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Heywood Middleton and Rochdale (HMR) Integrated Neighbourhood Teams

Integrated Neighbourhood Teams consist of multi professionals housed together to support a joined up approach to the delivery of health and social care.

There are 6 core neighbourhood teams across the Rochdale borough which consist of district nurses, community matrons, community nurses, therapists, general practices, social care and third sector services, offering both home visits for the housebound and treatment room appointments.

What we do

The service operates a 24 hour 7 days a week single point of access and nursing support both day and night. Integrated neighbourhood teams also offer a borough wide provision of services which includes;

  • Heart Failure
  • Bladder and Bowel Specialist Service
  • Tissue Viability Service
  • Community Neuro-Rehabilitation
  • Early Support Stroke Discharge
  • Speech and Language
  • Amputee
  • Centralized Falls
  • Enhanced Respiratory
  • Self-Management Service

HMR District Nursing and Community Matrons

Who is the service for?

Patients over the age of 18 who are registered with a Heywood, Middleton and Rochdale GP. The district nursing service provides generic nursing in patients own home, and treatment room appointments. The service is a key part of the Integrated Neighbourhood Teams

What does the service provide?

Nursing patients in their own home environment, there is also a treatment room service for patients registered with a HMR GP.

We provide skilled nursing care at home and in residential care homes, 24 hours a day 365 days a year for patients and families. Treatment room services are available 6 days a week, and evenings Monday to Friday.

The district nursing team offer a range of  clinical interventions for people aged 18 and over and works in partnership with specialist nursing teams, GPs and multi-agency teams to coordinate care as required.

Community matrons provide support for people with long term conditions and/or complex health and care needs.

Where is the service based?

  • Heywood Integrated Neighbourhood Team - Phoenix Centre
  • Middleton Integrated Neighbourhood Team - Storage World
  • Rochdale East Integrated Neighbourhood Team - Smallbridge Clinic
  • Pennines Integrated Neighbourhood Team - Littleborough Health Centre
  • Rochdale Central Integrated Neighbourhood Team - Nye Bevan House
  • Rochdale West Integrated Neighbourhood Team - Rochdale Football Club

Who to contact

Contact the single point of access: 0161 763 8525

Out of Hours Nursing Service

The HMR Out of Hours Nursing Service work from 5pm to 8am seven days a week based at Rochdale Infirmary. They cover the whole of the Rochdale Borough area. The team can be contacted via the Single Point of access number.

Who to contact

Contact the single point of access: 0161 763 8525

Bladder and Bowel Specialist Service

Who is the service for?

Patients over the age of 18, suffering with bladder and/or bowel difficulties, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

The bladder and bowel service will provide advice; treatment and care to patients who suffer with urinary incontinence, prostate problems; faecal incontinence and pre and post operative stoma care. 

The continence prescription service is for patients who obtain medical devices such as catheters and stoma products on prescription. Advice and help is available. 

Where is the service based?

Patients are seen within community clinic, or the patient’s home as need requires.

The service also provides clinic based support held at:

  • Smallbridge clinic - Tuesday pm and Friday am.
  • Croft Shifa Health Centre - Tuesdays and Wednesdays all day.

Who to contact

Contact the single point of access: 0161 763 8525

Tissue Viability Service

Who is the service for?

Patients over the age of 18, needing tissue viability and or lymphoedema (non cancer related) support, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

Treatment of complex, acute and chronic wounds, leg ulcers, vascular assessment and maggot therapy. Support and management for moderate and severe (non cancer) lymphoedema.

Assessment, diagnosis and treatment of complex, active and chronic wounds, offering advice and support for healthcare professionals and domiciliary and clinic based appointments.

Where is the service based?

Patients are seen within community clinic, or the patient’s home as need requires.

The service also provides:

  • Complex Leg Ulcer clinics at The Croft Shifa Health Centre (Wednesdays pm) and Langley Clinic (Tuesdays pm).
  • Complex wound care clinics at Smallbridge Clinic (Wednesdays am).
  • Lymphoedema Clinic (non cancer) at Alkrington Health Centre (Tuesday) and Smallbridge clinic (Thursday).

Who to contact

Contact the single point of access: 0161 763 8525

Adult Speech and Language Therapy

Who is the service for?

Patients over the age of 18, requiring support with communication or swallowing difficulties, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

The Adult Speech and Language Therapy Service, provides expert advice and interventions for those patients with swallowing and communication disorders.

A professional team, working collaboratively with all other disciplines to ensure safe recommendations and hospital avoidance.

Where is the service based?

Patients are seen within community clinic, or the patient’s home as need requires. The service also provides clinic functions from the Phoenix Centre, Langley Clinic, and Nye Bevan House.

Enhanced Respiratory Service

Who is the service for?

Patients over the age of 18, suffering with respiratory conditions, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

The service provides supported self-management via pulmonary rehabilitation, out-patient clinics and domiciliary visits for patients with chronic respiratory diseases and also responding to flare ups of conditions to ensure deflection from community and supported discharge from Pennine sites.

This is an enhanced service consisting of therapists, nurses, pharmacy and support workers and working closely with the matrons within the integrated neighborhood teams.

Where is the service provided?

Patients are seen within community clinics, or the patient’s home as need requires.

Pulmonary Rehabilitation is delivered out of Rochdale Infirmary and other community venues.

Who to contact

Contact: 01706 517771

Heart Failure Specialist Nurse

Who is the service for?

Patients over the age of 18, suffering with heart failure, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

The specialist heart failure service is involved with the care of patients with heart failure in a community setting from the time of diagnosis.

The service assesses and monitors individuals to ensure appropriate medications and treatments are commenced. And also considers the need for more complex interventions such as, specialist procedures or devices.

The service aims to improve service user’s knowledge and ability to self-manage their condition; this is done in a supportive way using information and advice about their condition and treatments.

The service works closely with other agencies and specialists to provide high quality care such as, the cardiac rehabilitation team, practice nurses, pharmacists, GPs, community matrons, the local hospice and specialist palliative care nurses.

Where is the service provided?

Patients are seen within community clinic, or the patient’s home as need requires. The service also provides clinic functions from Callaghan House, Phoenix Centre, Langley Clinic, Littleborough Health Centre and Nye Bevan House.

Who to contact

Contact: 01706 517771

Amputee Service

Who is the service for?

The HMR Amputee Service is for patients having recently undergone a lower limb amputation and are considering prosthetic rehabilitation.

What does the service provide?

The service provides pre and post-prosthetic rehabilitation for adults with lower limb amputation in close association with the multi-disciplinary team at the Specialised Ability Centre Manchester (SACM).

Where is the service provided?

The service is based at the Royal Oldham Hospital (ROH) where consultant and prosthetist clinics are also available. Once patients have progressed to an agreed level of mobility and independence they will be transferred to the HMR Community Amputee Service located at the Community Hub, Rochdale Infirmary. This allows patients to be treated at home or in their community environment.

Who to contact

Contact: 01706 517775.

Falls Prevention / Community Physiotherapy

Who is the service for?

Patients over the age of 18, requiring community physiotherapy and/or falls prevention interventions, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

The Falls Prevention / Community Physiotherapy service works integrally with the Integrated Neighbourhood teams, providing falls prevention and community physiotherapy.

The service has physiotherapists, falls prevention nurse and therapy assistants; the team provide assessment and treatment to enable a reduction in the risk of falling.

Environmental visits; provision of equipment and walking aids is also within their remit.

Where is the service provided?

Patients are seen within their home or clinics when appropriate.

Who to contact

Contact: 01706 517775

Early Supported Discharge for Stroke

Who is the service for?

The Stroke Early Supported Discharge (ESD) service provide rehabilitation for adults and the elderly who have suffered mild to moderate strokes in their first 6 to 8 weeks from hospital discharge. We aim to contact patients within 24 hours of their discharge from hospital and see them within 72 hours for assessment and treatment.

What does the service provide?

The Stroke ESD team work closely with the hospital to identify those patients who are likely to benefit from early rehabilitation at home. The team focuses on patient centred care and will set individual goals based on the patients’ needs and wishes. This may include support with physical or cognitive symptoms, speech and swallowing, personal care, meal preparation, and returning to hobbies or employment. 

Stroke ESD are an interdisciplinary team consisting of stroke specialist physiotherapists, occupational therapists, and speech and language therapy; a stroke specialist nurse, and rehabilitation support workers.

The therapy team work intensively during the 6 to 8 week period with patients to help them achieve their goals and can refer on to other services such as, the neurological rehabilitation team if further rehabilitation is required beyond this point.

The rehabilitation support workers having competencies in all disciplines and can work on a range of problems within sessions. Home exercise programmes may also be provided for patients to work on themselves.

All stroke survivors are entitled to a review 6 months after their stroke. The stroke ESD staff complete this comprehensive review with all strokes regardless of severity which focuses on stroke specific problems and will action or refer on anything that is identified as a concern by the patient. 

The team work closely with other agencies such as the Stroke Association, GPs and social services to ensure the patient gets the best care possible.

Where is the service provided?

Patients are seen within community clinic, but more so in the patient’s home.

Who to contact

Contact: 01706 517772

Self-Management Service

Who is the service for?

Patients over the age of 18, suffering with or caring for someone with a long term condition who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

Expert Patients Programme | Self-Management Service

A team of non-clinical staff, tutors, national trainers and volunteers who provide a portfolio of accredited 6 week self-management programme(s) to adults living with long term conditions/illness, disability and carers whose own health is affected by their caring situation.

The programmes increase confidence and activation, supporting and enabling both patient and carer to take ownership of their condition/situation and form a better partnership with their health care professionals in all aspects of the day to day management of their condition or caring situation.

Where is the service provided?

The service is delivered from a variety of venues across the borough such as, community centres and libraries.

Who to contact

Contact: 01706 517774

Community Neuro-Rehabilitation Team (CNRT)

Who is the service for?

Patients over the age of 18, suffering with a neurological diagnosis, who are registered with a Heywood, Middleton and Rochdale GP.

What does the service provide?

The Community Neurological Rehabilitation Team (CNRT) will deliver specialist neurological rehabilitation to patients with a neurological diagnosis that have a need for neuro-rehabilitation intervention.

Specialist input from the CNRT interdisciplinary team will ensure a patient makes the appropriate route towards recovery with co-ordinated and cohesive care, and a person centred approach.

The interdisciplinary team consists of physiotherapists, occupational therapists, a speech and language therapist, specialist social worker, and therapy assistants.

Where is the service provided?

Patients are seen within community clinic, or the patient’s home as need requires. The service also provides clinic functions from Callaghan House and Nye Bevan House.

Who to contact

Contact: 01706 517774

HMR Treatment Room Service

HMR Treatment room appointments are available Monday to Saturday at a number of community locations. For non-house bound patients able to attend a treatment room, appointments can be made by our single point of access.

Treatment room services include wound care, dressing changes, suture and clip removal, ear care, injections and self-management advice.

For clinic details and times please visit our website.

Who to contact

Contact the single point of access: 0161 763 8525

Who to contact

Website
https://www.pat.nhs.uk/.../integrated-community-services.htm
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