IT’S stories like the one about the brain injured man who managed to go home that really make us appreciate the work of the community nursing team.

As Ruth Chard, social care occupational therapist with Northumbria Healthcare Trust, says of hospital patients beset by serious ill health, “we want to give them the hope of going home.

“We had one gentleman who went from hospital to a care home following a brain injury. We were told that such was the effect on him, he needed to go into secure accommodation.

“But we got that man home, back with his dogs, in a rural location, with support – it has been a great success story.”

Ruth, who is part and parcel of the long-term community support team, and short-term services co-ordinator Paul Ellwood agree that it is those ‘wins’ that make their jobs so worthwhile.

Paul said: “We get a lot of good feedback. We get messages from people saying they were sad we had to leave – you build up a relationship with the clients.”

Community matron Sarah Winspear emphasises that it takes a collaborative approach – the partnership working of several different teams and sometimes organisations – to achieve such a success.

Her own team of community nurses work closely with the long and short-term care teams, the GP practices and, indeed, Tynedale Hospice at Home.

“It’s all about collaboration,” she said. “The aim is to try to keep people in their own homes as long as possible and we all play our part in that.”

Sarah’s team of 13 comprises a district nurse and sister, one and the same person responsible for the day to day running of the team, staff nurses and a healthcare assistant.

“The staff nurses deliver the care on a day-to-day basis, but if there’s a complicated hospital discharge I will get involved and draw up an emergency care plan,” she said.

“My role is to deal with the more complex patients – those at risk of being admitted to hospital, which is usually patients with chronic conditions and end of life patients.

“I have extended skills, which means I’m qualified to carry out clinical examinations and I can prescribe, so I have more capacity to keep them at home than the community staff nurses.”

Long term conditions they dealt with included chronic obstructive pulmonary disease, multiple sclerosis, Parkinson’s, rheumatoid and osteoarthritis, head injuries and dementia.

The focus of all three teams, whether it is helping to bring someone out of hospital or to prevent them going in in the first place, is to make that experience as comfortable as possible for the patient.

Paul Ellwood and the rest of the short-term support team get involved at the most fundamental level – ensuring patients can get washed and dressed.

The team begin working with patients at the point of discharged from hospital. “Maybe someone has had a stroke,” he said. “We go to practise washing and dressing with the client, and I would say ‘how did you manage before your stroke?’ and ‘how did you manage with the occupational therapists in hospital?’

“I find out what the client can and can’t do and assess whether they need help or special equipment.

“We are out visiting the client the same day they come home from hospital and we don’t pull out until all their needs have been met and their ongoing care is sorted.”

Ruth picks up the thread here. “With a stroke, for example, it’s about getting a patient back into a routine when their body is different,” she said.

“They will have practised things in hospital with occupational therapists and physiotherapists, but it can be a difficult transition going home.

“We can do a lot to help though, and sometimes just simple changes are required.

“It could be the layout of their house or a room needs to be changed – simply a case of moving furniture – or they might need a walk-in shower installing, or perhaps a ramp to provide wheelchair access to their front door.”

Reducing the risk of falls was imperative, and there again simple remedies, such as fixing down rugs and threshes, were often very effective.

“Falls are the biggest killer really, because of the complications that arise from broken hips and banged heads,” said Ruth.

“Once someone has had a fall, their confidence goes too and anxiety develops about going out.”

All of their jobs are made that bit more challenging by the very rurality of the patch, said Sarah. “Some patients live miles from anywhere urban and that brings its demands.

“Last year, we had a husband who had to drive his wife out on a tractor to us.”

The team did have access to pool cars that were 4x4s though, which had certainly been used by the nurses travelling out to the hinterlands of Bellingham. “They do a lot of walking too,” said Sarah.

“There is always support at the end of the telephone, but you do have to be more resilient and be able to use your initiative in this job.

“You don’t know what you are going to find when you go into somebody’s house.”