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Community intervention offer north Kerrier trial team

A trial team has started to work differently in the North Kerrier Primary Care Network. The team brings together a broad range of skills to work as 1 team and support people in their own homes wherever possible.
Initially this team includes colleagues from Corecare STEPs service, Cornwall Partnership NHS Foundation Trust’s Home First, advanced nurse practitioners and Cornwall Council adult social care.

Donna Bedford, a nurse from reablement services, tells us how the community intervention offer’s way of working has helped a man in her care.

The story

The team has started supporting a local man who has had a long history of self neglect. He has refused help many times and has not allowed people to enter his home. On this occasion he agreed to meet with Donna in his home with his friend present.

Donna said: “I tried to have a chat with the man to put his mind at ease. I like to find a niche with my cases, to find something we’ve got in common to build the trust.”

Donna started to build a rapport with the man and he became more relaxed and agreed to accept help and support. Donna has been able to organise regular visits to help with his personal care needs, providing him with treatments and assistance, which she says sets a good foundation to build on.

Donna says: “The man had quite a difficult history and he was able to tell me more about it as our conversation unravelled. I feel I have now gained more rapport with him so I can organise other services and improve his environment which will help to lift his mood.

“The benefit of being part of the community intervention offer is that when I visit a person I can talk confidently about the different services my colleagues can provide, rather than having to pass on a person’s details to another team. The service I work with can provide reablement, nursing care and help with social care needs and we have access to a doctor once a day. We are 1 service, which means the person only has to explain their story once. If this man had to talk to lots of different people from different services, I don’t think he would have engaged”.


  • Offers of help had previously been declined.
  • Lack of trust.
  • Self neglect was causing health issues which would have resulted in a hospital admission.
  • Multi-agency assistance required.

Outcomes and solutions

  • Multi skilled approach identified the best support for this person.
  • The team established the most appropriate person to visit and provided a holistic response.
  • A timely response.
  • Positive engagement and an agreed plan of support is now in place enabling this person to gain confidence and eventually manage his own self care.
  • 1 hospital admission has been avoided.

Keep up to date with news on integrated working across the Cornwall and Isles of Scilly health and care system, specifically the Embrace Care programme.

Added on 15 December 2020, in Case Studies - Embrace Care News

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