Multi-disciplinary Care Home Support Team (MDT)

Our MDT is made up of healthcare professionals including a general nurse, mental health nurse and physiotherapist. The team meet every Monday where they plan personally-tailored care plans that will be offered to the residents they are working with. Each team member brings a different specialism to the table; allowing the team to build up a complete picture of how best to help each resident, delivering the Connecting Care+ vision of “person-centred” care.


A unique aspect of the MDT is the strong relationships they have built with care home staff. In the past, relationships between health and social care organisations and care homes were very fragmented. However, homes now work collaboratively with our team to shape the future of care in Wakefield.


The team have built confidence in care home staff through ad-hoc training sessions and advice. Such sessions include Staying Steady and Posture, Position and Pressure training; empowering care home staff with the confidence to handle, stretch and mobilise residents. This overall provides quality of life for residents, whilst minimising falls and up-skilling staff.



Case Study of MDT in Action:

Mr P moved into a care home after his wife was unable to care for him following his discharge from hospital after a bout of pneumonia. His condition was deemed to have low rehabilitation potential and he had to be nursed from bed and fed a pureed diet. Mr P was highlighted as presenting ‘challenging’ behaviours and his wife mentioned Mr P’s frustrations of being bed ridden and how he had made many attempts to stand and leave his bed.


The MDT discussed the concerns of Mrs P and identified that an assessment was required with a mental health nurse and general nurse. The assessment took place at the care home, with Mrs P in attendance and a care plan for Mr P was put into place. Within the care plan, it was agreed that Mr P would further be assessed by:


  • The speech and language therapist regarding his diet
  • The physiotherapist regarding rehabilitation potential
  • The occupational therapist to assess for required equipment such as appropriate seating.


The physiotherapist developed an exercise plan for Mr P, and with time and encouragement from his wife, Mr P is now able to stand and walk again. Mr P also now has a chair that allows him to sit in the lounge with other residents and is therefore spending time out of his bed and his room, reducing his social isolation.


Without the involvement of the Team, Mr P would have been moved to an nursing unit. Mrs P says she has felt listened to, and reassured by the team, she has also been able to make a much more informed decision, with greater confidence, regarding his care and is pleased with his recovery. The intervention and support of the MDT had a huge impact on quality of life and the mental and physical health and wellbeing of Mr P, and has overall meant that Mr P has been able to avoid:

  • A move to an inappropriate placement in a nursing unit
  • Being nursed in bed instead of being mobile (it was wrongly believed that he had no rehabilitation potential)
  • Pressure sores
  • Referral to consultant psychiatrist and involvement from mental health teams
  • Unnecessary medications for challenging behaviour.