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Frailty Service

Established in April 2015, WECS offers healthcare services to residents in Residential and Nursing Homes, as well as to housebound patients residing in Weymouth and Portland. Our team operates in collaboration with all local GP Surgeries and the broader multi-professional community teams.

Arms

Residential and Nursing Homes

Every care home receives a weekly visit from a member of our team, typically their designated clinician. In the event of leave, one of our team members will provide coverage.

 

Our approach involves proactive, comprehensive assessments, monitoring chronic diseases, and engaging in advanced care planning, all aimed at preserving the quality of life, enhancing symptom management, and ensuring the delivery of personalized care. When appropriate, we address end-of-life care planning as well. Dr. Laura Godfrey supervises the medical care for all residents in Residential and Nursing homes.

Each home is affiliated with a specific GP surgery, and you can reach out to the designated clinician through this surgery. We maintain a close working relationship with MUCS (Mobile Urgent Care Service) and often conduct urgent visits to the care homes. Additionally, our Frailty Assistants frequently visit care home patients to address pressing needs.

Housebound Patients

Individuals who are experiencing frailty or are at risk of becoming frail can be referred to WECS for a comprehensive and thorough assessment that takes into account all aspects of their health and care requirements, including social factors, the risk of falls, and their nutritional status. This assessment is conducted in the form of a 'comprehensive geriatric assessment.' It also involves identifying the individual's care priorities and facilitating advance care planning to tailor the care accordingly.

Typically, this assessment is carried out by experienced Frailty Practitioners, such as Nurses or Nurse Practitioners. In more complex cases, Dr. Elizabeth Jones or Dr. Laura Godfrey may also be involved. Frailty Assistants, who are Health Care Assistants, may also provide support during these visits.

The primary objectives of these proactive visits and assessments are to enhance the quality of life, mitigate the risk of deterioration, optimize the management of chronic medical conditions, reduce the likelihood of hospital admissions, and support individuals in remaining in their own homes for as long as possible, thus reducing the necessity for admission to care homes. Referrals are made to the broader multi-professional team when necessary to help achieve these goals.

Following the initial assessment, some patients may be discharged if they are currently managing well or if they are not housebound. For patients who remain on the caseload, annual visits are conducted to identify any new issues, monitor chronic diseases, and ensure overall well-being is sustained. Patients are encouraged to contact the surgery if their circumstances change and they require additional support, with the flexibility to arrange visits sooner if needed.

Holding Hands

In each care home, there is a designated WECS clinician who conducts regular weekly visits, and each home is affiliated with a specific GP Surgery. Dr. Laura Godfrey oversees the medical care for all care home residents in her capacity as the primary GP. The team collaborates with Dr. Godfrey, who reviews care home residents when necessary.

Here's a list of care homes, their respective named clinicians, and the linked GP Surgeries. To contact the WECS team for a specific care home, please reach out to the surgery.

Dr. Laura Godfrey

  • Anning House – Cross Road Surgery

  • Queen Charlotte Care Home – The Bridges Medical Centre

  • Weymouth Care Home – Royal Crescent Surgery

Dr. Elizabeth Jones

  • Fairfield Nursing Home – Wyke Regis and Lanehouse Medical Practice

Trish Pugh

  • Danmor Lodge – The Bridges Medical Centre

  • Goldcrest Care Home – Dorchester Road Surgery

  • Chestnuts – The Bridges Medical Centre

  • Rodlands – The Bridges Medical Centre

Lesley Oakes

  • Crecy Care Home - Royal Crescent Surgery

  • Elsadene - Royal Crescent Surgery

  • Weymouth Manor - Wyke Regis and Lanehouse Medical Practice

Sharon McLoughlin

  • Agincourt – Dorchester Road Surgery

  • Friary House - Royal Crescent Surgery

  • Buxton House - Wyke Regis and Lanehouse Medical Practice

Hannah Murphy

  • Trafalgar Care Home - Royal Crescent Surgery

  • Primrose Lodge – Dorchester Road Surgery

Andy Smith

  • Legh House – Wyke Regis and Lanehouse Medical Practice

  • Bosworth Care Home - Royal Crescent Surgery

  • The Lawns - Royal Crescent Surgery

Nancy Stafford

  • Kingsley Court - Royal Crescent Surgery

  • Ingleside Care Home - Royal Crescent Surgery

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Reach- Drug and Alcohol services

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