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Who we are

Our Integrated Community Frailty Team provides assessment, treatment, support and a two hour rapid response, for Knowsley registered patients 65 or over, who are at risk of hospital admission.

The aim of the service is to reduce the number of people needing to go to hospital by keeping patients safe in their own home, however they will also have access to the step up beds in the community.

The Integrated Community Frailty Team is led by community matrons with advanced skills in the frailty pathway, and is supported by nursing staff, therapists, social care professionals, medicines management and specialt falls assessors.

The service is available 8am to 7pm Monday to Friday and 9am to 5pm at weekends.

Our service is for Knowsley patients 65 or over who are registered with a Knowsley GP, and at risk of a hospital admission.

Our Integrated Community Frailty Team works in partnership with Knowsley Clinical Commission Group, Knowsley Council, North West Ambulance Service, St Helens and Knowsley University NHS Trust (who provide access to their Frailty Unit), and Aintree University Hospital (with direct access to their frailty clinics).

If you are at risk of a hospital admission, an urgent referral will be made into the service by your GP or community nursing team.  

You will be visited within two hours from the referral being made. An advanced clinician will contact you over the phone to inform you that they are on their way to visit you at home.

They will ask you some questions, conduct a physical examination and take some observations to determine what the best treatment is that you require. Most of our staff can prescribe any medication that you may need.

Following this initial assessment, they will discuss and agree with you a care plan and involve other professionals from the Frailty Team as required. This may include a medicines management review, social care assessment, reablement to support you at home, and a therapy or falls assessment.

Following your initial assessment, the advanced clinician may decide that it's in your best interest to be looked after in one of our intermediate care beds in Knowsley. We will aim to organise the transfer on the same day, subject to bed availability.