Our Single Point of Referral number is 0300 033 0333 

Email: cnwl.cis3borough@nhs.net

The Community Independence Service (CIS) is an intermediate person-centred service providing advanced short-term nursing care, occupational therapy, physiotherapy and social care to people with immediate health issues or needs which affects their mobility or day-to-day activities. The service aims to provide safe clinical care at home which helps people to avoid unplanned hospital admission or returning to hospital after a recent discharge.

The service is available seven days a week from 8am to 10pm for adults over the age of 18 who live in, and are registered with a GP in the following boroughs:

  • Hammersmith & Fulham
  • Kensington & Chelsea
  • Westminster

Including nursing and care homes.

CIS consists of three teams in each Borough:

Urgent Community Response (UCR)

Provides fast access to a full assessment and the care you need.  Once we have received a referral, we will assess you on the same day.  As a community service we will visit you where you live, and in the most urgent cases we aim to be with you within 2 hours. ​​​​​

The service is available seven days a week from 8am to 10pm (including public holidays).

The UCR service will usually work with you for up to 5 days. However, the length of support we provide will be based on your individual needs and what assistance you require. 

Home First

Our colleagues in the community will work with you to provide short-term support following your discharge from hospital through Pathway 1.  Our Pathway 1 team is made up of professionals across organisations working together, such as carers, therapists and social workers. We will contact you within 24 hours of you returning home, and provide your immediate care at home.  Depending on what support you need: this may include help with day-to-day tasks.
 
The service is available seven days a week from 8am to 8pm (including public holidays).

You will be supported for at least three days; during this time, we will agree with you what your longer-term needs may be, and draw up a care plan.

Rehabilitation

Will work with you to help regain or maintain your health and independence at home.  We will carry out a complete and thorough assessment of your needs and current symptoms or problems, where you live. Then we will work with you to set individual goals: things that you would like to get help with, work on, and achieve with our support, to ensure that you can stay independent for longer.  The majority of people are seen within 48 hours, with non-urgent referrals assessed within 14 days.

The service is available five days a week, Monday to Friday, from 8:30am to 4:30pm.

The Rehabilitation service will usually work with you for up to 6 weeks. However, the length of support we provide will be based on your individual needs and what assistance you require. 

Case Management

For Hammersmith & Fulham:

Case Management provides a comprehensive and collaborative approach to your healthcare. We will work closely with you and all other professionals and practitioners involved in you care to develop a personalized care plan tailored to your specific needs that will support you to live independently and safely at home. 

The service is available five days a week, Monday to Friday, from 9am to 5pm. 

The CIS Case Management service will provide support that is flexible. We will work with you for anywhere between 3 and 8 weeks. However, the length of support we provide will be based on your individual needs and what assistance you require. 

Urgent Community Response

All Urgent Community Response referrals require a phone conversation from a health or care worker at 0300 033 0333.

An electronic referral through SystmOne should be completed for services using SystmOne. However the electronic referral should not delay the clinical handover.

In order to enable our teams to see the person on the same day the cut off point for new referrals is 8pm.

Please note routine and task based (that is, for the sole purpose of blood tests or ECG provision) home visits are outside of our scope; the service is not intended to replace urgent district nursing who can respond after 24 hours.

Home First

Referrals are made directly to the Home First team assigned to the hospital.

Rehabilitation

If considering a referral to rehabilitation but not sure what service is required, please refer to the guidance in the 'Related Links' section on this web page. Referrals to CIS from clinicians should be sent to SPoR via cnwl.cis3borough@nhs.net or via the SystmOne referral wizard (GPs).

To be accepted all referrals must include:

  • Reason for referral, explanation of clinical need that requires community rehabilitation intervention
  • Explanation of expectations from referrer of rehabilitation service. This includes what do you think can be achieved/what are the goals?

The triaging therapist may need to call the referrer to discuss further in order to appropriately prioritise

Self-referrals

If previously known to the service (within the last six months), self-referrals will be considered dependent on the outcomes of previous input and the current potential to achieve goals. To make a self-referral call 0300 033 0333.

Reablement

All reablement referrals must go via the appropriate Social Services Line:

Residents of Hammersmith & Fulham:

Tel: 0800 145 6095

Residents of Kensington & Chelsea:

Tel: 0800 587 0072

Residents of Westminster:

Tel: 020 7641 2500

If you need help in a crisis, please do the following

  • If you become unwell at any time it’s important you or your family, friends or carers contact your GP, Out of Hours GP or 111 (available 24 hours a day, 7 days a week) as soon as possible. 

  • If you require immediate attention and feel that it is a life-threatening situation, call 999.

Find your closest GP on NHS Choices.

Related Links