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Community Health and Social Care

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Community Health and Social Care is made up of a team of professionals who provide nursing and social support in the homes of adults in Guernsey. Their aim is to help people maintain the best possible quality of life and independence in their own home.

The aim of Community Health and Social Care Services is to support people to live independent, healthy lives. Respect for service user's choice is recognised at all times. Service users and their carers are encouraged to participate in planning, implementation and evaluation of care where appropriate.

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, including end of life care if this is the person's choice. The community teams work closely with other health and social care professionals and allied services, to work towards a seamless and integrated, cost effective and evidence-based service.

For more information about the Lifeline Telephone Service, Meal on Wheels, the Voluntary Car Service, Home Help and Shopping services, 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 223020

*Out of hours, bank holidays and weekends, please contact us on Tel: 01481 220000 [PEH switchboard]*

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.

For information on community based mental health services and adult disability services please see the links at the bottom of the page.

  • Social Care

    • Senior Carers
    • Senior Carers provide support with personal care such as washing, dressing, and assistance at meal times or help prompting medication. They will provide assistance as necessary but also encourage independence.
    • The service user is requiring assistance with personal care e.g. washing, dressing, going to the toilet, catheter care, maintaining nutrition, prompting with medication. By the provision of social care support in the community, home care provision 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 carer. A care plan will then be provided.
  • 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. Telephone contact can be made with a community nurse via the hospital switchboard (01481 220000).
    • 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
  • Rapid Response Team

    • The Rapid Response Team is a multi-disciplinary team 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, for a maximum of 14 days.
    • To access this service:
      • The service user must be assessed by a doctor as being medically stable                      
      • 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
  • Reablement Service

    • Reablement is a new health and social care initiative provided by the States of Guernsey. It is staffed by an occupational therapist, physiotherapist, social worker, nurse and a team of Reablement 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.
  • 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
      • Adult Community 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
    • Social Security will normally pay for up to 4 weeks respite care a year.  In most cases there is no charge for this service.  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.
    • 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, and have a bed in a home (a certificate from the Needs Assessment Panel is not a guarantee of a bed).
      • Has 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:
      • Has lived in Guernsey or Alderney for at least 12 months, immediately prior to claiming Long-term Care Benefit.
  • Respite at Home - Sitting Service

    • Respite at Home, Sitting Service is available if you need a break from caring and you are unable at any time to leave the person you care for, giving you the opportunity to do some of the things you cannot do whilst you are caring. The Sitting Service provides breaks for informal carers but 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 Community Nurse
      • Adult Community 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 4 hours day time care weekly or a maximum of 2 nights a week as assessed by a professional in a crisis or high care needs situation.  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/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.
    • For more information on the above services please contact the Respite Co-ordinator on 01481 223973
  • 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.
  • Support Services

    • Home Help Service
    • The home help service will help with basic domestic and household tasks.
    • 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.
    • The service user is requiring assistance with domestic tasks such as cleaning and ironing.
    • 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 family member 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 helping with basic maintenance / handyperson duties and other basic odd jobs/minor adaptations, such as fitting key safes and handrails. They also carry out the delivery and collection of equipment for nursing requirements in the home. The service aims to help people remain independently in their own home.  Other tasks will be considered on request.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. While there is no limit to the number of requests that can be made, work will be prioritised as to the urgency of need.
    • 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.
    • 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. This may be undertaken by:
    • The shopped for service - for service users who are unable to undertake this task even if assisted e.g. due to mobility restrictions or frailty.
    • Assisted shopping - to promote independence support may be provided to accompany to the shops and assist as required.
    • 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.
    • 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: http://www.gvs.org.gg/meals-on-wheels.html 
    • 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

    • The Community Urology/Continence Team provide a free service to all Bailiwick of Guernsey patients registered with a G.P. practice.
      • On referral to the service, an assessment of the patient's needs will be made based on the information received. Where possible the patient will be offered a nurse of the same sex.  
      • A clinic or home appointment will be made so a more in depth assessment may be undertaken. On completion of the assessment an individualised treatment plan will be discussed and agreed with by the patient and further follow up contacts will be made. 
      • Referrals can be made by the patient's G.P. or other members of the Multidisciplinary Team. We also accept self-referrals, although we may need to consult with your G.P. for further medical information before making an appointment to see you.
      • How to contact the service - Community Urology/Continence Service, Princess Elizabeth Hospital, Telephone:  01481 220000 ext: 25448 or 25449.
  • Uro-Oncology Service

    • The Uro-Oncology Service is run by the Medical Specialist Group in conjunction with Health and Social Care.  The principle aim is to provide a comprehensive range of services that will adequately provide support for patients' who have either just been diagnosed with a urological cancer and/or require on-going support for an already established urological cancer. 
      • The service is led by our Consultant Urologist who in turn is supported by a urology cancer clinical nurse specialist, medical specialist group practice nurses, uro-physiotherapist, community urology team and administrative team.
      • Upon receiving a diagnosis, the results will first be discussed with you in consultation with the Urologist: The clinical nurse specialist will normally also be present at this meeting. The information you receive will address the specific issues relating to your diagnosis i.e. type of cancer, additional investigations required, treatment options and where to obtain further information.  Following the consultation with the Urologist you will then be given the opportunity of discussing your diagnosis and treatment options more fully with the clinical nurse specialist.  It is understandable that you may feel anxious immediately after receiving your diagnosis and will require some time to consider and adjust to any changes in circumstance.  You may have additional questions and concerns you wish to discuss straight away.  The clinical nurse specialist is there to assist you by way of providing  on-going support, advice and any additional information you may require at this time.
      • Details of your consultation with the Urologist and nurse will be documented and held securely in our medical records department for future reference along with any subsequent investigation and test results.
      • Further appointments may be necessary in relation to possible additional investigations and follow-up consultations.  These can either be made at the time of your initial consultation or may be posted to you depending on the type of investigations/consultations and where they need to be undertaken i.e. certain investigations are only available in the UK.
      • Please be assured of continued support and advice from the Uro-Oncology team which will remain open to you for as long as you feel that it is of benefit.
      • Please find attached a list of contact details for the Uro-Oncology team, should you have any immediate questions/concerns.  The contact details of our Community Urology team are also included. 
    • Uro-Oncology Team 
    • Mr Owen J Cole - Consultant Urological Surgeon
    • The Medical Specialist Group 
    • Tel : 01481 238565  Ext 2201
    •  
    • Sara De La Rue - Clinical Nurse Specialist  Uro-Oncology
    • The Princess Elizabeth Hospital 
    • Tel : 01481 220000  Ext 25453
    •  
    • Medical Specialist Group Nurses
    • Tel: 01481 238565 Ext 2284
    •  
    • Sophie Tyrell
    • Urology Physiotherapist
    • Guernsey Physiotherapy Group
    • Tel: 01481 232900 (Appointments made subject to referral by Consultant Urologist)
    •  
    • Patricia McDermott
    • Nurse Consultant - Community Urology
    • The Princess Elizabeth Hospital
    • Tel: 01481 220000 Ext 25448
    •  
    • Steve Mundy
    • Clinical Nurse Specialist - Community Urology
    • The Princess Elizabeth Hospital
    • Tel: 01481 220000 Ext 25449
    •  
    • Lydia Whattam
    • Urology Nurse Specialist
    • The Princess Elizabeth Hospital
    • Tel: 220000 Ext 25449
  • Colorectal / Stoma Service

    • Colorectal and Stoma Care Clinical Nurse Specialists are key workers or patients with a Bowel Cancer or Inflammatory Bowel Disease diagnosis by:
      • Providing on-going support;
      • Being responsive to patient's needs;
      • Acting as a link between other professionals such as Consultant Colorectal Surgeons and Consultant Oncologists;
      • Reviewing patients with bladder cancers and gynaecological cancers that require stoma formation and providing pre-operative counselling.
      • Providing appropriate, relevant information regarding diagnosis, investigation and treatment options;
      • Providing pre-operative counselling and psycho/emotional support for patients given a new Bowel Cancer or Inflammatory Bowel Disease diagnosis. This includes explanations about the intended surgery using enhanced recovery;
    • Referral details
    • It is a free service to all Bailiwick of Guernsey patients registered with a GP Practice.
    • Referrals are accepted from all Health Care Professionals and self-referrals from patients or their relatives requiring advice/ongoing support.
      • Contact us:  The Princess Elizabeth Hospital Tel: 01481 220000 Ext: 4282 
      • Sadie Robilliard  Clinical Nurse Specialist Colorectal / Stoma                         
      • Andrea Le Page Clinical Nurse Specialist Colorectal / Stoma
  • Specialist Palliative Care Team

    • What is palliative care?
    • 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.
    • Who are the Palliative Care Team?
    • The team consists of: A team of clinical nurse specialists and a palliative care social worker
    • The Palliative Care Specialist Nurses' role focuses on symptom control and support from diagnosis throughout a patient's illness, end of life care and bereavement.
    • The social worker is able to act as a care co-ordinator and help patients and families understand their options, identify services they need, and assist with completion of necessary paperwork, such as social security benefit claim forms or advanced care plans.
    • The team is highly trained in supportive and palliative care, they are supported by various other health care professionals including; dieticians, physiotherapists, community services and other specialist nurses.
    • We also have access to a team of Palliative Care Consultants who provide us with valuable support and advice from their wide knowledge and experience.
    • 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 
    • 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.
    • How to contact the service
    • Community Services-Telephone:01481 223020 and ask for Specialist Palliative Care Team.
  • Palliative Care Social Worker

    • The Palliative Care Social Worker is based within the Specialist Palliative Care Team predominantly supporting people living with a life limiting illness, their carers and family during a time of change and uncertainty associated with disability, loss and grief. The Social Worker works collaboratively with other multi-disciplinary professional teams surrounding the person and those important to them including family members, to ensure that services and interventions take account of the whole person, keeping them at the centre of their care. 
    • A variety of support options can be provided to both the person and those that are important to them. This can include:
      • Sourcing practical help and support at home identified through the completion of psychosocial assessment.
      • Accessing other support services including; care at home, community nursing support, carer respite, hospice care, residential and nursing home placements.
      • Providing advice around benefit entitlements.
      • Advocacy.
      • Psychological and emotional support.
      • Supporting people to prepare for the end of their lives through advance care planning and crisis interventions.
    • The Specialist Palliative Care team is based within the Castel Hospital with Community Services and in the Bulstrode Oncology Unit.
    • Referrals to the Palliative Care Social Worker can be made by G.P's, hospital staff, Specialist Palliative Care Nurses, Community Nurses, and other agencies. Self-referrals can also be made, this includes from family members, with the person's consent.
    • Contact: 'Referrals Coordinator' in Community Services on 01481 223020 
  • FAQs

    • 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 223020. 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.

 

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Extra Care Housing Urology Service Handy hints for patients Community Services Department Day Care & Community Support [Revised Nov-19] Extra Care Housing, Residential and Nursing Homes 2022

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