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Integrated Care Teams

We provide nursing, treatment and support in the home and local community for people with a range of health problems or conditions.

Community care nurses


Who is this service for?

Our service is for adults with a range of health issues, from illness or injury to longer term conditions. We help patients who have been discharged from hospital, need longer term rehabilitation, or are housebound.

Get access to this service

Contact your GP or health professional to discuss this service. They can make a referral to an Integrated Care Team if they feel the service would meet your needs.  

How we can help     

Our teams are made up nurses, therapists, practitioners, assistants and support workers who work together to provide care and treatment in your home and local community. The teams are led by a community matron.

We carry out a holistic assessment of your rehabilitation and care needs and then develop an individual treatment plan. We will regularly review this plan for your individual needs which is regularly reviewed. Sometimes we will need to make a referral or consult with another specialist service, such as social services or a community mental health team.

We provide several different services, in a variety of settings including:  


Some of the things we typically help with include:

  • Supporting you to return home after a hospital admission

  • Helping you live as well as possible if you have a long term illness

  • Helping you with your walking or balance

  • Providing you with equipment that makes your daily activities easier

  • Provide care and treatments for pressure wounds

  • Support you in using a catheter

  • To reduce the risk of you falling at home