Main duties of the job
The Plymouth Dementia Pathway provides specialist assessment, diagnosis, treatment, and ongoing support for people with dementia and those experiencing memory difficulties. The service offers comprehensive cognitive assessments to inform diagnosis and delivers evidence-based post‑diagnostic interventions and support to help individuals and their carers live well with dementia across the course of the condition.
Main Duties and Responsibilities
As a Senior Dementia Practitioner, you will:
* Undertake comprehensive assessments for individuals referred to the Plymouth Dementia Pathway
* Contribute to diagnostic processes and formulation in collaboration with the multidisciplinary team
* Deliver and support evidence‑based interventions for people with dementia and their carers
* Undertake risk assessments and implement appropriate risk management plans
* Manage a defined caseload autonomously, prioritising workload effectively
* Complete duty days including triage of new referrals
* Work collaboratively within a multidisciplinary team including psychiatry, psychology, therapy, and support staff
* Provide clinical advice, leadership, and support to other team members
* Contribute to the supervision, mentoring, and development of junior staff and trainees
* Support service development and continuous quality improvement
* All staff are expected to be able and willing to work across a 7‑day service
Job responsibilities
Dimensions and Context of Role
The post‑holder is responsible to the Manager of the Plymouth Dementia Pathway (PDP) for the assessment of needs, development, implementation, and evaluation of care for patients from a specified group of patients.
The post‑holder is responsible for providing care coordination to a defined group of people suspected of having memory problems, to determine if further investigation is required for a formal diagnosis of dementia. Once a diagnosis is given, a range of treatment options and post‑diagnostic support services are offered to enable people with dementia and their relatives/carers to live well with dementia. This includes caseload management of patients diagnosed with dementia who are experiencing BPSD.
The post‑holder is responsible for caseload management and support to staff within PDP and to provide teaching and supervision to students and others undertaking educational programs.
Professional Responsibilities & Patient Contact
* Be accountable for the direct patient care/support provided by the Plymouth Dementia Pathway at all times
* Maintain high standards of clinical/professional care/support for people with dementia, their family/carers
* Work as part of a MDT to ensure the best possible outcomes for the person with dementia and their family/carer
* Act upon referrals from primary and secondary care, providing assessment, implementation, and development of programmes of care to individuals, groups and families
* Have responsibility for own caseload of patients and take responsibility as lead professional or care coordinator as appropriate
* Provide case‑load supervision and line management for Band 3, 4 & 5 practitioners
* Participate in duty cover and provide appropriate supervision for junior team members
* Maintain a caseload of clients with a significant degree of BPSD and liaise with suitable MDT for ongoing care and support for the patient and their families
* Identify and undertake specialist and comprehensive assessments to assist in the diagnosis of people suspected of having dementia, including life history, social and family circumstances, preferences, physical and mental health needs, and current level of functioning and abilities
* Inform the person with suspected dementia and/or their family/carer about the assessment and diagnosis process and any investigations required
* Obtain patient consent to care and treatment in accordance with the Mental Capacity Act, ensuring those with dementia who lack mental capacity remain at the centre of decision‑making and are fully safeguarded
* Promote a recovery model that empowers people with dementia, their family/carers to be at the forefront of decision making and ownership of their treatment plans
* Assess the effectiveness of medication prescribed for the symptoms of dementia and report observations back to the prescriber as required
* Recommend and provide a range of effective evidence‑based treatment and intervention plans at all stages of a person’s dementia journey based on sound clinical decision making
* Promote holistic care and suitable adaptations tailored to each individual’s needs
* Promote independence of people with dementia, addressing activities of daily living that maximize independent activity, enhance function, and minimize need for support
* Re‑assess people with dementia where there are changes in emotional well‑being and behaviour
* Promote least restrictive practice, maximizing independence and freedom while ensuring safety of others
* Undertake risk assessments and implement actions and intervention plans that fully consider risk formulation
* Promote positive risk to allow clients independence and autonomy of choice
* Be responsible for decision making and coordination in a crisis situation, seeking advice and guidance from other professionals as necessary
* Commit to the treatment of people with dementia in the community, reducing inappropriate admissions to acute or inpatient hospital settings
* Consider and coordinate psychiatric inpatient admission and apply for a Mental Health Act assessment when appropriate
* Complete social circumstances reports and attend Mental Health Act tribunals as required
* Support discharge planning and joint reviews of patients with dementia with the psychiatric inpatient unit staff
* Recognize end‑stage dementia and liaise with the end‑of‑life care team when appropriate
Communication and Working Relationship Skills
* Communicate clearly and effectively with people who have dementia, their family/carers and other professionals, maintaining confidentiality
* Communicate with individuals who have English as a second language using approved interpreters/services
* Demonstrate a positive attitude, respecting and showing courtesy towards people with dementia and their families/carers
* Analyze information and formulate professional judgments
* Manage conflict between individuals as necessary
* Adhere to professional boundaries at all times
* Coordinate and plan individual care with other teams and services to provide seamless service delivery for people with dementia
* Attend and represent the Plymouth Dementia Pathway in meetings such as Child Protection, Adult Protection, Mental Health Act tribunals, and CPA reviews
* Participate in various forums and steering groups within the organisation and wider community as required
* Liaise, advise, develop and maintain good relationships with service users, carers, relatives and fellow health and social care professionals
Knowledge and Experience
* Experience working with people with dementia and their families in settings such as home, care home, or hospital
* Sound knowledge of dementia, risk factors, preventative strategies, signs and symptoms, and types of dementia and impact
* Understanding of the assessment and diagnostic process for dementia
* Knowledge of treatment options, including post‑diagnostic support and cognitive enhancers
* Knowledge of behavioural and psychological symptom management in dementia
* Adherence to legal and ethical frameworks, including the Mental Health Act, Mental Capacity Act, Care Act, Equality Act, Human Rights Act, CPA, and Clinical Governance
Planning and Organisational Skills
* Support the meeting of targets and provide regular information to enable team performance
* Allocate team members in accordance with skill mix, prioritizing and delegating appropriately
* Ensure clinical meetings are led by relevant team members and all patients are reviewed with decisions and plans acted upon
* Attend multidisciplinary meetings for the protection of people with dementia and related services
* Contribute to planning and implementation of service developments within the Plymouth Dementia Pathway, formulating policies and protocols as required
* Review processes and procedures within the pathway in line with guidance such as Department of Health and NICE
Analytical and Judgement Skills
* Support triage of referrals to the Plymouth Dementia Pathway based on eligibility criteria
* Provide dementia care and interventions in settings most appropriate to patient needs
* Match a person with dementia’s needs to available skills and resources
* Lead crisis assessments, supporting risk identification, formulation of plans, and communication with the wider health and social care community
* Report incidents of harm or near misses in line with LSW incident reporting policy and take actions to reduce recurrence
* Investigate complaints and review incidents, producing reports, recommendations, and action plans as required
Person Specification – Skills
* Skilled and experienced clinician, particularly in assessment management of risk and crisis intervention
* Skills in completing assessments for capacity
* Good communication skills (verbal and written)
* Empathic outlook on health care delivery respecting clients’ dignity and human rights
* Interpersonal skills
* Supervisory and leadership skills
* Risk assessment and management skills
* Calm and adaptable
* Ability to work flexibly
* Ability to work autonomously and as part of MDT
* Recognise and manage stress in self and others
* Ability to commute within the locality in a timely manner
* Creative, enthusiastic and self‑motivated
* Ability to manage change
* Willingness to participate in service development
* Ability to work flexibly to support the Manager in developing a healthy team culture and driving change at all times
* IT skills such as Microsoft Teams, online diary systems, patient recording systems
* Experience with Eclipse and adult social care systems
* Specialist clinical skills (CBT training, psycho‑social interventions)
* Staff appraisal skills
* Understanding of Continuing Health Care
* Knowledge and skills in medication management relevant to the post
Qualifications
* RMN/Dip HE – NMC Registration
* Postgraduate specialist knowledge and/or experience in community mental health setting
* Supervisor and/or assessor training in line with the University of Plymouth or willingness to complete this training
* Recovery
* CBT
* Solution Focus Therapy
* Management/coaching qualification
* Experience at a senior level including managerial experience, staff supervision and operational issues
Knowledge
* Demonstrate evidence‑based practice
* CPA and record keeping
* NSF & MHA and NICE guidelines
* Demonstrate a commitment to professional development and be an able educator
* Evidence of life‑long learning (academically and professionally)
* Evidence of knowledge of legislation required for the role
* IT knowledge/skills
* Knowledge of national and local strategies and developments in mental health services
* Able to draw upon a range of skills to support and deliver change within an MDT
Experience
* Relevant experience of working with adults with a history of severe and enduring mental illness
* Relevant experience in community mental health setting or evidence that the candidate can fulfil the functions of a community mental health practitioner
* Care coordination experience
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Equal Opportunities
Livewell Southwest values diversity and encourages applications from all sections of the community, including those with armed forces experience, lived experience of mental health, neuro‑diverse conditions and learning disabilities. If you need assistance or reasonable adjustments during the application process, contact the Recruiting Manager listed in the job advert.
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