THE RIGHT SUPPORT AT THE RIGHT TIME: HOW SOUTH WARWICKSHIRE UNIVERSITY NHS FOUNDATION TRUST'S COMMUNITY TEAM IS HELPING RUGBY PATIENTS STAY SAFE AT HOME

The situation 

A patient in Rugby was experiencing severe mobility difficulties, which made moving around and completing everyday tasks very challenging. They were also living with distress related to Post Traumatic Stress Disorder (PTSD) and their skin health was declining, increasing the risk of wounds and discomfort.

Without the right support, there was a growing risk that their condition could worsen and lead to a hospital admission. The patient needed coordinated care to support both their physical health and emotional wellbeing, while helping them remain safely at home.

What we did

Our community nursing and therapy teams at South Warwickshire University NHS Foundation Trust (SWFT) worked together to carry out a joint assessment in the patient’s home. This included nurses, the Community Response Team (CRT), physiotherapists and occupational therapists, who worked closely to understand the patient’s individual needs.

Following the assessment, we put a coordinated care plan in place. This included:

• Providing essential equipment such as a hoist, hospital bed, specialist mattress and commode to support safer movement, improve comfort and help protect skin health.
• Supporting safer transfers and positioning to reduce the risk of injury and support wound care.
• Referring the patient to additional specialist services, including mental health services, bladder and bowel services, social care and safeguarding teams.
• Working together across teams to provide joined-up, personalised support focused on both physical and emotional wellbeing.

Outcomes

The coordinated support made an immediate difference. The patient was more comfortable, safer, and better supported to manage daily life at home.

Their skin care and mobility needs were addressed, reducing the risk of further deterioration. At the same time, referrals to additional services ensured their wider health and wellbeing needs were recognised and supported.

Most importantly, early intervention and effective teamwork prevented the situation from reaching crisis point and avoided an unnecessary hospital admission. The patient was able to remain at home, with the right support in place to protect their health, wellbeing and dignity.

Through early intervention and strong teamwork, we were able to make a meaningful difference to the patient’s daily life.