NHS England Innovative Practice Award – for developing an admission avoidance service model
Since 2021, we have prevented 3500+ service users from being re-admitted into hospital through our Rapid Response Service.
| Reduced Package of Care (POC) | 47% |
| Discharged with No POC | 38% |
| Taken Over By Reablement Team | 5% |
| Admitted into Hospital | 5% |
| Taken Over By Reablement Team | 3% |
| Moved to Nursing/Care Home | 2% |
In Bedfordshire, under a sub-contract
with ELFT, we provide rapid response
and reablement homecare services
We have been awarded zonal partners
and shadow strategic partners with
Oxfordshire County Council.
We are also preferred and approved
providers in Central Bedfordshire &
Bedford Borough.
Nursing Care (Level-3) is a specialized form of home care designed to support individuals with long-term health conditions that require expert assistance. This flexible service caters to a range of health needs, including:
- Cerebral palsy care
- Multiple sclerosis care
- Physical injury recovery
- Provide regular daily support or live-in care tailored to specific needs
- Collaborate closely with specialists (doctors, physiotherapists, occupational health services)
- Continuously monitor and report condition changes
- Adjust care plan as needed to ensure optimal well-being
- Assist with routine activities (personal care, shopping, household tasks)
- Offer live-in care options for constant support
- Provide companionship and meal preparation to enhance daily living and emotional wellbeing
- Develop customized care plans using SMART objectives (specific, measurable, achievable, relevant, time-bound)
- Coordinate with occupational health therapists for effective recovery
- Ensure a safe home environment is set up to promote smooth rehabilitation
- Provide critical at-home care before and after bariatric surgery
- Offer support throughout the journey, not just medical needs
- Assist with lifestyle changes recommended post-surgery
- Monitor for signs of infection, blood clots, and internal bleeding post-operation
- Provide motivation and reassurance for the next steps
- Support conversations with nutritionists and follow the prescribed diet plan
- Help implement and maintain a new exercise regime
- Tailored support based on individual needs and condition progression
- Flexible service adaptable to changing requirements
- Ability to remain in one's own home
- Support for daily activities while preserving autonomy
- Integration with other healthcare professionals
- Integration with other healthcare professionals
- Companionship and social interaction
- Assistance with maintaining a healthy lifestyle
- Continuous monitoring and feedback
- Targeted support for achieving positive outcomes
- Added reassurance during vulnerable periods
- Safe and familiar environment for care recipients
- Often more affordable than long-term hospital or facility care
- Reduces unnecessary hospital visits and stays
By providing comprehensive Nursing Care (Level-3) at home, individuals with various health conditions can receive expert support while maintaining their independence and quality of life in a comfortable, familiar setting.
| Reduced Package of Care (POC) | 47% |
| Discharged with No POC | 38% |
| Taken Over By Reablement Team | 5% |
| Admitted into Hospital | 5% |
| Taken Over By Reablement Team | 3% |
| Moved to Nursing/Care Home | 2% |
In Bedfordshire, under a sub-contract
with ELFT, we provide rapid response
and reablement homecare services
We have been awarded zonal partners
and shadow strategic partners with
Oxfordshire County Council.
We are also preferred and approved
providers in Central Bedfordshire &
Bedford Borough.
~ M. K. - Sister of Service User
Our Health Care Assistants undergo the highest standard of comprehensive training in medical skills, equipment use, emergency response, patient education, communication, infection control, and cultural competence.
All completed training is signed off by our Advanced Nurse Practitioner
Our service runs 7am-10pm daily, including weekends, with 24/7 on-call coverage and a single point of access for all referrals.
By collaborating and partnering with various healthcare providers who are already involved in community-based care, this service aims to create integrated, multi-disciplinary care pathways
This allows for smooth care transitions, sharing of information and assessments, and a comprehensive, coordinated approach to treating patients intensively in their home environment while avoiding unnecessary hospital admissions.
The Gold Standard Framework (GSF) is a widely used training program and accreditation process focused on enabling high- quality delivery of palliative and end-of-life care, both in hospitals and community/home settings
We aim to ensure our clinical teams, protocols, and care pathways meet best practice standards for providing comprehensive, compassionate palliative and end-of-life care to patients being treated at
