Community Children's Nursing Team

The Fife Community Children’s Nursing Team is part of the wider Children and Young People’s Community Nursing Service which is also based in Carnegie Unit, Queen Margaret Hospital, Whitefield Road, Dunfermline KY12 0SU. The Community Children’s Nursing Team consists of 1 x Nurse Team Manager, 2 x full time Community Children’s Nurses, 2 x part-time Community Children’s Nurses and 1 x part-time Health Care Support Worker, who cover a geographical area from the Kincardine Bridge in the west, the Forth Road Bridge in the South up to Tayport in the north (this includes the East Neuk of Fife). See map on next page. As of January 2014, a Health Care Support Worker (HCSW) has joined the community children’s nursing team to support service delivery. This is an exciting new post which will be based in the community and also in the clinic environment carrying out specific aspects / episodes of care 

Home Visiting Service (based: Children’s Ambulatory Care Unit, Victoria Hospital, Kirkcaldy)

As a result of a review of children and young people’s services in Fife (2011) an integrated approach to acute care from the Children’s Ward, Victoria Hospital, Kirkcaldy is providing a much more collaborative model of care.

The aims of the service are:

  • To facilitate early discharge from the ward / ambulatory care
  • Prevent hospital readmission
  • Enable parents to feel confident and competent when caring for their child at home
  • Provide health promotion for the whole family
  • Make effective links with the primary health care team and between hospital and community.

The Home Visiting Service receives referrals from the children’s ward, Ambulatory care, G.P. assessment unit and A+E at the Victoria Hospital, Kirkcaldy. Other referrals include self referrals, minor injuries unit (QMH), other hospitals (e.g. RHSCE + Yorkhill Hospital). Their contact number is: 01592 729078

Community Children’s Nursing Team – staff list

Community Children’s Nurse Manager


Community Children’s Nurses

Gill Deaves               Phyllis Davidson                  Nicola Davies 

Community Children’s Nurses (Home Visiting Service)

Joanne Bruce           Aileen Kyle     Pauline Clemison

Health Care Support Worker

Ashleigh Patterson



Mission Statement of the Fife CCN Team

As community children’s nurses, we consider the needs of the child / young person within the context of the family unit.  We believe that parents and family members are the primary carers, and that effective care delivery depends upon negotiation and partnership between ourselves and the family.

The provision of support and education from the team is based upon respect for the child / young person and their family. Each child / young person and their family have individual needs which will be assessed and a jointly agreed, appropriate plan of care will be offered to them in partnership with the family.

Principles of Service Delivery and Key Aspects of Care:

  • To assess and plan care in conjunction with the child / young person and their family
  • To facilitate early discharge through inter-agency and multi-disciplinary liaison
  • To reduce unnecessary hospital admissions and provide co-ordination and continuity of specialist paediatric care
  • provide continuity of care at home for children / young people with additional and complex health needs
  • teach and support children / young people and their families, enabling them to become as independent as possible
  • offer co-ordination and collaboration of care
  • continuously assess and evaluate care delivery to meet the individual needs of the child / young person and their family

 The CCN service is provided in the family’s home, or in community settings for children / young people requiring:

  • Wound care, post-operative care, support and advice on discharge from hospital
  • Administration of SC injections for children with Crohn’s disease or rheumatoid arthritis e.g. Methotrexate.
  • Support to oncology children / young people and their families in Fife e.g. regular blood sampling
  • Support of home enterally fed children / young people in collaboration with the multi-disciplinary team.
  • Support of preterm infants and children / young people on home oxygen.
  • Support to children / young people at home with compromised airways requiring assisted support with NP airways or tracheostomies.
  • Support, advice and co-ordination of care for children / young people with complex health needs.  This role encompasses that of the key-worker and links closely with education, social work and voluntary services.
  • Care and support for children / young people with chronic illnesses and their families
  • Orthopaedic home traction care
  • Teaching and education for children / young people, parents and staff
  • Additional support and education for schools and other professionals involved in the child / young person’s care
  • Palliative care at home, supported by our pathway.
  • Short-term acute conditions requiring nursing intervention: e.g. diarrhoea / Bronchiolitis / Asthma 

Children up to the age of 16 years, or young people who still receive extended education can be referred to the team by any professionals, parents and / or carers. (We would not consider any new referral to the team if they are over 16 years and not already on the caseload). Each child / young person will be individually assessed by the receiving community children’s nurseand parental consent is always required before a referral can be accepted.  Referrals can be made to the CCN team in writing via email / hard copy.

Community Children’s Nursing

Here is a list of the different services and agencies that the community children’s nurses are in regular contact.


Children & Young People's Palliative Care

 In 2008 following the death of a young person within NHS Fife it was identified that there was no structured approach in the delivery of care to children & young people  (C&YP) requiring palliative care/end of life care.

Following the development of a multi-agency/ multi-professional group we have now achieved an integrated multi-agency care pathway which was launched in autumn 2012 (a link to our pathway has been provided)

Thankfully as reflected nationally numbers of C&YP with palliative/end of life care needs remain small in our area, the service delivered is now of high quality and equitable across NHS Fife.

 In conjunction with Colleagues within NHS Lothian an Anticipatory Care Plan (ACP) document was developed. The ACP is a family held document used to promote and record discussions with the C&YP and their family around life, relationships, wishes, hopes and fears.

The ACP compliments and supports the C&YP’s CYPADM (Children Young People Acute Deterioration Management) or can be used independently.

The ACP can be initiated by the CCN ( Community Childrens Nurse)/ Lead Clinician it is also good practice to involve all professionals who know the child. The ACP should be completed following a course of discussions this ensures that the C&YP anf families wishes are clearly identified.


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