to recover and rehabilitate. The aim of the service is to help you regain your confidence and to live as independently as possible at home.
- The length of time the Reablement service will be involved will be dependent on what you have decided you need to work on, this can be for a few weeks but usually no more than six weeks. As you improve and your needs change, so will the support that you receive at home.
- A plan will be put in place before discharge to discuss any ongoing care needs, and if necessary, you will meet with the Reablement Social Worker to discuss how these needs may be met.
- This is a free service, however you may be recommended to purchase equipment, such as walking aids and home equipment, to assist you to maintain your independence in your home.
- The service is available 7 days per week from 07.30am - 8.30pm for a maximum of six weeks.
- Contact details - Community Services. Tel: 01481 223900
Preventative Care Practitioner
- The Preventative Care Practitioner service offers proactive, advanced clinical assessments which aim to improve the lives of older people, with a holistic approach to care.
- OT style home/environmental and lifestyle assessment
- Paramedic style medical assessment
- Based on recommendations from NICE guidelines (Falls/Older People independence and mental wellbeing), SLAWS 2020 vision, Future vision of the Health and Social Care Services.
- Patients who hit milestone birthdays are sent a letter offering an appointment for the Preventative Care Practitioner to come into their home to undertake an assessment, inclusive of occupational therapy and medical. This service is offered to people who are not already receiving a care package so helps to identify people in the community that currently aren't known, or aren't well known to Community Services, who might need some support. The role addresses patient concerns or areas which can be improved and patients are supported to navigate into the correct community service if necessary, with recommendations around appropriate supportive equipment and available support from charities.
- Contact details - Community Services. Tel: 01481 223900
Respite Care
- Respite Care is a service that offers carers a break from the ongoing responsibility of caring for an ill, frail or disabled adult who is being looked after at home. This can be a planned break for a carer or can be arranged as a result of an emergency situation.
- Requests for respite care can be accepted from various sources, including:
- Yourself
- A relative
- GP
- Community Nurse
- Mental Health Services
- If a referral has been accepted, a full assessment of a person's care needs will be undertaken by a health and social care professional. There is respite provision at the following settings, subject to availability and individual care needs:
- La Nouvelle Maraitaine and Rosaire Court extra-care facilities
- Private nursing and residential homes
- Corbiere Ward, Oberlands Centre
- Respite breaks are funded through the Long-term Care Benefit. To be eligible to claim this, the person requiring care must:
- Have been assessed as being in need of care which could be provided in a private residential care or private nursing home
- Be in possession of a valid Needs Assessment Panel Certificate issued by HSC, which will need to be renewed every 12 months.
- Have an allocated bed in a home (a certificate from the Needs Assessment Panel is not a guarantee of a bed).
- Have at any time, lived in Guernsey or Alderney for a continuous period of 5 years (if you have not, you will not be entitled to claim Long-term care benefit and:
- Have lived in Guernsey or Alderney for at least 12 months, immediately prior to claiming Long-term Care Benefit.
- Social Security will normally pay for up to 4 weeks respite care a year. However, there may be an additional daily charge made by some of the private homes. This will be a private agreement between the customer and the provider.
- Contact details - Community Services. Tel: 01481 223900
Respite at Home - Sitting Service
- The Respite at Home Sitting Service is available for informal carers if you need a break from caring and you are unable at any time to leave the person that you care for. This can give you the opportunity to do some of the things you cannot do whilst you are caring. The Sitting Service does not provide cover for 24 hour private care.
- Requests for the Sitting Service can be accepted from the same sources as Respite Care. i.e.
- Yourself
- A relative
- GP
- Adult Community Services
- Mental Health Services
- When a request for a sitter is received, a Health or Social Care professional may arrange to visit you to make an assessment of care needs. A recommendation will be made regarding the level of care required and a support worker will be allocated to you.
- You may be in need of a regular weekly break, or a much needed rest to catch up on some sleep. An agreement will be made with the co-ordinator but the normal weekly allowance for sitting is four hours day time care or a maximum of two nights a week as assessed by a professional. We try to base sitting hours around care needs and on occasion may be flexible. It may not always be possible to provide the day or time requested but we will do our best to find a suitable alternative.
- Sitting may also be arranged on an ad-hoc basis to allow the carer to attend appointments etc.
- There is no charge for the Sitting Service.
- Contact details - Community Services. Tel: 01481 223900
Social Work Team
- Anyone can ask for help from Social Services at any time in their lives, although it may be necessary for people with mental ill health/physical, sensory or learning disability to be referred onto a specialist team. The Social Workers also provide support to the Princess Elizabeth Hospital and respite co-ordination for service users.
- Although professionals would like to respond to everyone who asks for guidance, there are guidelines about how quickly people can be seen and the types of support which may be available. These guidelines are not discriminatory and apply to everyone, based on people's needs.
- Referrals will be screened for/from any consenting adult and either signposted for advice or information to the relevant professional or allocated for assessment of a social need. This may be for reasons of illness, frailty, vulnerability, social isolation, access to respite or long term care or financial concerns.
- Contact details - Community Services. Tel: 01481 223900
Support Services
- Lifeline Telephone System
- The Lifeline telephone system enables help to be summoned in an emergency 24 hours a day by simply pressing a button on a telephone or on a pendant which is worn by the user. Pressing the button alerts the control station at the PEH who can try to gauge what the issue is and contact a named person if help is required. If no named supports can be contacted the emergency services can be summoned. The application for the service can be made via your health or social care professional e.g. GP, Social Worker or Supported Living Support Worker. A line payment is charged for the service which is arranged via Sure Ltd.
- There are no age restrictions and the system is available to residents of Guernsey, Alderney and Sark.
- If there is a fault with a Lifeline system, please contact Sure on 01481700700 and they will register this as an urgent fault for repair as soon as possible.
- Voluntary Car Service
- This service provides transport for service users to hospital or necessary health related appointments.
- This service caters for service users who have no available relatives or for other reasons are unable to use public transport or provide other means of transport. Referrals should be made by a Health & Social Care Professional or GP surgery. Further information can be accessed through Health Information Exchange Guernsey: http://www.information-exchange.org/
- Community Services Support Team
- This service assists people to live in their own homes by short term loan provision of medical equipment (upon clinician referral) The service also takes on the fitting of key safes and handrails. (This service may incur a nominal charge; the service user will pay for the materials used or goods fitted, on top of the nominal charge). This service is available to adults who, for a variety of reasons including mobility difficulties, cost etc. cannot access other maintenance/handyperson services and where there is no other available option or family/friend support available.
- Meals on Wheels
- This service delivers cooked meals to those who need and request it. This service is provided by the Guernsey Voluntary Services (GVS) for a nominal charge. The service is available 6 days a week - Monday to Saturday. To find out more about the service please visit: Meals on Wheels | GVS
- To receive Meals on Wheels a person must be referred to the GVS by a doctor or other medical professional, and the facility is available to all the housebound who need it, not just the elderly.
Community Urology/Continence Service
- This service provides assessment, support and advice to those with urology or continence issues. The team consists of two clinical nurse specialists who work closely with the consultant urologist.
- You may be referred to this service by your G.P, other health professional, or alternatively you may self-refer. Following your referral we will assess your needs and offer you an appointment, where a more in depth assessment may be undertaken.
- Contact details - Princess Elizabeth Hospital, Telephone: 01481 220000 ext: 25449.
Colorectal / Stoma Service
- The Colorectal and Stoma Care Service is in place to care for patients undergoing major bowel surgery which can include formation of a stoma. We also provide support for patients who have a bowel cancer diagnosis from the start of their treatment pathway. The team consists of three clinical nurse specialists who work closely with the consultant surgeons and medical oncologists to support patients.
- Contact details - Princess Elizabeth Hospital, Telephone: 01481 220000 ext: 25452
Tissue Viability and Lymphoedema Service
- This service provides clinical assessment, advice and guidance to those with complex tissue viability and lymphoedema care needs in the community or acute settings.
- The team consists of three tissue viability clinical nurse specialists, two of which also specialise in lymphoedema.
- You may be referred to this service through your GP, or other allied health professionals, you can also self-refer, but we will ask for further medical history from your G.P.
- Contact details - Community Services, Telephone: 01481 223900 and ask for Tissue Viability or Lymphoedema Specialist Nurses.
Specialist Palliative Care Team
- Palliative care is an approach which improves the quality of life for patients and their families facing life-threatening illness, through the prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems.
- The team consists of: a team of Clinical Nurse Specialists, a Palliative Care Social Worker and two Associate Specialist Doctors in Palliative Care.
- The team are supported by various other health care professionals including; dieticians, physiotherapists, community services and other specialist nurses.
- How can they help you?
- Pain control - we aim to treat all aspects of pain, including pain caused by any previous underlying illness.
- Symptom control - we aim to treat the majority of symptoms which occur throughout the illness.
- Provide psychological and emotional support - to patients and their families.
- End of Life Care - supporting people to prepare for the end of their lives through advance care planning and crisis interventions
- Referrals Patients are referred to the Specialist Palliative Care Team by GP's hospital staff, Social Workers and other agencies. We also accept self-referrals, although we may need to consult with your Doctor before making arrangements to visit you.
The family of a person with a life-limiting illness can self-refer even if their relative is not on our caseload. We can offer emotional support and talk in general terms about illnesses and treatments but are unable to talk specifically about their relative's condition.- Contact details - Community Services, Telephone: 01481 223900 and ask for the Referrals Coordinator.
The Admiral Nurse Service for families who care for persons living with dementia
- Dementia is a life limiting, progressive, neurodegenerative disease, for which there is no cure. It is one of the major health problems facing health and social care services.
- The unique dementia expertise and experience an Admiral Nurse brings is a lifeline - it helps families live more positively with dementia in the present, and face the challenges of tomorrow with more confidence and less fear. This short video shows what Admiral Nurses do:
- How can an Admiral Nurse help me?
- If communication gets hard, we're on hand with skills and techniques to help you stay connected to the person you love.
- If someone with dementia is showing signs of fear or distress, we'll work with you to find the best ways of preventing or managing this.
- If your family is struggling to cope, we will help you get the best possible additional care and support for your loved one.
- If you have questions you can't get answered we'll take the time to really understand the problem and give you the expert support you need to tackle it.
- Admiral Nurse Support
- Admiral Nurses work with people with dementia, carers and relatives across Guernsey,
- We provide one-to-one support, expert guidance and practical solutions to help you and your loved one. This can be done via telephone, face to face visits and Admiral Nurse Clinics.
- Who can refer?
- Referrals can come from GPs, other health professionals or from the carer / relative themselves.
- To access the Admiral Nurse Service, at least ONE of the following 3 criteria must be met:
- The person living with dementia has a known or suspected dementia diagnosis
- The carer of the person with dementia has unresolved, complex needs (psychological, social, spiritual, physical nature) which cannot be met by the current care team;
- The carer of the person with dementia requires support which cannot be met by the current care team.
- How to refer?
- In the first instance please telephone the Admiral Nurse Service at Community Services on 01481 223900.
- For Healthcare professionals and GP's please use the referral forms.
- Discharge
- The Admiral Nurse Service supports people through key transition points on the dementia journey. Once you feel able to cope with your caring role again, we will discharge you from our service. If your needs change in the future, you can always re-refer yourself back into the Admiral Nurse Service.
- To re-refer, please ring 01481 223904 or email: Admiral.nurse@gov.gg
- Hours of opening
- The Admiral Nurse Service is open Monday to Friday, 9am - 5pm, (excluding Bank holidays)
- If you need to speak to someone outside of these times, please ring the Admiral Nurse UK Dementia helpline 0800 888 6678 (Freephone) or email helpline@dementiauk.org
FAQs
- Am I entitled to an assessment of my needs?
- Adults residing in Guernsey and Alderney are entitled to an assessment of their health and social care needs by a qualified professional. Carers are entitled to an assessment in their own right.
- What if my needs change?
- People can request a review of their care plan undertaken by the allocated lead professional if their needs change or if they wish to request longer care hours/anticipate future care needs. Contingency plans are discussed at assessment and identified within the persons individual support plan.
- What if I wish to stop a service?
- In order to stop a community service that you may be receiving, you must contact the main hospital switch on 01481 223900. Clients are given direct line numbers to the admin office depending on which GP surgery team they are aligned to.
- What if I go into hospital or respite care?
- If you go into hospital or respite care for just a few days care packages will be reinstated on your return home. If a person needs to be reassessed following admission as their existing care package no longer meets their needs, then a new care package will need to be organised and set up accordingly and there may be a wait particularly if a complex care package needs organising.
