Alternatives to hospital admission
Cardiac Rehabilitation
This is a home visiting service for patients in the early post discharge period after a Myocardial Infarction and
Cardiac surgery.
It provides clinical home and hospital reviews and medicine reviews as appropriate according to need. It also
provides: independent prescribing to support the service; enrolment of patients on to cardiac rehabilitation
exercise classes; and, delivery of community cardiac rehabilitation exercise classes. The service is located at
Royal Berkshire Hospital and in the community at a variety of locations.
The service is available 08:00-16:00 Monday to Friday. Fax referrals are received 24 hours a day.
Contact
0118 9899822
Community IV Cellulitis service
The Community based IV service is a joint pathway between the RBH and community nursing services. The
patient should be referred as detailed below; A clinical assessment of the patient will be made in CDU and
the midline inserted and first dose given. The patient is then discharged to the care of the GP with community
nursing team administering follow up doses of antibiotics. Full clinical protocol available on Doctors desktop.
The IV Therapy High Tech Team are available between 08:00-18:00 Monday to Friday.
The IV Therapy High Tech Team is available between 08:00-18:00 .
0118 937 4877
Contact
Community Geriatrician
Comprehensive geriatric assessment of elderly patients in their own home or community clinic. Typical cases
include patients with complex co-morbidities, frequent users of GP or acute services, complex medical/social
problems including cognitive impairment and capacity issues, or anything else the GP is struggling with.
Support for GPs with admission avoidance if you are unsure whether your patient is safe to stay at home;
these cases will usually also require rapid response team input as well (see under Admissions Avoidance);
this referral needs to be made separately.
NB same day diagnostics require RACOP clinic at the RBH.
This is a Mon-Fri 9-5 service only with limited cover for annual leave.
Full service information and referral form available at
http://www.royalberkshire.nhs.uk/docs/Reading_GPs_Community_Geriatrician_Referral_Form_and_Info_She
et.doc
Reading Dr Shashi Gadgil
Mobile 07824377988 NB no reception in my office!
Contact
Office 01189605318
Fax: 0118 960 5726
PA Anna Swann 0118 9605193
Voicemail: leave your direct line as it can take a long time to get back via
switchboard/reception.
West Berkshire Dr Sarah Logan
Mobile: 07775026154
Direct Line: 01635 27 3583
Fax: 01635 27 3798
PA Marea Simpson : 01635 27 3573
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
Wokingham Dr Yetunde Sote
Mobile 07786801081
Direct Line: 0118 9492919
Fax 0118 9495260.
PA: Julie Brown 0118 949 2919
Community inpatient beds
A time limited, intensive, clinically-led period of care in Community Hospital beds
The patient’s progress managed through a period of hospital-based rehabilitation. A goal/outcome based
intervention plan is designed tailored to the patient’s individual needs.
The service is available 365 days .
Contact
0118 937 4877 Reading fax: (09:00-19:00) 0118 937 3744
0118 949 5176 Wokingham (08:00 – 19:00)
01635 292 120 West Berkshire fax: 01635 292 115
Community Matrons
Community Matrons proactively provide individualised care planning and coordination over the lifetime of the
patient. They help the patient to understand their disease pathways and how to recognise early symptoms or
changes in their health status.
The service is available from 08.30.00-16.30 Monday to Friday.
Contact
0118 937 4877 Reading fax: 0118 937 3744
0118 949 5176 Wokingham
01635 292 120 West Berkshire fax: 01635 292 115
Community Nursing Service
The service delivers a comprehensive Community Nursing Service, fully integrated with the Primary Health
Care Team to provide care/support, largely within a domiciliary setting, for patients with a wide range of
nursing needs, including the acutely ill, chronically sick, patients requiring specialist nursing interventions and
those at the end of life for both planned and unplanned care support.
The service is available from 07:00 – 19:00, 7 days a week
Contact
0118 937 4877 Reading fax: 0118 937 3744
0118 949 5176 Wokingham
01635 292 120 West Berkshire fax: 01635 292 115
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
Domiciliary Physiotherapy Service
This service provides physiotherapy when patients are unable to access Outpatient department services or
when assessment and treatment is more appropriate in the home. Assessment, advice, mobility equipment
and treatment are offered for a wide range conditions.
Referrals are made through Single Point of Access.
Contact
0118 949 5176 Wokingham Fax: 0118 949 5160
0118 937 4877 Reading Fax: 0118 937 3744
01635 292120 West Berkshire Fax: 01635 292 115
Earlier Supported Discharge (Stroke)
This multi-disciplinary service provides Earlier Supported Discharge to acute stroke patients, strokespecialised rehabilitation to patients in their homes immediately upon discharge from the stroke unit for up to
6 weeks.
It provides intensive stroke specialist rehabilitation to patients in the community and stroke specialised care,
support and information to patients and their carers. Referrals are made through discussion at the twice
weekly MDT on the Acute Stroke Unit at RBH and via telephone discussion at other times, with completion of
a discharge checklist. Patients can re-refer themselves once known to the service.
The service is available 08:00-16:30.
Contact
01635 292 120 West Berkshire fax: 01635 292 115
Falls Prevention
The aim of this service is to reduce the number of falls and resultant injuries including fractured limbs and soft
tissue damage, through evidence-based programmes of assessment and education.
The service is available 08:30-16:30 Monday to Friday. Fax referrals are received 24 hours a day.
Contact
0118 955 6860 fax: 0118 958 3259
Heart Failure Nursing
This is a community based service for patients with a diagnosis of systolic heart failure (Left Ventricular
Systolic Dysfunction) confirmed by echocardiogram. Patients can either be reviewed in their own homes or
in one of the Community Heart Failure Clinics based in each locality. This service provides clinical and
medicines reviews with the aim of optimising evidence based heart failure medications to improve symptom
control and education about self-management. Access to Telehealth is available for those patients identified
as being suitable. Advice and support is offered to patients who are approaching the advanced stage of their
disease and close links are maintained with the Consultant Cardiologists and Consultants in Palliative Care to
enable access to expert advice when required.
The service is available for the whole of Berkshire West between 09:00-17:00 Monday to Friday.
Contact
0118 927 3423
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
Fax: 0118 927 3423
Intravenous Therapy
This service provides intravenous treatments given in community settings to enable patients to have their
treatments closer to home.
Treatments are given in day treatment units in Newbury and Wokingham and also at home (where
appropriate) and delivered by a team of specialist nurses. Treatments given include:
IV Fluids for re-hydration, Blood products (e.g. blood transfusions), Intravenous antibiotics, Intravenous drugs
(e.g. pamidronate, magnesium) and Total parenteral nutrition (IV feeding).
Contact
0118 937 4877
Neuro Rehabilitation
This multi-disciplinary team empowers patients and their carers to realise their full potential using a client
centred, holistic, goal orientated rehabilitation approach and treatment in their preferred place of care.
It comprises: Occupational Therapists, Physiotherapists, Psychologists, Speech and Language Therapists, a
Specialist Stroke Rehabilitation Nurse and Therapy Assistants. There are inpatient Neuro-rehabilitation beds
on Donnington Ward, West Berkshire Community Hospital, for patients unable to be discharged home from
an Acute setting. There is a time limited (up to 12 weeks) specialist neuro-rehabilitation for individuals with
realistic, achievable goals that may improve or maintain their ability to perform activities of daily living that are
purposeful, functional and meaningful to that individual. It empowers and enables the individual and their
carer to manage their own condition.
Ward referrals: To the ward manger or via SPA
Community Referrals: CBNRT Referral form posted or faxed to SPA
The service is available 08:00-16:30.
Contact
01635 292 120 West Berkshire fax: 01635 292 115
Night-Sitting
This service provides emergency night-time support for vulnerable adults. Up to seven nights of emergency
sitting may be provided for reasons including: UTIs, chest infections, support following a fall without fracture,
carer illness or hospital admission, emergency carer respite.
Referral criteria:
The service user must be safe to stay at home.
Any necessary equipment is already in the home.
There are emergency contact details for the service user if the carer is in hospital.
The service is available 22:00-07:00. Referrals received between 08:00-19:00 7 days a week.
Contact
0118 937 4877
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
Older peoples Mental Health services in Reading
Common Point of Entry
Provides a single point of entry for mental health services for all ages including older people in Berkshire.
The team will take referrals and direct them to the appropriate service. They will also offer advice and
signposting to other services as appropriate. All new referrals should go through CPE.
Service is available 08.00 -20.00 Monday – Friday.
Contact
0300 365 0300
Community Mental Health Team for Older people
Provides assessment, treatment and on-going support for older people with severe and enduring mental
health problems. This includes younger people with a diagnosis of dementia. The team comprises Health
and Social care staff who visit people at home and offer support to them and to their carers. The team also
offers psychological support to patient s and carers both on a 1:1 basis and in therapeutic groups.
Service is available: 09.00am – 17.00 Monday – Friday.
Hazelwood – 0118 9605959
Contact
Crisis/Home Treatment Team for Older People
Offers urgent assessments and intensive support to older people in crisis to prevent the need for hospital
admission. Also acts as gatekeeper to in-patient beds in Prospect Park Hospital for older people.
Service is available 09.00 - 19.00 Monday – Friday
09.00 - 17.00 Weekends and Bank Holidays.
Outside these hours the adult Urgent care team provides cover for older people.
Contact
Hazelwood 0118 9605959 – Monday – Friday 9am – 7pm
0118 9605975 - Weekends & Bank Holidays 9am – 5pm
Urgent Care 0300 365 0300 – at all other times.
Out of Hours Evening Nursing
This service offers an evening, qualified nursing service and will visit patients in their own homes or
residential settings to provide short term nursing care under the umbrella of Intermediate Care.
It is based at Wokingham Hospital and West Berkshire Community Hospital.
The service is available between 19:00-23:00.
Contact
0118 949 5176 (19:00-23:00 - Monday to Friday)
0118 978 7811 (Out of hours – Westcall)
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
Out of Hours End of Life Night Nursing
This service is for patients who have reached the end of their life irrespective of diagnosis, and the patient,
family or informal carer is aware of their prognosis.
The service offers assessment and care but is not a sitting service. It operates between 23:00 – 07:00, 7
days a week.
Contact
0118 949 5176 (23:00–07:00 - Monday to Sunday)
0118 978 7811 (Out of hours – Westcall)
Out of Hours Service (WestCall)
This service provides urgent and unscheduled primary care during the Out-of-Hours period. It provides
advice, treatment, medication and onward referral, to those patients whose conditions cannot wait for
treatment until their own GP Practice is open on the following working morning.
The service is based at Wokingham Community Hospital (Operations Centre/Administrative Office), Royal
Berkshire Hospital Foundation Trust (treatments) and West Berkshire Community Hospital (treatments).
Contact
0118 978 7811 (Monday-Friday 18.30 - 08.00, Friday 18.30 - Monday 08.00 and
during all public holidays)
RACOP (Rapid Assessment Clinic for Older People)
The purpose is to see older patients who need urgent specialist medical assessment. It is used as a means
of preventing admission to hospital where the patient may be able to remain at home with guidance from the
consultant with support from intermediate care services.
RACOP clinics are led by a consultant or Specialist Registrar in Care of the Elderly and are based at Royal
Berkshire Hospital, Dellwood and West Berkshire Community Hospital.
Contact
0118 322 6547 Royal Berkshire Hospital (weekdays except Thursday)
01635 292 120 West Berkshire Community Hospital fax: 01635 292 115
0118 960 5193 Reading (Dellwood) – (Thursday - limited diagnostics)
Rapid Response and Intermediate Care
The service offers intermediate or integrated care (social care, physiotherapy, occupational therapy, nursing
support) to patients at home as an alternative to admission. The service has a focus on re-ablement
(rehabilitation and supporting people to adapt and adjust to any reduction in function in order to support
independent living).
The service aims to assess all rapid referrals within two hours, following which a decision is made about
whether the patient can be accepted. A care package can then be put in place at short notice later that day.
In practice the types of patient who tend to be suitable for the service are:
 Older people
 Patients who are medically stable
 People who are expected to have a temporary increase in their care needs (for up to six weeks, the
maximum period that the additional care is usually offered)
The service is particularly good at managing the following medical problems:
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
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Patients who have had a fall, requiring primarily occupational therapy and physiotherapy, and may be
supported at home
Patients with reduced mobility
Patients with constipation or urinary symptoms
Patients with dementia
Patients with a mild infection requiring oral antibiotics, and without delirium
End of Life Patients
Referrals are accepted for patients in the community, in the Emergency Department or on the Clinical
Decision Unit.
Contact
Reading 0118 937 4877
Wokingham 0118 949 5176
West Berkshire 01635 292120 fax: 01635 292115
Reading Borough Council – Reading 24 Out-of-Hours emergency care
An Out-of-hours service (24 hours) designed to assist people to remain in their own home with home care
support. This is to prevent unnecessary admissions to hospital or residential care, resulting from an
emergency situation such as a carer is taken ill or needs to be admitted to hospital and the cared for person
cannot be left without some additional care or where an individual may have sustained an injury or have a
temporary illness that means they are unable to care for themselves safely in their own homes and would
otherwise be admitted to hospital.
Contact
07894938503
Respiratory service
It is a community based respiratory service for patients with long term respiratory diseases including COPD
patients. It aims to help patients regain confidence, improve symptoms, and prevent avoidable hospital
admissions through rapid intervention and regular reviews Home Oxygen Specialist nurses undertake home
oxygen reviews at 6 months for new prescriptions and annually thereafter.
Rapid Response Specialist Nurses and Physiotherapists provide domiciliary visits to a patient’s home within
two hours in response to a referral from a GP or health professional to stabilise the patient’s condition and to
support them to remain independent and out of acute care. This may be followed by a further period of
reablement.
The Pulmonary rehab programme will then provide twice weekly supervised exercise and education
programme for patients disabled by their breathing at the MRC Scale of 3 and above, (despite being on
optimal medical therapy as defined by NICE guidelines, and who have been classified as Mild/Moderate
disease).
Oxygen saturations should be ideally at 92% or above but patients can be reviewed if they have an oxygen
prescription.
The service is available from 08:00-17:00 Monday to Friday (after 16:00 the patient may not be seen
until the following day).
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13
Alternatives to hospital admission
Contact
0118 982 2946
Fax: 0118 952 5442
Single Point of Access
Single Point of Access (SPA) is a telephone based system for handling all referrals to community health
services (provided by Berkshire Healthcare Foundation Trust). There are three SPAs for each of the local
authority areas (Reading, Wokingham, West Berkshire).
Patients can be referred to the SPA by GPs, community nursing teams, hospital staff and social care teams.
Contact
0118 937 4877 Reading Monday – Friday 08:00 – 19:00
0118 949 5176 Wokingham Monday to Friday 08:00 – 19:00
01635 292120 West Berkshire Monday to Friday 08:30 – 17:00 (17.00 – 19.00
message with phone number to arrange later assessment)
To view this information on your smart phone open the following link:
www.berkshirewest.nhs.uk/ic and ‘add to home screen’.
Date amended: 24.01.13