High Impact Change Area A: Embedding effective support for unpaid carers – case studies

Plan

The Carers Intensive Support Team (CIS) in South-East Essex supports vulnerable and ageing carers who are caring for a person with suspected or confirmed dementia, frailty or an older person with mental health concerns. The cared for must have suspected or confirmed dementia (any age), frailty or mental health problems (over 65). The carer is over 65 unless caring for someone with dementia then the Carer can be any age. 

The team is non-clinical and consists of a Team Lead, six Senior Support Workers and an Administrator. The team has weekly group clinical supervision with a Dementia Nurse Specialist to discuss any clinical concerns they may have for the carer or cared for. 

Implementation

Based in the Dementia, Older Adult’s Mental Health and Frailty Services, CIS work in the Community setting and are integrated with PCN’s, other Community Health Teams, Adult Social Care in two Local Authorities, the local Acute setting at Southend Hospital and the third sector. 

The team provide crisis intervention to prevent carer breakdown and manages rising risk using comprehensive personalised Carer Health and Wellbeing Checks for physical, mental, social and emotional Health. They support carers who may be living with long term conditions, and who neglect their own physical and mental health due to their caring role. They empower and enable carers to think about their wellbeing by accessing community offers to build resilience and manage their caring responsibilities.

CIS have a unique service offer with direct electronic access to health systems enabling contact with PCN’s, GP’s and community health as needed, as well as working closely with Adult Social Care, Discharge Teams, Community and Acute settings, Care Providers and Care Homes to provide wraparound support for carers. 

Once referred the team support the carer to care in any community dwelling, usually their home setting or sheltered accommodation. The team continue to support if the cared for goes into Hospital, respite or a permanent residential setting. Generally, support is only discontinued when requested by the carer.

The team provide eight community Carers’ Health and Wellbeing Drop-in Support Groups across the two local authority areas and a further Carers’ Frailty Hub at Southend Hospital each month.

Outcome 

CIS was funded in 2022 for one year with two senior support workers for crisis response. Year two and three funding was increased to provide six senior support workers that enable and demonstrate prevention of crisis and manage rising risk through the Carers’ Health and Wellbeing Checks. This has been achieved through regular monitoring of information requests, KPI’s, outcomes and a Carers’ Voices research piece by the University of Essex. 

The team have avoided hospital admission or care home placement for 100% of the carers supported by CIS. 100% of carers have been responded to within the agreed time frame. The Team Lead is currently exploring funding opportunities for the continuation of the service post June 2025.

Contact

Nancy Smith – Carers Intensive Support Lead & Integrated Practice Support Officer

Email: [email protected]

Plan

The original Carers Hub at Bedford Hospital functioned independently, separate from the wider hospital structure. Recognising the need for integration, Carers in Bedfordshire collaborated with the Patient and Liaison Team to create a joint Hub called the ‘Patient Experience Hub’ that provides a comprehensive support system for both patients and carers. The Hub focuses on delivering early assistance, helping patients and carers navigate the healthcare system, share experiences, and resolve concerns promptly. A key objective is to direct patients and carers to appropriate services efficiently and effectively within a hospital setting.

Implementation

The Hub's primary function is to offer early-stage support to carers, ensuring they have access to relevant advice and understand their rights. This holistic approach supports carers in several essential ways:

• Access to benefits and welfare advice: helping carers navigate financial support systems
• Information on funding care: offering guidance on the financial aspects of long-term care
• Support through discharge planning: assisting carers with the complex process of planning a patient’s discharge from the hospital
• Communication with hospital staff: acting on behalf of carers to ensure they remain informed about their loved ones
• Emotional support during care planning: helping carers through the emotionally challenging process of planning ongoing care
• Bereavement support: providing critical emotional support during times of loss
• Signposting to services: connecting carers with relevant community resources
• Continuing support: ensuring carers receive ongoing support to reduce the likelihood of hospital readmissions.

Additional activities

The Hub offers a range of services to further assist carers:

• Carers packs: Tailored packs for dementia and learning disability carers, including concessionary parking and carer visiting cards for ward access
• Ward visits: Volunteers regularly visit wards to identify carers and raise awareness among hospital staff
• Carer awareness training: Hub staff provide monthly ‘Carer Aware’ training for new hospital staff as part of their induction
• Advocacy: Hub representatives attend hospital meetings to advocate for carers’ rights and promote the service.

Outcomes

The Carers Hub has made a significant impact, conducting over 1,200 carer conversations and 500 staff conversations annually. New carers are invited to register with Carers in Bedfordshire, ensuring they receive continuous support.

Carers have shared positive feedback about the initiative, with comments like:

You brought me back to life after my wife went into care.”

I felt like I’d been hit by a bomb. The hub gave me a place to talk and cry – I don’t know where I could have done this if it wasn’t there.”

The success of the Hub has led to its inclusion in Bedford Hospital’s 3-year Patient Experience strategy, further cementing Carers in Bedfordshire as a key partner in delivering holistic healthcare support.

Next steps 

Carers in Bedfordshire hospital staff now have access to the hospital’s Nerve Centre system, which will improve communication with staff and help identify carers when patients are admitted. Staff are working alongside the Patient Experience Matron to enhance the hospital’s digital infrastructure for better carer identification and support. We are also working with the trust to rename the Hub to include the word ‘Carers’, to ensure patients and carers feel more welcomed. 

Plan

The dementia cafe is dedicated to establishing a friendly, relaxed and calm place, bringing together and supporting patients with dementia, along with their family/ carers. 

Implementation

This monthly forum offers an important opportunity for families and carers to come together and share experiences, stories, and strategies for coping. Additionally, it allows access to professional advice, with support for any concerns raised and the ability to discuss practical solutions to take care of someone with dementia. This service is further bolstered by carers being signposted to relevant organisations such as Alzheimer’s society, Carers MK, Age UK etc. 

Outcome

There has been extremely positive feedback from patients, families/ carers and staff, reporting improvements in appetite, an increase in engagement between patients and staff and a reduction in boredom, restlessness and agitation amongst patients.