• Care from the Home Ward (Frailty) can help a person living with frailty stay at home where they are most comfortable, avoiding being admitted to hospital.
• For a person living with moderate or severe frailty, being cared for at home can improve the outcome of their care and their experience by reducing any disruption to their lives and the lives of their family and carers.
• The Home Ward (Frailty) can support people to return home more quickly after a hospital visit, reducing the risk of them becoming less independent.
• The ward will work alongside others involved in the person’s care to ensure a plan is put in place for after their time on the ward.

It is jointly led by Community Matrons and Consultant Geriatricians, supported by a pharmacy team, the third sector and specialist input from community teams such as the Long Term Conditions Service and adult social care.

People referred will be seen and assessed by a Community Matron or Trainee Community Matron within two hours of the referral being received (where clinically indicated), unless the referral is made after 5:30pm.

Following the initial assessment they will be accepted on to the Home Ward (Frailty) if they meet the criteria, and the overall responsibility for their care will transfer to the team and a Consultant Geriatrician. The initial assessment may involve rapid blood tests if appropriate.

The Home Ward (Frailty) is there to assess and provide clinical support to people who:

• have been identified as moderately or severely frail using the electronic frailty index (eFI) and/or have a Rockwood score of 5 or more
• are aged 65 or above
• are registered with a Leeds GP
• have been seen by a referrer/healthcare professional (with the exception of NHS 111)
• can be cared for safely at home, for example, have a NEWS2 score of less than 5 (with the exception of single score of 3 in one parameter) dependent on the person’s baseline NEWS2 score (see the exclusion criteria below).

Exclusion criteria

People will not be accepted onto the Home Ward (Frailty) if they are displaying signs of an acute medical/surgical emergency, for example: overdoses, poisonings, alcohol withdrawal, intoxication, sepsis, seizures, allergic reactions, eye conditions/changes in vision, suspected significant injury after a fall/trauma, diabetic ketoacidosis or hyperosmolar hyperglycaemic state, stroke/transient ischaemic attack (TIA), venous thromboembolism (VTE) and myocardial infarction.

If you are unsure whether somebody is suitable, you can call the Primary Care Advice Line (PCAL) on 0113 2065996. This line is available Monday – Friday 8:00am-8:00pm, Saturday – Sunday (including Bank Holidays) 8:00am-7:00pm, Christmas Day 9:00am-5:00pm.

Referral needs to be from a clinician who has seen the person face to face (or NHS 111) and uses either the eFI or Rockwood score to determine their frailty score. The following are listed as able to refer but some may need a clinician (such as a GP) to support the referral:

• Primary care (GPs, Advanced Practitioners, and Physician Associates)
• Yorkshire Ambulance Service
• Community care beds
• Care homes (both residential and nursing can refer via a GP or Registered Nurse)
• Neighbourhood Teams and Leeds Community Healthcare NHS Trust’s specialist teams
• Leeds and York Partnership NHS Foundation Trust clinicians following a discussion with a Consultant Geriatrician
• Leeds Teaching Hospital NHS Trust clinicians following a review or a discussion with a Consultant Geriatrician or Emergency Department consultant
• Clinicians from NHS Trusts outside of Leeds following a review by a Consultant Geriatrician or Emergency Department consultant

A referring clinician needs to have seen the patient face to face to make a direct referral (unless they are an NHS 111 referrer). If this is the case, referrers can contact our Single Point of Urgent Referral (SPUR) on 0113 843 2291 to be connected to a Community Matron.

Non-clinical referrers should contact the patient’s GP or the appropriate Neighbourhood Team Triage Hub to identify if the patient meets the clinical criteria. More information on the areas covered by each Triage Hub can be found on: leedscommunityhealthcare.nhs.uk/NeighbourhoodTeams

Service operating hours:

• The Home Ward (Frailty) is a 24 hour service, operating 7 days a week, taking referrals between 8:00am-8:00pm.
• Referrals for patients that require same day assessment will need to be made between 8:00am-5:30pm.
• Referrals received between 5:30pm-8.00pm will be assessed the next day.