Job overview

The post-holder will work as part of a multi-disciplinary team including nurses, physiotherapists, occupational therapists, healthcare assistants, and administrators to provide rapid assessment and treatment to patients who have urgent care needs in the community. The postholder will work in partnership with colleagues in the acute sector, social services, intermediate and primary care services to safely avoid unnecessary hospitalisation.

The post holder will lead on the clinical assessment and management of patients with complex and acute needs, including those with established frailty, who would otherwise require an acute hospital admission. You will be responsible for making advanced, autonomous clinical decisions, overseeing daily MDT reviews, and ensuring that all patients receive safe, high-quality, person-centred care within a maximum 14-day episode. Reflecting CNWL's commitment to empowering its people, you will provide professional leadership, supervision and mentorship to Band 6 and junior colleagues, and act as a key point of escalation for clinical concerns across the team.

The post holder will be a highly skilled advanced nurse who will support in the leadership of the Hospital at Home team/ UCR, deputising in the absence of the Clinical pathway lead.

The post holder will assist with and directly triage urgent patient referrals with undifferentiated, varied and complex needs ensuring holistic assessment and community care pathway planning is undertaken to directly prevent unnecessary acute hospital admission.

The post holder will work in conjunction with community services and acute setting to facilitate effective and safe return home from emergency departments and acute non admission areas.

The post holder will act as an expert clinical resource to Rapid Response Team Members, facilitating high quality evidence based practise and ensuring patients from variety of acute and community settings appropriately access out of hospital community health and social care services and receive effective rehabilitation.

As a senior member, you will be expected to be a practitioner with a broad range of competencies who is able to adapt to a wide variety of clinical circumstances. You will be part of a community team where your proven ability to make high level clinical decisions will aid patient recovery. This will include having a direct link to the patient’s discharging medical team for liaison and 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 high impact clinical decisions. 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 specialist skills to assess, plan, implement and evaluate interventions and to ensure that all members of your team do so accordingly.

Your exceptional caseload management and communication skills will enable you to prioritise patient care and delegate to junior members of your team. You will also work closely with other senior nurses, social workers, therapists and other health or social care professionals to establish and maintain a holistic approach for these patients.

Post holder will undertake delegated line management of staff, both informal and formal basis

The post holder will assist the pathway lead to provide clinical support and co-ordination for the team and participate in undertaking Rota duties.

The service will operate on Monday to Sunday on an 8am – 10pm basis

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MAIN DUTIES AND RESPONSIBILITIES

·       To assess, plan, implement and provide evaluation of health care needs in conjunction with patients, their carers and other appropriate members of the multi professional team.

·       To have agreed areas of responsibility where you lead across the team

·       To provide nurse leadership and management support to the team

·       To see patients with potentially undifferentiated diagnosis including; objective assessment, physical assessment, treatment, follow-up and developing care plans.

·       To ensure all patients on the caseload are managed well and discharged safely either to their GP or for further ongoing assessment, rehabilitation treatment and care.

·       To be responsible for keeping up to date with current issues and events in Primary and Secondary Health Care

·       Liaising with community services partners

·       To take a supportive lead role in the development of the Rapid Response Team(s) and integrated team working with other services.

·       To provide support and health education for patients and carers through effective interpersonal skills.

·       To support team members to comply with professional codes of conduct and trust organisational policies and procedures and the implementation of performance management when required.

·       To be able to work flexibly as required and requested by the line manager to meet the needs of the service.

·       To ensure that own mandatory training and junior nurses’ mandatory training is kept up to date in line with Trust policies.

CLINICAL

·       Undertake comprehensive assessment of health and social care needs, utilising an appropriate assessment tool in achieving Person Centred Care.

·       Undertake advanced practitioner level, physical examination of patients needing complex chronic disease management and resolution or containment of disease complications.

·       To promote good practice in order to improve standards of care.

·       Recognise the early symptoms of disease exacerbation, acute illness and injuries, based on an understanding of chronic diseases, the disease process, current evidence and practice standards.

·       Make direct referral of patients for medical assessment and diagnostic procedures.

·       Demonstrate a high level of clinical judgement, acting autonomously in a variety of contexts, including acute and primary care settings.

·       Discuss and agree assessment outcomes with patients, carers and other health care professionals, enabling them to think through the risks to health and wellbeing and planning how these can be managed.

·       To be able to delegate appropriately, ensuring that staff are competent to undertake and perform delegated duties and tasks.

·       To be able to recognise own limitations and seek help/guidance when appropriate.

·       To prevent unnecessary hospital admissions by responding to LAS, GPs, community colleagues and actively identifying patients in conjunction with medical teams from Emergency Department, Adult medical unit, Clinical decision unit, Short stay unit, that would benefit from Rapid Response Team intervention and out of hospital services.

·       To participate in the development and evaluation of teaching programmes for students on community programmes and junior members of staff.

COMMUNICATION

·       Establish close working relationships with leads of other community services based in borough, including District Nurses, community matrons, GPs and Social Care staff.

·       To actively participate and where required lead the daily handover meeting, and any MDT ensuring all patients are discussed and plans are clearly articulated and patients are allocated to appropriate team members.

·       Effectively manage patient information and analyse data from a clinical perspective and write reports.

·       To ensure effective communication with patients/clients and their carers, including the provision of patient education, health promotion and emotional support where appropriate.

·       To ensure effective communication with all members of the multidisciplinary team at all levels.

·       To ensure daily communication is maintained across the team to ensure safe, appropriate and effective patient care

·       To record treatment and care carried out in a variety of settings on appropriate documentation. Records must be kept up to date and accurate in accordance with Trust policies and professional standards

·       To provide accurate written and verbal reports as and when required.

·       Chair any clinical meetings related to improving service delivery.

·       To maintain confidentiality of information relating to patients, staff and organisation.

·       To have the ability to interpret and communicate, complex, contentious and sensitive information to patients, carers and members of the multidisciplinary team.

·       Demonstrate ability to appropriately work with barriers to communication and communicate with a sympathetic and empathetic approach to patients and carers.

·       To ensure team members adhere to record keeping policies and provide accurate documentation.

EDUCATION/TRAINING

·       To line manage clinical and support staff as required

·       Develop own knowledge and skills, within competency framework, in order to function as an advanced clinical practitioner.

·       To report all clinical and non-clinical incidents or near misses promptly and when required, lead and/or co-operate with any investigation undertaken

·       To ensure efficient and effective use of resources within own practice.

·       To undertake formal and informal supervision of junior staff and actively participate in own clinical supervision.

·       To understand and adhere with all Trust policies, procedures and guidelines and ensure other team members adhere to policies.

·       To promote the local and national priorities of health care delivery e.g.Long Term Conditions and National Services Frameworks.

·       To independently analyse and manage complex changing clinical situations in conjunction with supporting the nursing team.

·       Assist in the development and monitoring the quality of the Rapid Response Team service and contribute to the development of quality measures, including the full audit process.

·       To work in full partnership with other disciplines and organisations to influence and shape service delivery.

LEADERSHIP

·       To demonstrate and utilise a variety of leadership and influencing skills and be able to work with health and social care colleagues in many local organisations.

·       To provide leadership and line management to delegated members of the team.

·       To comply with NMC code of conduct and PREP requirements.

·       To act as a mentor/preceptor to new staff, junior staff, students and other non-qualified team members and support them to achieve their learning objectives.

·       To participate in the Appraisal process and in so doing identify training needs for self and delegated members of the team and encourage access to professional development opportunities.

QUALITY

·       Contribute to the audit, evaluation and improvement of the service in relation to clinical performance, user expectations and effectiveness of the service.

·       Comply with local clinical policies and guidelines.

·       Contribute to the development or review of clinical policies and guidelines related to the care of patients with chronic disease with particular concern for those who may require attendance at A&E or admission to hospital

·      Contribute to the further development of clinical standards, as part of service benchmarking and audit processes.

OTHER

Emergency Management

·       Is competent in anaphylaxis and resuscitation techniques

·       Undertakes annual update training

Professional Responsibilities

·       Incorporates Life-Long learning strategy into own and others practice

·       Identifies skills required in order to achieve competencies required to do the job 

·       Contributes to own appraisal and maintains own professional development

·       Sets objectives which are specific, measurable, realistic, achievable and timely

·       Demonstrates awareness of Trust  guidelines for safe record keeping

·       Works within the guidelines established by relevant professional body

·       Maintains Registration

·       Use of evidence based practice

Working for our organisation

Our values
• Compassion: Our staff will be led by compassion and embody the values of care outlined in our Staff Charter.
• Respect: We will respect and value the diversity of our patients, service users and staff, to create a respectful and inclusive environment, which recognises the uniqueness of each individual.
• Empowerment: We will involve, inform and empower our patients, service users, carers and their families to take an active role in the management of their illness and adopt recovery principles. We will ensure our staff receive appropriate direction and support, to enable them to develop and grow.
• Partnership: We will work closely with our many partners to ensure that our combined efforts are focused on achieving the best possible outcomes for the people we serve.