About Us: The Confederation, Hillingdon CIC works with General Practice and other healthcare providers to deliver its vision for “Hillingdon to deliver the best primary care outcomes for patients in the whole of London”. We are a not-for-profit community interest company. The Confederation works to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We deliver excellent clinical services ourselves both at scale and complementary to General Practice. We are the provider representative voice for local General Practice into the wider NHS and other Partners. We are ‘of the NHS’ but independent, innovative and transformational. The Confederation determines to develop as an attractive place to work, providing rewarding roles and opportunities to grow in order to attract and retain great staff that in turn delivers our vision. Our Values: Job Summary Dementia is currently the seventh leading cause of death among all diseases and one of the major causes of disability and dependency among older people globally. It has physical, psychological, social and economic impacts, not only for people living with dementia, but also for their carers, and families. People living with dementia have poorer outcomes than the rest of society with the highest mortality rates, highlighting a need for more support. The Dementia Support Coordinator will work across the North Neighbourhood of Hillingdon to support people and their carers with dementia to achieve better health outcomes and experience of services throughout their care journey. You will be highly motivated and proactive with a flexible attitude, keen to work and learn as part of a team and committed to providing people, their families and carers with high quality support. You will act as the main point of contact for the person living with dementia and their carer to ensure that services are co-ordinated and reflect what is important to them and enable them to access appropriate health and care support in a timely fashion. Annual Health Checks are an important mechanism for ensuring that the needs of people with dementia are regularly reviewed. You will support patients and carers so that any actions that result from the Health Check are put into place, acting as link between patients, Primary Care and wider health and care services. The successful candidate will be based within the North hub or practices within the North. This is an important new role and whilst not a clinical role, it will require relevant training such as safeguarding, confidentiality and data protection etc. and they will be full supported by the practice teams. The post holder will: Work closely with GPs and other Primary, Secondary community Care and public health professionals within the neighbourhood to identify and manage a caseload of patients with Dementia. Work with people and their carers and primary care staff to organise and prepare for Annual Health Checks, enabling them to be actively involved in managing their care and be supported to make choices that are right for them. Help to connect patients and their carers with relevant services, ensuring that reasonable adjustments are made that facilitate improved access to services, and promote optimum outcomes for the person. Working with carers to help identify what will help the person living with dementia to live well with dementia and potentially prevent care home and hospital admissions Working with the carer to manage and identify their stress and manage their well-being as this may prevent deterioration in the person living with dementia. Actively seek engagement opportunities and co-ordinate such events Focus on prevention and proactive care by supporting opportunities to improve current pathways and service delivery. Focus delivery of this comprehensive model to reflect local priorities, promote inclusion and reduce health inequalities. Identify and report on key themes and issues to inform the strategic approach to service development. Primary Responsibilities Proactively identify and work with a cohort of people to support their personalised care requirements. Support the Practice to establish preferred means of communication and coding to comply with relevant guidance. Establish who is the person’s main support and support the practice to ensure this is documented. Identify barriers to accessing health and care services, and plan actions to overcome and support access to services. Work with Practices, people and their families and carers or other support services to prepare for the Annual Health Check (AHC). Review attendance to appointments and follow up those which have not attended or not been supported to attend and support to reschedule as appropriate. Bring together a person’s identified care and support needs and support them to explore their options with the clinicians to produce a single personalised care and support plan. Help patients and their carers prepare for conversations they have with Primary Care professionals, ensuring that their changing needs are addressed. Develop plans to meet the additional health needs of people with Dementia who come from ethnic communities that experience health inequalities. Support the coordination and delivery of Multi-disciplinary Team Meetings within PCNs and with Admiral Nurses and CNWL. Identify unpaid carers and help them access services to support them. Identify and raise any issues or concerns relating to care provision. Work independently on a day-to-day basis, making decisions within scope of role and actively seek supervision where required. Act as a Dementia Champion and support Personalised care Enhance staff education and training for Dementia by working closely with Public Health colleagues to develop a train the trainer model Communication and Record Keeping Develop strong working relationships with GPs, practice, Memory Clinic, Admiral Nurses and community teams relevant to your role. Ensure that all relevant professionals are kept up to date so that any issues or concerns can be appropriately addressed and supported. Proactively conduct follow-ups on communications from out of hospital and in-patient services. Actively participate in multidisciplinary team meetings in the North Neighbourhood when appropriate. Keep accurate and up-to-date records of contacts, adhering to information governance and data protection guidance. Maintain records of referrals and interventions to enable monitoring and evaluation of the service. Service Development Actively seek feedback from people, their families, and carers about the impact of the care coordination. Act as a Champion for dementia and a point of contact for Dementia across the North Neighbourhood Identify any issues and report to the North Neighbourhood Senior Leadership team to enable learning and action. Provide feedback to continually improve the service and develop the role. Support the induction of new in post Dementia Support Coordinator. To contribute to and participate in the development and maintenance of mechanisms to audit the quality of care and clinical effectiveness of clinical services. Link with other people who have similar roles in other areas. Review the Right Care Dementia scenario and apply approaches where appropriate and seek service improvements. General Duty of Care: Put the interest and needs of the patients first and foremost. Contribute to the development of policies and plans relating to equality, diversity, and reduction of health inequalities. Adhere to policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety. Undertake continual personal and professional development, providing evidence of learning where required. Take an active part in regular appraisals. Collaborative Working Relationships Foster and maintain strong links with all services across the PCN and neighbouring networks. Explores the potential for collaborative working and takes opportunities to initiate and sustain such relationships. Demonstrates use of appropriate communication to gain the co-operation of relevant stakeholders (including patients, senior and peer colleagues, and other professionals, other NHS/private organisations e.g. CCGs). Can recognise personal limitations and refer to more appropriate colleague(s) when necessary. Liaises with other stakeholders as needed for the collective benefit of patients including but not limited to: Patients and their representatives. Other healthcare professionals including community pharmacists, pharmacy technicians, social prescribers, first contact physiotherapists, physicians associate and paramedics. PCN Board of Directors CNWL Clinical Lead for Dementia Carers Network Hillingdon GP Practice Safeguarding Leads. Hillingdon Memory Assessment Service Community Mental Health Teams Wider community and secondary care services Neighbourhood Teams Dementia leads at acute hospitals and key ward managers Admiral Nurses Social Prescribing Link Workers Voluntary, Community and Social Enterprise (VCSE) providers of dementia services Social Care Services Community pharmacists and support staff Professional Development Work with your line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the role and responsibilities. Involved in one-to-one meetings with line manager monthly to discuss targets and outcomes achieved. Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Review yearly progress and develop clear plans to achieve results within priorities set by others. Knowledge, Skills and Experience Required Recognises priorities when problem-solving and identifies deviations from normal pattern and can refer to seniors when appropriate. Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct. Education, Training and Development Understands and demonstrates the characteristics of a role model to members in the team and/or service. Demonstrates self-development through continuous professional development activity. Leadership Demonstrate understanding of, and contributes to, the workplace vision. Demonstrates ability to improve quality within limitations of service. Reviews yearly progress and develops clear plans to achieve results within priorities set by others. Demonstrate ability to motivate self to achieve goals. Promotes diversity and equality in people management techniques and leads by example. Health and Safety/Risk Management The post-holder must comply at all times with all local Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents using the organisations Incident Reporting System. The post-holder will comply with the Data Protection Act (1984) and the Access to Health Records Act (1990). Equality and Diversity The post-holder must co-operate with all policies and procedures designed to ensure equality of employment. Co-workers, patients and visitors must be treated equally irrespective of gender, ethnic origin, age, disability, sexual orientation, religion etc. Patient Confidentiality The post holder must at all times respect patient confidentiality and, in particular, the confidentiality of electronically stored personal data in line with the requirements of the General Data Protection Regulation and in keeping with The Confederation, Hillingdon CIC Information Governance Policy and procedures. The post holder should not divulge patient information unless sanctioned by the line manager and required for the role. Communication & Working Relationships The post-holder will establish and maintain effective communication pathways at all times with project team members. Special Working Conditions The post-holder is required to travel independently between sites (where applicable), and to attend meetings etc. hosted by other agencies. Job Description Agreement This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position. This description will be open to regular review and may be amended to take into account development within The Confederation. All members of staff should be prepared to take on additional duties or relinquish existing duties in order to maintain the efficient running of the service or function. This job description is intended as a basic guide to the scope and responsibilities of the post and is not exhaustive. It will be subject to regular review and amendment as necessary in consultation with the post holder. Person Specification Essential Criteria GCSE grade A-C in Maths & English or skills level 2 in Maths & English (or equivalent) Experience of working with or caring for people with dementia Knowledge of national priorities to improve outcomes for people with dementia Experience of working in health, social care, and other support roles in direct contact with people, families, or carers (in a paid or voluntary capacity) Experience of working within multi-professional team environments Experience or training in personalised care and support planning Experience of providing motivational coaching to support people’s behaviour change Knowledge of Safeguarding Children and Vulnerable Adults policies and processes Able to work without day-to-day supervision Ability to identify risk and assess / manage risk when working with individuals Ability to recognise and work within limits of competence and seek advice when needed Can communicate complex and sensitive information, both verbally and in writing Excellent interpersonal, influencing and negotiating skills Work effectively independently and as a team member Able to build effective working relationship with people, families and professionals. Ability to produce timely and informative reports Ability to organise, plan and prioritise Committed to the delivery of fair and equitable services Positive attitude Committed to collaborative working Good understanding of equality of opportunity Ability to provide service supporting people from all backgrounds and communities DBS reference standards and criminal record checks Willingness to work flexible hours when required to meet work demands Ability to travel across the locality on a regular basis Ability to use Microsoft Office applications – Word, Outlook Desirable Criteria Knowledge of how the NHS works, including primary care and PCNs Experience of data collection