The post holder will work within an integrated team to proactively manage, co-ordinate the Rapid Response service within the Wokingham Integrated Social and Health Team (WISH). Support patients with multiple complex long term conditions and those with shorter term health issues, with responsibility for ensuring all health and social care needs are met to improve health outcomes, preventing unnecessary admissions to hospital and reducing the length stay of a hospital admission. The RRAT service and the Rapids Service will be combined so that the post holder will provide a service to both RRAT and Rapid referrals.
To comprehensively assess patients with complex physical, mental and social care needs using advanced clinical examination skills, detailed history taking and biometric monitoring and evaluation skills To have an understanding of the combined impact of all of the patient’s conditions on their health and social care needs in order to improve health outcomes and quality of life Develop individualised treatment and management plans using evidence based practice and proactively monitor patients and review care plans To use advanced skills and expert knowledge to identify subtle changes in condition and take appropriate action To identify and plan preventative measures and anticipatory care needs To hold a recognised Independent and Supplementary Prescriber qualification and to prescribe according to agreed protocols and polices. To maintain accurate, contemporaneous and comprehensive records of care, using Rio, Adastra and any other recording systems used within the WISH team. To perform a medication review and prescribe and change medications as required in accordance with national and local guidance To make direct referrals on to other services or professions, request diagnostic tests and instigate treatments and interventions as required To analyse signs and symptoms, laboratory tests and other measures of function, in formulating a diagnosis To work as an autonomous practitioner, managing and prioritising own caseload, through clinical judgement, according to local and national guidelines and identified need. To work in a variety of settings, exercising a high level of judgement, discretion and decision making in clinical care. To continuously review practice and participate in implementing change as appropriate and defined within the trust policy To work according to the NMC Code of Conduct and professional practice and the relevant legislative framework and exercise professional accountability at all times To be responsible for keeping professionally updated and registered with the NMC To use advanced skills and expert knowledge to perform a comprehensive assessment of physical, mental health and social care needs that addresses the combined impact of all of the patient’s conditions in order to improve health outcomes and quality of life. To make referrals on to other services or professions, request diagnostic tests and instigate treatments and interventions as required. To manage multiple chronic diseases, cognitive and functional impairment. To identify and plan preventative measures and anticipatory care needs. To proactively monitor patients and review care plan whilst on the Rapid Response service using an MDT approach.
Support Self Management of Long Term Conditions
To work in collaboration with patients and carers, identifying self management needs and increase their knowledge of their condition, in order that they develop skills to manage their condition effectively To provide the necessary tools and equipment to patients so that they can monitor their condition, identify warning signs of complications and crisis and know when to call for support. To support self-management programmes. To provide information to patients, their carers and families so they can make informed choices about current and future care needs. To prepare the patient and their family for changes in condition and support choice for end of life care working in partnership with the community nursing services to deliver optimum care.
Care Co-ordination and Cross Organisational Work
To work in collaboration with the Primary Health Care Team including all health, social care and voluntary agencies to provide care for patients and their families and informal carers in their own home, within given resources. To work in partnership on the development, management and ongoing review of the care plan with the patients GP, specialists, pharmacists, social care and other services and professions as required. To prioritise and coordinate the multiple health care needs of the patient. To develop a personalised care plan that reflects individual needs, preferences and choices and provide the patient with a Person Held Record of Care. To negotiate and agree with patient, informal carer/family and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professions as appropriate. To co-ordinate the delivery of care plans. Maintain responsibility for the patient’s pathway throughout all components of the health and social care system to prevent duplication, and delays in care. To manage the care of the patient whilst active on the WISH team caseload and handover care to other services as appropriate.
To establish and maintain effective communication and liaison with the Primary Health Care Team and other agencies involved in caring for patients in the Community i.e. voluntary and statutory agencies, relatives and carers To communicate in a professional and sensitive manner with people, their relatives and carers taking into consideration their need for dignity, privacy and independence as well as their cultural and spiritual values. To communicate to a variety of forums the role of the Rapid response Specialist Nurse. To effectively communicate at all levels of the organisation; to a variety of health and social care professionals working in primary, community and secondary care, out of hours providers, voluntary organisations and patients and carers. To maintain accurate and up-to-date patient records, informing other professionals about changes in the patient’s condition where appropriate. To provide high quality written reports and any other written documentation as necessary. To act as advocate for the patient as required to ensure their individual needs, preferences and choices are delivered
To develop systems for auditing in order to determine standards of practice and use research awareness skills to critically appraise the effectiveness of practice To submit statistical and contractual monitoring returns within agreed time scales To participate in the development, implementation and evaluation of protocols, guidelines, policies, integrated care pathways and tools. To participate in the evaluation regarding the process, outcomes and impact of the Rapid Response Service and to help develop service delivery across NHS Berkshire West. To act as a change agent and innovator and lead on the development of new systems and ways of working across the whole system to meet the needs of people with complex multiple long term needs. To provide support to newly recruited WISH team members.
Education, Training and Development
To provide education and training for other staff and students including pre- and post- registration nursing students To access appropriate and relevant training opportunities that will enhance both personal and professional development
Leadership / Management
To exercise leadership and judgment to ensure good clinical practices and maintain high standards of care and review these at regular interviews.
To be actively involved with performance and clinical audits.
The post holder will also provide clinical supervision of circa 4 - 5 therapy assistants ( Band 2,3 and 4) The post holder will also line manage 1 – 2 Band 6 nurses
This job description lists the main tasks but is not exhaustive and will be regularly reviewed and updated in discussion with the post holder and their Line Manager.
This job description is not exhaustive and can be altered in consultation with the post holder.
Any other duties which may be requested by the line manager in order to facilitate the smooth running of community nursing.
The Trust is an equal opportunities employer. The post – holder is at all times expected to carry out their duties in accordance with the Trusts Equal Opportunities Policy.
The Trust operates a non smoking policy. Staff are not permitted to smoke on Trust premises.
The post – holder is required to take reasonable care of the health and safety of him/her acts or omissions at work, and to co-operate with the Berkshire Healthcare NHS Trust to ensure that statutory and departmental safety regulations are adhered to.
You may be required to work at or from any additional location as may be determined by the Trust from time to time. The Trust also reserves the right from time to time to change your base on a permanent basis to a location determined by it at the time that the change is made.
You may also be required to travel between Trust premises as may be required for the performance of your duties.
The Trust reserves the right to amend your job description and/or your duties from time to time. You also agree that you will work with the Trust to deliver the Trust’s services, including without limitation, by complying with lawful and reasonable instructions from the Trust by adapting to new ways of working and attending training courses determined by the Trust from time to time.
CONTINUING PROFESSIONAL DEVELOPMENT
To attend and contribute to staff meetings and Forums, supervision sessions, training courses, seminars and workshops, to ensure the development and enhancement of current working practices.
To participate in all personal review meetings, and take responsibility for personal and professional development. Responsibility for developing the role and the services provided.
DATA PROTECTION ACT
You should be aware of the Data Protection Act and follow the local Codes of Practice to ensure appropriate action is taken to safeguard confidential information.
HEALTH & SAFETY
You are required to take responsibility for Health and Safety Risk Assessment and Workplace Inspections, and to take reasonable care for your own health and safety and that of other persons who may be affected by his/her acts of omissions.
You are also required to co-operate with all staff to ensure that all statutory regulations, policies, Codes of Practice and departmental safety procedures are adhered to, and to attend relevant training programmes.
Managers at all levels have a responsibility to act as role models to ensure that Infection Control is on the corporate and service agenda and remains a priority in terms of attention and resources.
All staff providing direct patient care must ensure that they follow procedures aimed at reducing the risk of passing on the organisms that can cause infections.
All staff, collectively and individually, have a duty of care in following best practice in adherence to guidelines which is a fundamental requirement in underpinning the management of Infection Control.
Your attention is drawn to the confidential aspects of this post. You must not disclose any information of a confidential nature relating to the Trust or the service that it provides, or in respect of which the Trust owes an obligation of confidence to any service user, client or third party during of after your employment except in the proper course of your employment or as required by law.
You must not remove or copy any documents or tangible items including software which belongs to the Trust or which contain any confidential information from the Trust’s premises at any time without proper advanced authorisation. You must return to the Trust upon request and in any event upon the termination of your employment, all documents and tangible items which belong to the Trust or which contain or refer to any confidential information and which are in your possession or under your control.
A breach of confidence could result in dismissal.
You should be aware that regardless of any disciplinary action taken, a breach of confidence could also result in civil action for damages.
The Trust aims to provide the highest standards of care. To further this aim you are expected to adhere to acceptable working practice as defined in Trust policies and guidelines. You also have a personal responsibility to your team and service to keep up to date and, if you encounter unacceptable practice, to raise though accepted channels.
ASYLUM & IMMIGRATION ACT 1996 AND AMENDMENTS
In order to comply with the Asylum and Immigration Act 1996, it is Trust policy to check documentation of all applicants in respect of proper immigration status to work in the UK. Employment will not be offered to any applicant or employee who does not have valid leave to remain in the UK or is subject to conditions, which prevent the individual from taking up employment.
SAFEGUARDING CHILDREN AND VULNERABLE ADULTS
Safeguarding of individuals who come into contact with our services, whether a child or young person, person with Learning Disabilities or an older or vulnerable adult, is the responsibility of all employees of Berkshire Healthcare NHS Foundation Trust in whatever capacity they are employed.
The Trust adheres to the Berkshire Local Safeguarding Children Boards Child Protection Procedures, and all employees have a duty of care and a responsibility to safeguard and promote the welfare of children.
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