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Main Duties and Responsibilities.

To conduct holistic assessments utilising your nursing knowledge to ascertain health and social care needs as well as equipment and therapy to promote independence and avoid hospital admission. You will be part of a community team where your ability to make clinical decisions will aid patient recovery. This will include liaising with patient’s hospital discharging teams for advice support where necessary and with the patients GP or other health care professional to prevent hospital admission. 

You will provide complex assessments and interventions and will make clinical decisions within your scope of practice. You will be expected to work autonomously whilst drawing assistance from other colleagues in primary and secondary care. 

You will use evidence based principles/current best practise and skills to assess, plan, implement and evaluate interventions and to ensure that all members of your team do so accordingly. 

Your caseload management and communication skills will enable you to prioritise patient care and manage your own caseload. You will also work closely with senior clinicians, practitioner’s social workers, and other health or social care professionals to establish and maintain a whole systems approach for our patients

Communications

•        To gain consent from patients, negotiate and agree goals in conjunction with patient choice

•        To address distressing and emotional needs of patients and carers in an exemplary manner. To communicate sensitively with patients and their families some of who have high levels of distress caused by pain, dementia, long-term disability and terminal illness 

•        To provide advice on patient care to other health, social and voluntary sector services.  This may involve challenging or negotiating changes to treatment programmes or care plans set by other professionals. 

•        To advise and train members of other agencies, health care professionals, carers and families in aspects of care. 

•        To communicate effectively with all other health sector and outside agencies for information exchange/ gathering and problem solving. 

Responsibility for Patient Care 

•          To be professionally and legally accountable for all work undertaken. To work within the standards and guidelines of the team, the Trust, and the conduct and standards of your relevant professional bodies, NMC 

•          To deliver care to patients within their home that is technically excellent, expressly personal and ensures patients’ and carers’ dignity is enhanced. 

•          To undertake highly skilled and complex clinical activities directly related to the assessment, planning and evaluation of patient care. 

•          To develop your skill set with advanced techniques and other skills not normally associated with your profession. 

•          To make clinical decisions and communicate the rationale clearly

•          To document fully and clearly to a very high standard 

•          To ensure effective implementation of infection control policies

•          Management of complex patient care ensuring that risks are adequately assessed, minimised, translated into appropriate care plans and reported across the organisation as appropriate 

•          Manage the effective coordination and continuity of patient care working closely with external agencies and community colleagues

•          To ensure that clinical practice is contemporary to meeting the needs of patients and families

•          To ensure that each patient has a comprehensive assessment of need, including risk assessment and that their care is culturally sensitive and addresses issues of diversity 

•          To participate in resource projects and health promotion programmes as requested

•          To work closely with the Acute trust, GPs, nursing, social care and therapy colleagues and the VCSE sector to prevent inappropriate hospital admissions 

•          Assess for, prescribe and issue a range of equipment, mobility aids and aids to daily living. 

•          To undertake other duties that may be allocated

Key Liaisons

•        Integrated Urgent Crisis Team colleagues.

•        Social Care Assistant Team Managers

•        Community nurses 

•        Other continuing care teams

•        Hospital Doctors and GP’s in community. 

•        Hospital and community allied health professionals 

•        Specialist hospital and community practitioners.

•        Digital Health

•        Extensive Care Team

•        NWAS

•        Neighbourhood teams

Planning and Organising

Prioritise workload or activities in order to meet the demands of the Urgent Crisis team

Responsibilities for Physical and / or Financial Resources

Ensure safe and efficient use of equipment, resources and consumables at all times Order stock and audit stock levels 

Responsibilities for Human Resources and Leadership

To be responsible for the safety and welfare of patients, colleagues and self during the treatment period in accordance with professional standards and health and safety regulations. 

To work at other sites in the Trust, specifically across IUCT and ITS, if required

Comply with Trust Standard Operating Procedures, Policies and processes; and other related guidelines.

Attend regular team meetings to ensure local and national, health and social service initiatives are implemented within the service; contributing ideas for improvement and sharing lessons learned. 

Participate in regular clinical supervision and appraisals as per trust policy

Act as a positive role model, establishing and maintaining interpersonal relationships with team members, encouraging innovation.

Actively participate and support in service development.

To actively participate in clinical governance processes with a particular emphasis on identifying and handling risks that affect patient care 

To ensure appropriate evaluation mechanisms are in place to check that the service continues to meet the required standard and quality

Maintains best practice and own fitness to practice through continual professional development 

Comply with the incident reporting process and contribute to the resolution of complaints as required.

Research, Development and Audit 

To participate in audit as required by the department and Trust. 

To use audit results, current research and government guidelines to recommend changes to service delivery and to demonstrate evidence- based practice.