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Home » Health Professionals » Patient Pathways » Admissions avoidance » Cambridge and Ely

Cambridge and Ely

On this page you will find local contact information about falls prevention, JET, social services, community respiratory team, breathe easy groups, mental health, community geriatrician, RADAR admissions avoidance, neighbourhood teams, help at home, health and wellbeing network, ambulatory care, step up beds, Carers' Trust, reablement, admissions avoidance team, SAFE and Home Instead.
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The contact information on this page is for health professionals only, thank you.

Page contents

Falls Prevention 

Falls Prevention is part of the Healthy You service. Visit www.healthyyou.org.uk or email eh.healthyyou@nhs.net.

Early Intervention Team

Based at CUH

  • Phone: 01223 274752 (main office)/ 01223 348306( SDEC office)
  • Mobile number: 0775474 8123 (8 AM - 8 PM)
  • Email: add-tr.eit@nhs.net


The Early Intervention Team consists of Frailty Specialist Nurses, Therapists (PT/ OT) and Discharge Planning Specialist Nurses.

They offer single referral point for Frailty assessments, Therapy assessments and Discharge Planning assessments to Emergency Department and Medical Assessment Units/ SDEC.

EIT believe in strong multidisciplinary team work, valuing the individual contributions of the team, as well as supporting the wider organisation in understanding and caring for frail older people.

Monday to Sunday from 08:00 to 20:00 (subject to staffing)

Role of the team

  • Early Intervention Frailty Nurses will screen patients for frailty markers in ED and initiate Comprehensive Geriatric Assessment for moderately frail patients aged 75+ admitted via Emergency Department.
  • Early Intervention Discharge Planning Nurses will complete collateral history and facilitate admission avoidance and early discharges from ED/ SDEC. Provides discharge planning support and offer discharge planning assessments ( e.g Fast track, Hospital equipment) to the ED & SDEC wards (EAU4, N2).
  • Early Intervention Team Therapists will assess mobility, function and assist with admission avoidance and early discharges from ED and SDEC wards.
  • Early Intervention Team works closely with community services and voluntary services to prevent unnecessary admissions.
  • Front of House Social workers work with in EIT to support ED with admission avoidance (Mon – Fri)


Refer by calling EIT Mobile Phone number, 8am-8pm


Telephone:  0300 123 9996 
Urgent two or four hour response service that supports people over the age of 18 with long-term conditions, in their home environment, when they become very unwell and need urgent care, but do not need to go to hospital. 
Have a look at this leaflet for more information.
7am – 8pm Monday to Sunday.

Social Services 

Emergency Duty Team – OOH – adults/children:  Telephone -  01733 234724
Adult Social Care: Telephone - Telephone  0345 045 5202
Children/Young People Social Care: Telephone 0345 045 5203

Community Respiratory Teams

  • Huntingdon,
  • Fenland
  • Peterborough
  • South & Central Cambridgeshire 

Tel: 0330 726 0077
Email: cpm-tr.communityrespteam@nhs.net   

Our working hours are from 8am to 6pm, Monday to Friday (excluding bank holidays).

Community Respiratory Service referral Form
Community Respiratory Team referral info
Community Respiratory Support Team - flyer


Older People’s Mental Health Service

Referrals can be from any health care professional, though it is usually GPs or with their support. 

Criteria – any mental health related concern – could range from memory to hallucinations for a patient registered at a GP Practice within the Cambs, P'boro, Hunts or Ely / Fens region.

We handle routine and high risk referrals (5 day referrals). Referrals of a more urgent nature would go directly to FRS from GP or concerned party.

Prism (under 65s) also offer a patient self refer process through their website.

Telephone: 01480 420178
GP referrals - cpm-tr.opmhreferrals@nhs.net

Under 65s - through Prism - 01733 748 777

NHS 111 option 2

The extension of the NHS  111 service enables callers who are experiencing a mental health crisis to dial the NHS urgent medical advice number, and by choosing ‘option 2’ will be put through to a member of CPFT’s new First Response Service.

Specially-trained mental health staff will speak to callers and discuss with them their mental health care needs – instead of them having to go to accident and emergency departments of local acute hospitals.

Not available when calling from Wisbech – mental health crisis is triaged as per 111 calls.  

Community Geriatrician

Cambridge City and South – Dr. Viveca Kirthisingha. Offering telephone advice, home visits and care home visits.  Also holds a falls clinic and rehab ward at Brookfields Hospital. 

Ruiz-Mendoza, Eladia Email. Eladia.Ruiz-Mendoza@nhs.net 

Peterborough-Dr Ruiz-Mendoza  

Works on inpatient units Intermediate Care Unit at City care Centre, Peterborough and John Van Geest Unit at Stamford Hospital, Stamford.  

Geriatric Liaison Services supporting the Old Age Psychiatric team at Maple wards, Cavell Centre, Peterborough 

Principal investigator in Parkinson’s disease Clinical Trials at Peterborough Hospital  

Supporting MFOP inpatient wards at Peterborough City Hospital  

Ely – Dr. Rhian Simpson
Works on inpatient units Lord Byron B at Brookfields in Cambridge and Welney Ward at The Princess of Wales Hospital, Ely. Community sessions supporting the Isle of Ely Neighbourhood Team staff and GP practices. Outpatient clinic at The Princess of Wales and can see patients in their homes, including care homes if appropriate.
Telephone: 07790 572459  Sec: 01353 772532 (Debbie Bovelle)
Email: rhian.simpson@nhs.net
Working days Tuesday (am) to Friday or telephone for advice

R.A.D.A.R. admission avoidance 

Advice and Assessment service for older medical patients.

Monday - Friday 9am - 5pm 

This line is for health professionals only. Please leave a voice message on the mobile if there is no answer and your call will be returned as soon as possible.  

Neighbourhood Teams 

Neighbourhood teams (NTs) are the physical and mental health care hub of the local community for over 65-year olds and adults requiring community services.  They work closely with GPs, primary care, social care and the third and independent sector to provide joined-up responsive, expert care and treatment.  

  • Telephone: 0330 726 0077 
    - Option 3 for Ely and Fenland area.
    - Option 5 for Cambridge area.

8am – 8pm - 365 days a year, from 01/12/2017
Community matron, district nurses, integrated care workers, mental health nurses, OT, physio, MDT co-ordinator.

Health and Wellbeing Network Cambridgeshire

The Health and Wellbeing Network aims to facilitate collaborative working across Cambridgeshire charity organisations and promote access into the wide range of interventions that the third sector offers.
Telephone 0300 666 0142 or visit their website.

Ambulatory Care – Addenbrooke's Hospital

The Addenbrookes ambulatory care unit focuses on treating various conditions that would usually have warranted hospital admission. The ambulatory care unit offers easy access to diagnostic tests, hospital consultants and specialist staff in one place.
Telephone: 01223 348314 (appointment enquiries).
Email: add-tr.macu@nhs.net
Monday to Friday: 8:30am to 8pm.
Weekends and bank holidays: 9am to 4pm.
For more information have a look at their website.

Lord Byron Ward Brookfields step up beds

In the first instance a phone call to the ward will establish if a bed is available or when one may be available, if the time line for bed is suitable referral forms will need to be completed and sent to ward for triage.
Telephone: 01223 219247 or 01223 219246
24 hour Prescription for Direct Admissions from the Community to Inpatient Beds in Community Hospitals
Patient Consent Form for Transfer to Lord Byron Ward

Inpatient Rehabilitation beds - Welney Ward, Princess of Wales Community hospital 

Telephone:  01353 772509 

Details of medical history should be emailed to: cpm-tr.welneyward@nhs.net

In the first instance a phone call to the ward will establish if a bed is available or when one may be available.

Referrals are accepted from GPs, JET and Neighbourhood Teams.  Criteria for referral require that the patient should be medically fit for rehabilitation with no requirement for acute medical input.  

Blood results and a recent medical review are also required.

Carers Trust Cambridge

Telephone: 01480 499090 or 0345 241 0954 or email care@carerstrustcambridgeshire.org
Provides support to carers, including emergency support.  Fully CQC compliant.  All referrals, including self referral welcome.  


Telephone: 01223 703235 Monday to Friday 9am to 5pm.
Reablement is a programme of short term support tailored to individual needs, to help re-learn the skills needed for daily living and reduce the amount of care and support required.
Reablement is about helping people to do things for themselves rather than having things done for them. Reablement programmes can last from as little as a few days to a few weeks.

Reablement south:

  • Cambridge City
  • Sawston 
  • Ely 

Breathe Easy Groups

  • Breathe Easy Cambridge
  • Breathe Easy Ely
  • Breathe Easy March and Fenland
  • Breathe Easy Wisbech
  • Singing for Breathing (Cambridge)

Contact details can be found on the British Lung Foundation website for each group.