Main navigation

Children’s Continuing Care

The Children’s Continuing Care team provides care and support to children, young people and their families who have continuing medical needs, life threatening or life-limiting care and end of life care needs.

Each care package is individually developed to ensure it is tailored based upon the individual needs of the child and family.

We care for young people aged 0 – 18 who have complex health needs to allow families to have some respite. We provide accessible, flexible and high-quality specialist community paediatric care.

Continuing care is not needed by children or young people whose needs can be met appropriately through existing universal or specialist services through a case management approach.

What conditions do we support?

  • Complex chronic respiratory conditions and oxygen dependency
  • Conditions requiring ventilator support – CPAP (Continuous Positive Airway Pressure), BIPAP (Bilevel Positive Airway Pressure)
  • Tracheostomy
  • Conditions which require oral/nasopharyngeal suctioning
  • Complex seizure management
  • End of life/palliative care
  • Enteral feeding with other complex health needs

How can we help?

The Children’s Continuing Care Team aim to deliver an individualised high-quality support service to your child and the family which includes:

  • Assessment of your child’s individual needs including the views of the family about those needs
  • Risk assessments covering issues such as clinical care, moving and handling your child, fire assessment and an assessment of the child’s environment
  • Individual care plans with the care and medication regimes which are specific to individual’s needs
  • A Home Care Agreement which parents or guardians are asked to sign
  • Training and assessment of community support workers to ensure that they are able the meet the child’s particular health needs
  • Out of hours support via the on-call mobile telephone which is available after 5pm daily
  • An agreed range of medical equipment which will be loaned to the family and serviced regularly combined with a range of disposable supplies (which are not usually available on prescription from the GP)
  • Regular contact with the team leader or named nurse
  • Access five days a week (9am to 5pm) to the nursing support and office help

Who might my child see?

The team is made up of qualified nurses and community support workers who provide packages of care which might include day time and/or overnight care. The care shifts are usually provided in the family home, although sometimes this can be in nurseries, schools or other settings as agreed.

Your child may be seen by a number of professionals and settings, including:

  • Community paediatricians
  • Community children’s nurses
  • Social workers
  • Health visitors and school nurses
  • Dieticians
  • Learning disability nurses
  • Transition services
  • Nurseries, schools, colleges
  • Respite care, hospices

How do I access the service?

Before making a referral, you should:

  • Ensure a nursing needs assessment has been carried out by the young person’s community nurse
  • Liaise with the appropriate consultant and other professionals
  • Look at the Bristol Scoring Tool
  • Speak to the continuing care lead nurse

The child must be registered with a GP in Wiltshire and/or be resident in Wiltshire. The following can make the referral:

  • GP
  • Social worker
  • Health visitor
  • Acute hospital

Once we have received the referral and it has been accepted, verbal contact will be made by the lead nurse to the family as way of introduction. The first appointment will be made and the lead nurse will visit the family home to get to know the child and the family. Risk assessments will also be carried out at this time.