Projects list

Promoting healthy ageing (prevention)

Evaluating the feasibility of the Nutrition Wheel & validating the questions

A research assistant from Bournemouth University aims to recruit up to 20 volunteers (working with older people in the community in Dorset) to use the Nutrition Wheel with older people they come into contact with. Data will be collected on the number of people the Nutrition Wheel was used with and likely risk of undernutrition, and focus groups / telephone interviews will be held to obtain qualitative feedback on the use of the Nutrition Wheel (e.g. ease of use, understanding the instructions etc). We will also use volunteers / care navigators working in Hampshire (through contacts with previous projects) to trial the Nutrition Wheel. In addition, we are currently validating the four

Village Agent Service

The scheme supports older people in rural areas, assisting them to access information and the support services they need. As an active member of their local community a Village Agent directs people to the information about such things as day care, foot care, computer training, transport for shopping and medical appointments, finding reputable tradespeople and help around the home. Village Agents operate in a variety of ways, from supporting individuals in their own homes, to running drop in advice clinics at local community venues, to organising social and well-being activities that encourage people to remain active and avoid loneliness and isolation.

Communicare in Southampton

Communicare in Southampton is a charity that can help anyone who needs support in particular those who have little or no support from elsewhere. We help through befriending and supporting isolated people across the city. Our new project is to organise 12 community tea parties throughout the year particularly focusing on sheltered housing and residential warden controlled accommodation. The events will include activities to promote physical and mental activity promoting health and well-being.

Time of Your Life Campaign

Time of your Life is a project aimed at looking forward to retirement and it was a collaborative approach with Southern Health Geriatrician, primary care and commissioners to put together a Z card to promote 10 top key messages to concentrate on in preparation for retirement. 1)Think about your current health and wellbeing needs, 2)understanding ageing is natural, 3)Keep moving, 4) Stay in touch with friends, family and your local community 5)Be Creative, 6)Prevention is better than cure, 7)Think about Finances, 8)Make home work for you, 9)Get everything in order, 10)Plan your care.

Connect To Support

Connect to Support Hampshire is an online information and advice guide and directory of services for adults with care and support needs who live in Hampshire. This website is intended for all residents who want to find out about local groups, activities and services within the community as well as formal care provision. It is also intended for people who may wish to arrange their own care provision.

Eat Drink Move

Eat, Drink, Move is part of a national initiative linked to #endpjparalysis and #last1000days looking at how we can value every moment of our patients

Enhanced Health Care in Care Homes pilot (EHCH)

The pilot is designed to bring health care services into the 15 care homes selected for the pilot. The part delivered by Southampton primary care Ltd is seeing residents and offering comprehensive geriatric assessments for each resident, medication reviews, long term condition reviews, sign posting to other services. Our team compromises a ANP, GP, HCA, Physiotherapist, OT and Dietician.

Living, not existing:Social Groups for older people

A pilot project exploring the benefits of weekly occupation-focused social groups held for older people who may live alone or in isolation in Wiltshire and the surrounding areas. The groups will be facilitated by a therapy outreach

Getting Granny Going

I am evaluating the project as an employee of the University of Portsmouth. It is a 3 year project to develop a range of outdoor activity projects along the coast and in parks for inactive Grandparents aged 55+ to get active with their family and friends. The project will identify best practice in intergenerational delivery for these audiences and test the effectiveness of reaching older people through family influencers and the use of non traditional settings and programmes.

Information and Advice Service Hampshire

We provide information and advice to any older person, their family, friends, carers or neighbours, on services and activities available to them. We can carry out benefits checks and assist with applications including form filling. We advise and assist on aspects of finances, housing, care and support, health care issues, transport, carer support, consumer issues, help in the home and legal information. We can assist people find reliable tradespeople and practical help. We provide information over the phone, via email and face to face including home visits where needed.

Use of Stem Cell glue in Total Hip Replacement Revisions

Hip replacement is a successful intervention that treats end stage osteoarthritis. However around 8,000 hip replacements per year in the UK are revisions of failed primary implants. Revision hip replacements are not as successful and failure due to loosening and infection are more common. An autologous stem cell glue, which is sprayed onto the implant surface at surgery, has been developed. This glue contains antibiotics and stem cells, which combats infection and enhances implant fixation. This invention is about to go into a clinical trial at the RNOH

Long title for this test project


Group Exercise Classes

These classes are specialist exercises classes. They are 1 hour long and are aimed at varying demographics. The different categories of classes are as follows: for older adults (65+) , those with reduced balance and mobility, for those living with MS, with Parkinson's, with effects of a Stroke. All the classes are physiotherapy led and accompanied by a therapy assistant and/or fitness instructor.

Inter generational food offer

Inter generational food offer with neighbourhoods so people can grow, buy, cook and eat together.

Living with frailty (mild / moderate)

Hospital Homecoming

Communicare in Southampton is a small local charity, based in the heart of Southampton, we are a friendly, neighbourhood charity that enriches the lives of lonely and isolated people in and around the city.The new project 'Hospital Homecoming

Dorset Frailty Toolkit

A project spanning primary and community services to give a model for the ongoing case-finding for frail patients from various sources. It also shows a way to approach to care planning to enable primary and community services to enter data on the same template

Hospital to Home Service

To improve the patients

Frailty Clinic Chandlers Ford

Facilitated meetings were funded and lead to the establishment of a monthly clinic for people living with frailty. A consultant physician works alongside a social care lead in a GP surgery with access to the GP, a mental health care lead, and the community team. It is an integration of health and social care. Patients are identified by all members of the community team and referred via the GP. A combination of mobility problems, carer needs and often memory problems was the best indicator of frailty. Patients had an holistic assessment over one hour then half an hour social care advice. Carers and relatives were involved at all stages and social care input was given for the home environment, benefits and advanced care plans and respite arrangements. Initially set up with goodwill this became a service reconfiguration with no additional cost the NHS.

Hampshire Reablement Pilot

Reablement is the process by which people are supported to recover from a period of illness. National best practice is to discharge people from hospital into their own homes with reablement support services and then, when needed, to commission longer term care from home. This model reduces length of stay in hospital for patients who no longer need to be admitted and enables long term care needs to be reviewed once the patient is back at home. In response to on-going poor DToC performance within the West Hampshire system and a recent CQC inspection plus external report from Newton Europe it was recognised that a strategic priority was to adopt a

Managing patients at risk of hospital admission

Tri Locality Care (TLC) Ltd has launched a Project, commissioned by West Hampshire CCG, to identify vulnerable patients and those at high risk of hospital admission and manage this caseload both proactively and reactively to maintain care outside of hospital, as appropriate. There will be strong links and close working arrangements in place with the community care team, the integrated care team, social and voluntary sector organisations as well as secondary care when needed. The team have been working with University Hospital Southampton FT and the Community Emergency Therapy team.

Frailty Assessment Unit

Patients over 80 identified within the Pitstop environment within the Emergency Department or via GP admissions are pulled by a Geritrician into a frailty assessment area which is supported by a multi disciplinary team. The service presently runs Monday to Friday 9 am - 5pm.

Reducing hospital admissions

By measuring the number of care plans in 6 care homes and intervening to write care plans. Training staff to ask questions and to generate care plans on admission

Polypharmacy in care homes

This project measures the extent of polypharmacy by undertaking a PDSA cycle, reviewing and evaluation of change and measuring against admission data

Implementation of the Comprehensive Geriatric Assessment (CGA) process in an acute hospital

Implementation of the Comprehensive Geriatric Assessment (CGA) process in an acute hospital improves quality of discharge for people living with frailtyimproves quality of discharge for people living with frailty

Implementation of the Comprehensive Geriatric Assessment (CGA) at University Hospital Southampton

Implementing the Comprehensive Geriatric Assessment (CGA) at University Hospital Southampton

Frailty Specialist Service Redesign

Patients over 75 often with complex co-morbidities are not getting access to specialist geriatric assessment and care planning early enough across HHFT. As a result some are being admitted unnecessarily or staying longer than they medically require. They are subject to multiple moves, multiple assessments and significant levels of deconditioning. This can have an adverse impact on patient outcomes. Organisationally this causes delayed transfers of care, increased bed occupancy and puts significant pressure on the available bed capacity across the trust. This situation is no longer sustainable. At BNHH we will aim to increase the number of 0 day discharges for frail patients by September 2019. Frailty refers to patients with 1 or more of the 5 frailty syndromes: falls, immobility, delirium, incontinence and polypharmacy. Key Principles • 24/7 pathway for frail older patients • Earlier specialist intervention • Comprehensive multidisciplinary assessment in an appropriate environment • ‘Home first’ principle • Prevention of deconditioning • Integrated model in collaboration with community partners (SHFT) Objectives • Increase the number of frail patients being seen in emergency department. • Reduce the time taken to recognition of frailty diagnosis • Reduce the time taken to initiation of CGA by a further 50% • Reduce the number of over 75yrs admissions by 10% within 1 year • Increase patient/carer satisfaction with regards to frailty pathway

Communicare in Southampton: Hospital Homecoming Service: Service Evaluation

Project aims for safer discharge of older and vulnerable people; Improve the quality of live and independent living; Reduce readmission rates

Population health management

What matters most to the patient Devising individualized, patient led management plans addressing the management health care conditions through social prescribing to achieve their stated goal. Caseload finding through GP note finding screening those with moderate frailty score, long term conditions (HF, high BP, diabetes, COPD, CKD) codes. 39 patients identified, nursing homes and severe cognitive impairment not approached, 3 declined, 10 patients visited.

Hello Southampton

Social welfare checks via Phone, “Hello Southampton”

Baseline frailty assessments for house bound patients

We complete baseline frailty assessments for generally housebound patients. We have had to change assessment process to be questionnaire based first to limit time in peoples homes

Admission avoidance

Admission avoidance in Dorset

Crisis (decompensation) / Severe Frailty

Acute Frailty Pathway (IOW)

As part of a wider group (looking at end to end system wide Frailty Pathway) we have begun working on an acute frailty pathway to implement early identification (screening at front door) and holistic overview assessment (CGA) to identify key risk and needs and facilitate timely discharge and handover of care to the most appropriate community teams. The programme is reviewed and modified through a PDSA cycle.

Frailty Support Team: proactive and reactive care for people living with frailty in the New Forest.

Reactive: managing people through a phase of acute decompensating of frailty to enable them to stay at home safely. Referrals coming from GPs and SCAS as well as the on call consultant at Lymington Hospital Proactive: supporting Care Homes in managing people living with frailty and ensuring robust escalation of care plans are written and agreed with residents and their families Care homes selected on their need for proactive support.

Role of ACP working with older people during Covid-19

Research into the role of ACP working with older people during Covid-19 Contact mboard@bournemouth for more details and to take part

The Frailty Hub

We are a relatively new team that has been set up to manage the expanding Frailty caseload. The practice has a population of 43,000 patients. At the moment approximately 1500 patients are managed. This includes severe, moderate and mild Frailty, and also encompasses vulnerable groups such as learning disabilities and mental health. We have a Care Coordinator who manages the Frailty Line- a direct phone number set up to allow patients to contact the team/practice directly. The team carry out proactive holistic 'top to toe' assessments and conduct follow up reviews ongoing to ensure patients feel supported.

End of Life

The Red Bag Scheme

Following a successful project in Sutton, Surrey the concept of the red bag has spread to Hampshire and is being trialled in a number of care homes and hospitals across the Winchester and Basingstoke areas. The red bag is a repository for the key items belonging to an individual on admission to hospital. It comprises the care plan and has a space for medication, hearing aids, dentures and other items the person needs to function.

Long Title

Testng best approaches and use of perfumes

General / Training

Hydrate in Care Homes - Hampshire

Hampshire County Council owns and manages over 23 care homes across the county caring for over 900 people. Hydration has been identified as an issue and following a small trial of Hydrate in Care Homes in a few of their care homes they have decided to spread this to all their Care homes. Hydrate in Care Homes is a set of steps that educates the staff team and introduces resources and processes. In NE Hants and Farnham this approach was evaluated and shown to reduce falls, UTIs and hospital admissions. It was then spread across Kent, Surrey and Sussex and similar outcomes shown. Hants CC has a project team that is implementing this work.

Developing e-learning for Frailty

Following on from an initial project to develop e-learning titled: An introduction to Frailty aimed at all staff that come into contact with patients, we have now developed a further e-learning platform to enable senior staff to treat people living with frailty. This project has been aimed at senior clinical staff including doctors, nurses and AHPs who do not specialise in older people

Hydration in Care Homes - Red Cups

We are part of the activity team from Westholme, a Hampshire County Council care home based in Winchester. We are a 74 bed home made up of 34 residential beds, 30 nursing beds and 10 discharge to access beds. We also specialise in dementia. We started working on the hydration project about 2 years ago, after being selected as a trail home for the Red Cup Project. The Red Cup project replaced all our glasses with red plastic ones. Staff were all given a training lesson led by the Clinical Commissioning Groups on the importance of hydration. It was explained the red cups were going to replace the clear glasses and the hope was that resident would take more notice of the red cups and it would remind them to drink. After this training session the manager appointed the activity team and a member from the kitchen as hydration champions. She also asked what would help staff with promoting hydration. Staff suggested that blenders would be a great help on each unit and smaller jugs so residents would be able to pour their own drinks.

Dorset Frailty Accreditation Pathway

The RCGP is developing GPs with Extended Roles (GPwERs). This includes those GPs previously referred to as GPs with Special Interests (GPwSIs) and the role of GP Extensivist in Dorset. The Dorset System have pre-empted this work and engaged with those currently working as Extensivists and GPwSIs, Nurse Consultant Practitioners, AHP Nurse Consultant Practitioners and Mental Health Practitioners, to identify the necessary development and accreditation pathways to support Dorset’s workforce.

Wessex AHSN Frailty Awareness and training

Presently across Wessex, there is variation in the understanding of frailty due to the lack of mandatory, formalised, structured training means that colleagues are unable to access standardised training according to their role, resulting in patchy awareness and knowledge. There is presently no requirement for Trusts to deliver induction or mandatory training relating to frailty. A task and finish group has been set up with local experts to develop a training and awareness programme that will bring together online resources, videos and available information to support the understanding and management of frailty as a syndrome. The training will map to Tier 1 and Tier 2 level Skills for Health competencies.

Community Support Workers Service

Project focus: To support patients at home to prevent hospital admission, to facilitate early discharge and support those at end of life. Short care only (up to 7 days) providing support with personal hygiene, dressing, food preparation, medication support, care when reaching end of life, basic nursing observation, continence issues, skin care, washing clothes and bed linens. The service is available between 08:00 – 20:00

Alzheimers Research UK app

Alzheimer Research UK app now available on Health Education England website

Improving frailty screening in the Emergency Department

Review of screening rates by ED Frailty Lead and Frailty Interface team. A comparison of CFS scores for 10 consecutive patient per day during June 2020 by the two different teams to assess variance. Education intervention carried out to improve accuracy of recording.