Care at home

We are a Children's Community Nursing Team, who provide nursing support and training to families of children and young people with health care needs. For example:

• Children/young people using a feeding device
• Children/young people with a tracheotomy tube
• Babies, children/young people on home oxygen
• Children/young People with complex health care needs who need nursing support in their home, nursery, school setting

In South Wiltshire there is a Paediatric Diabetes Specialist Nursing Service, who support children and young people age 0 - 19 years with diabetes (PDSN).

We support children and young people with complex health needs to achieve simple but important goals:

• To live safely at home
• To have their health needs supported by their family and carers
• To have their health needs managed in their community, including at school
• To reduce the frequency of hospital stays

We work with children and young people who would otherwise need to spend a great deal of time in hospital, to train and support their families to manage their health care needs and reduce hospital admissions.

Our team work with children or young people 0 - 18 years who are under the care of a Consultant Paediatrician at Salisbury District Hospital.

Our diabetes service works with young people under the care of a Salisbury District Hospital Paediatrician up to the age of 19.

Our team provide this service Monday - Friday 9.30 am - 4.30 pm.

We provide care in the Children's Unit at Salisbury District Hospital (opens new window), in a child's home, at their nursery, or in their school setting, depending on the need of the young person. We try to assess young people in the environment in which they need support.

Our team covers the Salisbury District Hospital catchment area, which includes south Wiltshire up to Tidworth and out to Warminster.

Children and young people can be referred to our team by a Consultant Paediatrician from Salisbury District Hospital.

There is no wait time to see our team. We will assess a young person's needs and plan an approach to meeting them depending on individual circumstances.

Unfortunately families cannot self-refer to our team.

We will work with a young person and their family for as long as they have an assessed need. Some young people stay with us until they transition into adult care.

The support of our team will continue as long as there is a nursing need to support the young person and their family.

If a young person has a continuing need for nursing support we will connect them to adult health services through transition clinics appointments. We use these appointments to make sure that young people and their families understand how their support will be delivered post 18 and to share our knowledge and understanding of their needs with our adult team.  

If families we work with inform us they are moving out of Wiltshire, we will find the contact details for the community nursing team in their new area and connect them. Wherever possible, we will share information and medical notes with the new team. Families moving into our catchment area can be referred to our team through a Salisbury District hospital paediatrician.

We are a children's community nursing team based out of Sirona care & health in Bath.

We work with children and young people with life-threatening or life-limiting conditions.

We provide nursing support and training to families of these young people. For example:

• Children/young people using a feeding device
• Children/young people with a tracheostomy tube
• Babies, children/young people on home oxygen
• Children/young People with complex health care needs who need nursing support in their home, nursery, school setting

Our team also provide a clinical psychology service.

The Lifetime Service offers a needs-led service within the community for children and young people with life-threatening, life-limiting conditions. This means we work towards the goals that are important for a young person to achieve, rather than following a set programme of care.

We aim to support children and young people and their families with complex health care needs to, as far as possible, reach their full potential. This includes:

• To live safely at home
• To have their health needs supported by their family and carers
• To have their health needs managed in their community, including at school
• To reduce the frequency of hospital stays

Our team work with any child or young person with a non-malignant, life-threatening, life-limiting condition aged 0-19 years, who lives in West Wiltshire. We also provide nursing care in this area for children and young people with a long-term condition who have a nursing need.

Our team, including admin staff, are available from 9am to 5pm, Monday to Friday.

Visits are planned with each family on an individual basis. Visits are usually at home, although Lifetime staff will accompany families to an appointment if helpful.

The Community Children's nurses can also provide training and advice in schools, nurseries and respite homes if needed and can also undertake some clinical tasks to avoid GP visits or out-patient appointments.

Once the child or young person has been given their diagnosis a professional involved in the child's care can refer, either by calling 01225 731 624 or accessing the referral form via the Sirona care & health website (opens new window). Young people and families can refer themselves to our team using the same route.

Our Lifetime nurses provide care and support from time of diagnosis or referral, throughout a young person's childhood and adolescent years, through transition to adult services. For a child with nursing needs and a long term condition, the Lifetime Service will provide nursing care so long as the nursing need exists.

The Lifetime Service also provide bereavement care for families for up to 18 months if a child or young person reaches the end of their life.

We often act as a professional liaison, or link person between children and families and other professionals who are involved in their care. If we don't know the answer to a problem we will try to refer families onto the most appropriate person/ organisation.

Our nurses will have initial discussions with the young person and their family at age 14, to begin planning for transition. Ongoing planning will then take place in parallel with the young person's care, to make sure their transition through adolescence and into adult services is as smooth as possible. Our team work hard to make sure young people and their families understand what is happening and are involved in decision-making. The discussion our nurses have with families around transition planning is supported by the Sirona care & health led Transition Health Action Plan and other relevant information leaflets, which will be shared with families as necessary. The Lifetime Service has Transition Guidelines that are regularly reviewed by a Transition Working Group.

If a family we support tells us they are moving out of Wiltshire, we can refer them to a similar service in their new county and will support the handover of care as far as possible by sharing information and advice. If a family move into Wiltshire who meet our criteria for nursing support, they can be referred by a health professional or refer themselves to our team in the normal way.

We are a highly specialised team of skilled nurses, who support young people with significant complex health needs and/ or technology dependency. It is highly likely that a child or young person in Wiltshire who requires our support will already be known to us and at any one time, we are likely to be working with less than 20 young people.

Our aim is to facilitate a good quality of life for children and young people with significant complex health needs and provide support that encourages timely discharge from hospital and allows them to remain at home.

We focus on delivering safe, sustainable, effective care packages, planned and delivered in partnership with families and carers.

A life threatening condition is defined as:

• 'Any illness or condition developed in childhood (before the age of 19 years), whereby the person is likely to die before the age of 40 years',
• 'Any condition developed in childhood that, without intervention, will limit the individual's life span.'

Technology dependency is described as:

• 'Those who need both a medical device to compensate for the loss of a vital bodily function and substantial and ongoing nursing care to avert death or further disability'

We work with children and young people under the age of 18, living in Wiltshire, with complex medical needs and/or technology dependency significantly over and above that which would usually be provided by NHS Wiltshire and Wiltshire Council.

We are a commissioned service, which means we have responsibility for delivering specialised care packages designed by a panel of children's commissioners. We are not able to alter this package, as the panel is responsible for making sure an individual's needs are met by their individual plan.

We work with children and young people under the age of 18, living in Wiltshire, with complex medical needs and/or technology dependency significantly over and above that which would usually be provided by NHS Wiltshire and Wiltshire Council.

We are a commissioned service, which means we have responsibility for delivering specialised care packages designed by a panel of children's commissioners. We are not able to alter this package, as the panel is responsible for making sure an individual's needs are met by their individual plan.

Packages of support are highly individualised and are therefore are delivered wherever is most appropriate for the child or young person, according to their health care plan.

Where there is an identified need for a specialist package of home care, an assessment is carried out by a community nurse and referred to a panel of children's commissioners, who decide how and when to meet an individual's needs.

As this is a highly specialised form of support, transition is supported to adult services at 18 years, where this is appropriate for an individual.

As the needs of young people we work with are complex and often life-threatening, each authority may approach their care in a specialised way. We will work with a family moving out of Wiltshire to refer or signpost them to an appropriate service in their new area and reduce the impact on their young person's care. If a family moves in to Wiltshire, they can access our service through our usual referral route.