Nursing in the Community

Nurses working in community settings need to be able to work independently, sometimes in less-than-ideal environments and without access to the levels of support and equipment that other may nurses take for granted.They often develop long-term therapeutic relationships with patients, many of whom are isolated and vulnerable, and reduce pressures on hospital services by facilitating early discharge or enabling patients to remain at home.This award category is open to individuals and teams working in the NHS or independent sector and from any community care setting.Entrants must be able to demonstrate their work has improved patient care or the effectiveness of their service and has outcomes to demonstrate this.

Blackpool Teaching Hospitals NHS Foundation Truste
Early parenthood service – supporting parents to be the best they can be

Blackpool has the highest rate of Children in Need and Looked After Children in the country, with the rate for those under the age of one being over four times higher than the national average. The Early Parenthood Service (EPS) was designed as a response to this and the decommissioning of Family Nurse Partnership (FNP) in order that the needs of a broader population could be better met, particularly those expecting parents with Difficult experiences in their own childhood and may be care experienced. Had children who are no longer in their care. Are experiencing vulnerabilities and whose lifestyle may pose a risk. The aim is to support Parents to be the Best They Can Be, by providing consistent and intensive support utilising a tool kit of evidenced based interventions throughout the antenatal period until the baby is up to three months old. EPS supports parents who may go home with their baby and those born into care. We considered recommendations of research, independent reviews, child safeguarding practice reviews, local information, and data to design a bespoke service integrated into the Blackpool Start for Life offer. A shared goal enabled a smooth and rapid development of a complex service. Putting the baby and their family at the centre enabled challenges to be considered as opportunities for growth and learning. EPS has been commissioned initially until 2027. 59 families have been referred to date, with amongst them 4 babies at significant risk of being removed have gone home with their parents. 4 families have been supported whose babies were born into care. We are currently working with 10 families in pregnancy whose babies are at significant risk of being born into care. Future plans are to evaluate, adapt, expand and integrate further into the Blackpool Partnership offer to families.

BrisDoc Healthcare Services
Homelessness cervical cytology

Homeless women often experience severe and multiple disadvantages, this severely impacts on their ability to access timely and appropriate health care and as a result of this are at increased risk or mortality and morbidity. Homeless women have the average life expectancy of 43 with almost a 3rd dying of preventable illnesses including cervical cancer. Homeless women face multiple barriers to accessing cervical cytology including not receiving or reading their invitation letters or follow up letters, high prevalence of sexual trauma, lack of washing facilities and complex intersecting substance misuse and mental health problems. With the Support of a volunteer GP the HHS nursing team were able to identify over .157 women who were either overdue a smear test or lost to follow up for existing smear tests, SWAG funding was procured and the HHS team hosted a treating event on trauma informed care for homeless women and the importance of cancer screening for homeless women. This training event was aimed at support workers working across housing and homelessness sector who would be supporting women to attend healthcare appointments. Availability of smear testing was widely publicised and an outreach clinic at a homelessness women's shelter has been set up with plans to attend women's hostels across the city. One of the biggest challenges was accessing up to date records for our patients, many patients at HHS only hold a temporary registration although they may access all their healthcare from us and so each record had to be individually looked up, cross checked and have alerts added to our notes. This was incredibly time consuming and could not have been achieved without a significant time investment from the volunteer GP. There were also concerns about opportunistic screenings being rejected by the laboratory as they were not 'due'.

Central London Community Healthcare NHS Trust
New starters skills enhancement programme

When newly qualified and internationally recruited nurses step into the demanding world of community nursing, they often face a daunting reality. Transitioning from theoretical learning to real-world practice, managing patient care independently, and navigating the UK's intricate healthcare system can be overwhelming. Recognizing these challenges, we launched the New Starters Skills Enhancement Programme (NSSEP) to bridge this critical gap. Our journey began with a vision to empower these nurses with the skills and confidence they need to excel. The NSSEP is a transformative five-day training programme designed to provide a solid foundation in community nursing. Implementing the NSSEP wasn’t without its hurdles. Securing protected learning time for nurses in a busy NHS environment was a significant challenge. Yet, the nurses' eagerness to learn and grow made it possible. We also faced the task of making our group-based simulations truly reflective of community practice, where nurses often work alone. Despite this, the collaborative simulations fostered a strong sense of camaraderie and the exchange of invaluable best practices. The impact of NSSEP has been profound. An overwhelming 98% of participants reported substantial knowledge gains, with 99.6% confident in applying their new skills regularly. Nurses highlighted increased confidence and practical competence, praising the interactive and realistic aspects of the training. As we look to the future, our focus is on refining the programme further. We plan to introduce more individualized simulations to mirror the solitary nature of community nursing, extend training duration for deeper skill consolidation, and enhance the realism of scenarios. Continuous professional development for our trainers will ensure we maintain the highest training standards.The NSSEP is not just a training programme; it’s a stepping stone for nurses, equipping them to provide exceptional care and make a significant impact in their communities.

Central London Community Healthcare NHS Trust
Senior nurse enhancement programme

Community healthcare is a complex nursing environment where the challenges faced in acute or hospital settings tend to be magnified. In particular our ability to retain middle to senior level staff (Band 6 and 7 nurses) presents a unique service perspective challenge when faced with a growing complex patient workload from diverse backgrounds and an ageing population. There exists a dual burden: maintaining high standards of patient care while adapting to rapid shifts in healthcare demands. The need to equip, empower and build resilience in nurses with enhanced clinical and leadership skills who are at the forefront of influencing both frontline and very senior line mangers gave birth to(SNEP).Designed by nurse educators, SNEP was crafted as more than just a training program—it is a catalyst for transformative change. It encompasses workshops, leadership seminars, real-world simulations, clinical skills and drills and patient scenarios for nurses to not only elevate their clinical skills but also to lead with confidence and creativity. The challenge of ring fencing protected learning time in a busy NHS organisation was nullified by the appetite for learning and growth. As sessions progressed, nurses who felt isolated in their roles have shared insights and strategies, fostering a spirit of camaraderie and collaboration. This exchange of best practices was crucial in raising the standard of care. Results were significant: nurses returned to their communities not just with better skills but with a renewed sense of purpose. They reported increased competence in managing complex cases, effectiveness in leading their teams, a motivation to pursue quality improvement initiatives—all contributing to heightened patient safety and care standards. Future plans of SNEP are promising with plans to introduce systems focused leadership through human factors modules to further reduce unwanted outcomes. The aim is to not just sustain but embed a culture of learning.

Dartford and Gravesham NHS Trust
Children's hospital at home team

The inception of the Children's Hospital at Home Team (CHAHT) at Darent Valley Hospital (DVH) in November 2021 emerged as a proactive response to anticipated surges in respiratory syncytial virus, bronchiolitis, and lower respiratory tract infections, aligning with national healthcare directives and the NHS 5-year plan. Informed by NHS England's ""Building the Right Support"" initiative (2015), which emphasizes community-based services for individuals with autism and learning disabilities, our team embarked on a comprehensive research and consultation process. Engaging both staff and service users, we gauged expectations and assessed the potential impact of such a service provision on care quality and overall well-being. A baseline audit, examining 732 children and young people presenting to the hospital Paediatric Assessment Unit (PAU), revealed that 37% of PAU activity comprised planned re-attendances for IV antibiotics, clinical reviews, and repeat blood tests. This underscored the imperative to introduce innovative pathways within our envisioned service. Despite tight timelines, our team successfully launched the service, focusing on delivering safe and high-standard care while expanding rapidly to meet demand. Central to our approach was the development of an integrated service model bridging acute and community services, prioritizing the child and family experience. This model, emphasizing home-based care, facilitated the shift from hospital based to community based service delivery, ensuring that patients and families receive the right care, in the right place, at the right time. The evolution of our service into the virtual ward program at DVH necessitates strategic expansion. Collaborating internally and externally, we are actively exploring partnerships with pharmaceutical colleagues to broaden our antibiotic coverage, engaging remote monitoring software firms to enhance patient monitoring capabilities, and integrating Point of Care Testing (POCT) solutions to streamline diagnostic processes. This initiative exemplifies a proactive response to healthcare challenges, driven by a commitment to delivering high quality safe care.

Leicestershire Partnership NHS Trust
Improving the confidence of community nurses in their ability and knowledge to help adults with type 2 diabetes become independent with insulin administration

The vast increase in adults living with diabetes mellitus, set to reach over 5.5 million by 2030, places huge demands on community nursing services; compounded by complexities of an ageing population with co-morbidities. A study conducted in 2022/2023 in a community and mental health NHS trust identified a lack of motivation to encourage patient independence, coupled with rising insulin administration errors. The project team was led by Natalie Leggatt, a student district nurse, who worked collaboratively with a patient partner, quality improvement advisor, clinical mentor, and an academic mentor to achieve the project’s aim of supporting patients to become independent with insulin administration. Baseline data was collected from electronic patient records and a co-designed community nursing staff survey. Co-designed improvement interventions were implemented using the plan, do, study, act (PDSA) method. The interventions implemented included: educational materials, individualised goal setting care plans and training. Data was collected post-implementation using the same baseline methods to assess the impact of the interventions. Barriers to independence with insulin management included resistance from patients or family members, a shortage of written patient education materials and unclear documentation of the patient’s journey. The need for staff and patient education about self-care for effective diabetes management was identified. Multidisciplinary team working was crucial and changes to the single point of access service were made. Co-designed information leaflets were introduced featuring pictorial and easy-read content. Factors that could impede self-care are now highlighted using new care plans and an insulin guidance checklist. Following the success of the interventions, they have been introduced in other teams and clinical directorates within the trust. The interventions are being cascaded across the integrated care system including social care, primary care, and acute care partners. The work has been shared at a national conference and gained interest from national care providers.

Lymphoedema Wales Clinical Network and Swansea Bay University Health Board
On the ground clinical education programme for lymphoedema in the community

Lymphoedema is a chronic progressive condition causing an excess accumulation of protein rich fluid. Swelling, pain, recurrent cellulitis, immobility, wounds and falls are commonly encountered. Lymphoedema is often seen by community nurses (research suggests 69% of caseloads is lymphoedema) due to the population profile of house bound patients (increasing age, frailty, inactivity, obesity, multiple comorbidities). Crucially due to a lack of national lymphoedema guidance, knowledge, competence and confidence in compression therapy, many patients are inappropriately managed and remain on caseloads unnecessarily. Thus, raising pressures on unscheduled care and exponential dressings and bandaging costs. Referrals (if accepted) to Lymphoedema Services often presented late, with patients having highly complex lymphoedema and wounds. Although education was available community nurses were not released and attending a course on lymphoedema did not change practice. Hence a solution was to create an 'on the ground' lymphoedema educator trainer model supporting community nurses in their day-to-day clinical work to increase knowledge and improve patient care. A successful grant enabled a pilot for two lymphoedema educators to work directly with community nurses for a minimum of three days each rising confidence and skills in bandaging and lymphoedema management. Data was collected before/ after intervention on resource use, costs and outcomes. Positively, significant benefits were recorded in a reduction of community nurse visits, patients being discharged off caseloads, decrease in consumables being used and patient outcomes statistically improved in EQ5D5L and LYMPROM. However, when the OGEP educators moved on to the next team the community nurses resorted back to previous practice thus it was imperative that OGEP became an embedded service not just a pilot. After lobbying for three-years to government and executives plus a Value-Based business case the OGEP is now imbedded in 6/7 health boards in Wales with 17 OGEP specialists in place. The impressive benefits continue.

NHS South Yorkshire Integrated Care Board and West Yorkshire Integrated Care Board
Creating, developing and sustaining nurse and carer partnerships across South Yorkshire

Our highly skilled primary, community nurses strive to improve enhance and deliver complex support in a timely way to our population of unpaid carers across England. The value of unpaid care is equivalent to a second NHS in England and Wales, with social and nursing care professionals struggling to create the necessary time and capacity to spend with their citizens across the life course. This creates disjointed community teams experiencing a ‘crisis of care’ and critically impacts upon timely access to quality care for unpaid carers that is desperately needed within our localities, at regional and national levels. Our Unpaid carers are challenged to care for relatives who have complex multimorbid long term conditions, encompassing illness, disability, and mental health issues. The burden of caring responsibilities is growing. As the workforce closest to their communities, our community care nurses share a long history of relational and therapeutic care, engaging and connecting with carers on an individual level. There is a critical imperative to formalise that partnership work to create ‘upstream’ preventative planned and timely services, that allows for equity and co production to enhance unpaid carers mental and physical wellbeing. Primary and community nursing teams led and collaborated with carers to establish three carers’ roadshows across Yorkshire. This sustainable comprehensive and flexible community model is now in its second year. Over the Course of three half days in 2023, Barnsley Leeds and Sheffield integrated care systems delivered a total of 2,310 appointments and developed critical conversations with Carers and their families, to improve timely access to quality care and services. Sixty-five health and care organisations participated in the three roadshows across Yorkshire, with 227 preventative health checks initiated and completed by thirty nurses with student nursing teams. The future of care offers planned community initiatives at place spread and adoption.

Shooting Star Children's Hospices
Silent on-call rota

Shooting Star Children’s Hospices embarked on a mission to address the unequal geographical distribution of paediatric palliative care services offering face to face cover, 24/7, due to workforce shortages. Working together, the Shooting Star Children’s Hospices Community Nursing Team and our specialist nurses working within our Specialist Paediatric Palliative Care Team (SPACE) piloted a “Silent on-call rota”. This commenced in 2021 and we have built on its offer as the team have increased their skills. By developing this rota, it means that 24/7, 365 days a year, a children’s palliative care nurse is available to support an end-of-life child either over the phone, in their home or in hospital, providing nursing support for the deteriorating child. To ensure the rota is fully staffed, we partnered with 13 Community Nursing Teams under three ICBs in our catchment. We have developed models of working by where the hospice staff lead the on-call as single service or we work alongside statutory services collaboratively to deliver the on-call. It has taken time to develop the workforce and policies to underpin delivery including supporting the infrastructure around a single nurse checking with virtual backup. By creating this rota and the flexibility of the nurses, it has ensured a nurse has been with every family in their darkest moment. In the time since it was launched, no family has been without 24/7 nursing visits. The service has been informally but widely praised for its success in addressing previously unmet needs and delivering an exemplar service that stands in relief to the gaps of other surrounding services. Other geographical areas across the country have been unable to deliver a consistent 24/7 community service. The goal is to achieve parity across our catchment and inspire others to do the same.

Tameside and Glossop Integrated Care NHS Foundation Trust
The delegation of insulin administration

Tameside was the first organisation nationally that successfully delegated insulin administration to carers, from both residential homes, assisted living and domiciliary care. Many patients in the community are cared for by the district nurses, and one of the tasks includes diabetes care management. This involves checking blood glucose and administering time critical medication, such as insulin. This task must be completed before meals, to gain an accurate reading of the blood glucose levels. Because of the rising demand for insulin among patients in the community, nurses find it challenging to reach patients promptly. Consequently, patients are left waiting for district nurses to arrive, posing a problem especially for those who prefer early mornings. This could also result in poorly controlled diabetes. Additionally, recruitment and retention issues may lead to patients having different district nurses, ultimately causing a lack of continuity in their care. The delegation of insulin administration is the teaching and training of care staff workers from care homes and domiciliary care. The delegation works across both health and social care services to empower,educate and implement the programme, which promotes the upskilling of care staff workers. The work is having a positive impact on the district nursing service, as it releases time for the nurses to support more complex patients in our community. Utilising the delegation of care programme and the continued support of the district nursing teams with our carers, has improved working relationships and better communication between services for those we care for. The carers now have more knowledge and skills to provide care and most importantly, the patient’s care is better managed in their own home.

University Hospitals Sussex NHS Foundation Trust
Hep C elimination in homelessness

Hepatitis C is a blood-borne virus that, if left untreated, can lead to cirrhosis and liver cancer. There are thought to be a further 70,000 people in the UK that may be living with Hep C without knowing. PWID, people experiencing homelessness and people who have been in prison are disproportionately affected. We wanted to find and test these populations, particularly those who do not regularly engage with health care professionals. We researched and connected with different agencies and venues in homelessness and inclusion health across Sussex. My prior experience as a nurse in inclusion health was an advantage in Brighton and Hove but in East and West Sussex more research was needed. Together with peers from the Hep C Trust, we contacted day centres, hostels, temporary accommodation, probation centres, refugee hotels, churches, mosques, approved premises and street outreach teams. We also used our clinical van with street outreach teams. This was often done at night. There were also a few testing events that were run in collaboration with other agencies, such as sexual and women’s health, Terence Higgins Trust and refugee charities. Testing days would then be set up. I would attend with a peer or colleague and a brief assessment and consent was taken. We would then use antibody tests or dry blood spots (DBST) to test for Hep C, HIV and Hep B. The tests were incentivised with £5 vouchers. If they were RNA positive, the patients would be referred through our viral hepatitis pathway and treated. Hep B or HIV positive results would be referred on to hospital teams. Due to the project, testing is now established and will continue at these venues and with these cohorts. I will also look at other at risk groups that we can target.