Job summary
The Urgent Care& Support Service is part of the NHS Urgent Community Response serviceworking to reduce hospital admissions from Nursing, Residential and LearningDisability care homes. The team responds to urgent care visits providingadvanced clinical assessment, diagnosis and management which includes proactivesupport and clinical trainingand education in combination with a dedication to building a network of healthand social care professionals working together.
Main duties of the job
Thesuccessful candidate will be able to work well both autonomously and within ateam using physical assessment skills (could be working towards completion ofphysical assessment skills as stated in the job specification) and willingnessto develop prescribing skills.
Theability to work flexible in the delivery of the service is essential and inreturn for your enthusiasm, commitment and hard work we can offer you afriendly and supportive work environment, a range of training opportunities forpersonal development (including Advanced Clinical Practice), access to clinicalsupervision, appraisal and a range of other benefits.
About us
Welcome to Your Healthcare CIC, formerly part of NHS Kingston we are anot for profit social enterprise, proud of delivering patient-led, high qualityhealth and social care community services for residents in Kingston &Richmond as part of the NHS family.
Job description
Job responsibilities
2. Job Purpose
1. To participate in providing a Nurse-led standardised level of support and care for Nursing, Residential and Learning Disability Care Homes in Kingston, working in partnership with care home providers. Focusing on promoting proactive care delivery and development of evidenced based clinical policies to improve standards and raise levels of knowledge and skills through education and support.
2. Being part of the Urgent Community Response Service, to provide an urgent care service to care homes enabling residents to be assessed, diagnosed and receive appropriate treatment reducing unnecessary A/E attendance.
3. To participate in working with care home staff to manage residents with complex or long-term conditions, clinically assessing and prescribing to prevent admission to hospital and advising on nursing intervention to avoid deterioration.
4. To participate in case management of patients with exacerbation of long-term condition/complex conditions where appropriate under the guidance of an Advanced Nurse Practitioner enabling care homes to prevent crisis situations arising, thereby avoiding inappropriate hospital admissions
5. Participate in working in partnership with the care home to improve the quality of care by providing enhanced clinical assessment, intervention and diagnostics
3. Dimensions
Monitor hospital admission, A&E attendance & ambulance call rates for individual care homes in the Kingston borough, targeting support to care staff in homes where emergency admission rates are high.
Assist in providing advice, support and clinical input to residents.
Assist in identifying complex patients requiring case management.
Assist in providing guidance on safe practice for individual residents to prevent unnecessary emergency hospital admissions, particularly in relation to end of life care.
Participate in training and support to care homes to encourage them to provide high-quality care to residents with complex needs and those approaching the end of life.
Support care homes in identifying training needs and recommend/sign post to appropriate training for staff.
Assist in providing training & support on a range of subjects alongside the Clinical practice educator. Provide developmental training programmes for care homes to adopt which would embed nationally recognised care practice ( NICE Guidance) for long term conditions.
Work in collaboration with other Health Care Professionals services for patients identified at risk of admission SALT, Dietician, Diabetes Nurse Specialist, Tissue Viability Nurse Specialist, Continence Nurse Specialist and Extended Scope Practitioner Lead Respiratory Physiotherapist
Participate in supporting care homes, linked and Adult Services to work collaboratively to achieve effective communication and provision of proactive medical/nursing/therapeutic care to prevent unnecessary hospital admissions.
Assist in collecting data as required supporting audit focusing on health outcomes and reduction of acute hospital emergency bed days.
4. Key Result Areas
Clinical
6. Use clinical reasoning and physical assessment to assess, diagnose and treat thephysical and psycho-social needs of residents with complex needs or those at risk of hospital admission. Participate in working with the care home to instigate therapeutic treatments based on best available evidence to improve health outcomes.
7. Use skills and clinical knowledge to assist in supporting the care home staff in identifying and monitoring subtle changes in the condition of residents/patients and in taking appropriate action to prevent/manage exacerbation of disease wherever possible.
8. Assist in working with the care home staff to recognise and interpret cues, signs and symptoms, instigate investigations and interpret results to formulate a diagnosis. Use skills and knowledge to make both a comprehensive and focussed assessment.
9. Order investigations as necessary.
10. Assist in supporting the homes in developing personal care plans and crisis management plans with residents carers, relatives and health professionals based on full assessment of medical, nursing and social care needs.
11. Participate in providing expert clinical care support and health promotion interventions.
12. Participate in providing support with the implementation of evidenced based clinical policies to underpin effective and consistent care management.
13. Use knowledge and skill to provide advice to patients and their carers on medicines management.
14. Work in partnership with GPs.
15. Assist in co-ordinating the seamless transfer of residents to appropriate services. Negotiate and agree with the patient, carers and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
Provide multi-disciplinary team (MDT) support for the development and maintenance of personalised care and support plans for care home residents, empowering residents with capacity to make choices about their healthcare.
Contribute to MDT meetings as part of the integrated system regarding individual residents and support a co-ordinated response from health and social care
16. Challenge professional and organisational boundaries which prevent delivery of integrated health and social care to prevent health deterioration or hospital admission.
17. Participate in identifying areas for skill/knowledge development and apply these to practice to provide continuity and high-quality patient-centred health care.
18. Participate in mobilising additional support as needed, palliative care, colleagues in the Joint Service Directorate, Adults Services and Carers Support Service.
19. To assist in establishing a network that can be used to streamline care pathways, working in partnership with other agencies.
20. Ensure effective co-ordination of care for individual residents within the care home setting under the guidance of the Advanced Nurse Practitioner/service Lead
21. Assist in ensuring that care homes provide baseline health data if the resident is admitted to hospital to support integrated, consistent care and facilitate discharge.
22. Work with the multi-disciplinary team to plan and implement high quality care.
23. Contribute Influencing, developing and pioneering changes in practice within care homes.
24. Participate in identifying patients who have complex care needs to formulate appropriate management
25. Participate in developing integrated care pathways between care homes, and A&E staff teams.
26. Champion Older People's issues in a variety of settings and Professional groups.
27. To work in partnership with the Advanced Nurse Practitioner to Initiate actions/recommendations relating to care homes to help reduce hospital admissions and delayed transfers to underpin the Care Closer to Home and Unscheduled Care Programmes.
Educator
28. Assist care home staff and other Professionals to enable competence and development of skills/roles in accordance with DH principles.
29. To participate in working with and teaching residents and carers to identify subtle changes in condition that may precipitate acute exacerbation of underlying condition or illness and assist in advising on the action to be taken ensuring care plans reflect this.
30. To participate in developing training packages for residents, informal carers and care staff to promote independence; plan for unavoidable progression in conditions and educate in the areas identified as causes for A/E admissions UTI, dehydration, falls, chest infections/ aspirational pneumonia, palliative care and enhance dementia care practice.
Communicator
31. Use a high level of interpersonal, IT and communication skills to communicate effectively with residents and care home staff, including communication of sensitive and complex information about individual condition.
32. Participate in preparing residents and their families for changes in condition and support choice about end of life care in partnership with palliative care team
33. Effectively communicate at all levels of the organisation with a variety of health professionals, users and carers to provide the best health and social care outcomes for older people.
34. Assist in providing the interface between hospital and Primary, Community & Social Care and Care Home settings.
35. Maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions of pressure.
36. Keep accurate timely documentation and up to date care plans.
37. Provide high quality written reports and any other written documentation as necessary.
38. Listen and empathise with the needs and wishes of users and their carers.
Researcher
39. Contribute to evaluation of the project particularly in relation to impact on avoiding hospital admission.
40. Participate in identifying the population at risk within the care homes using local data and information from a variety of sources.
41. Critically evaluate and interpret evidence-based research finding from diverse sources making informed judgements about their implications for changing and/or developing services and clinical practice.
42. Continually evaluate and audit the quality and effectiveness of the practice of self and others, selecting and applying a wide range of valid and reliable approaches and methods that are appropriate to needs and context.
Person Specification
Other factors
Essential
43. Valid driving license
44. Must be a car driver and have use of car
Qualifications
Essential
45. Registered Level 1 Nurse
46. Diploma/Degree in Nursing Studies
47. Clinical reasoning in Physical assessment (or working towards completion)
Desirable
48. V300 Non-Medical Prescriber
Experience
Essential
49. Demonstrate broad experience post registration within a variety of core areas
50. Continence/catheterisation management
51. Tissue viability
52. PEG Management
53. Palliative Care
54. Long term conditions
55. IV Management
56. Experience of assessment and delivery of care to people with complex needs
57. Negotiating and working across organisational boundaries
58. Working as part of a multi disciplinary team
59. Mentoring students and other health care professionals
60. Experience of lone working and decision making
Desirable
61. Experience of working in a community setting
Knowledge
Essential
62. Knowledge of NMC Code
63. Understanding of national policy governing the delivery of adults and older peoples services
64. Awareness of current developments in health and social care
65. Knowledge of clinical governance/ risk management and reporting
66. An understanding of the implications of cultural difference for service delivery
67. Knowledge and understanding of audit and research
Desirable
68. Awareness of issues surrounding care homes
Skills and abilities
Essential
69. Evidence of up-to-date based knowledge and skill
70. Evidence of ability to maintain high standards of care
71. Evidence of professional development and knowledge
72. Able to analyse situations and problem solve as necessary
73. Ability to develop and maintain partnership working
74. Ability to motivate staff
75. Report writing skills
76. Teaching carers, residents and staff
77. IT Skills
Personal qualities
Essential
78. Able to work under pressure
79. Self-motivated
80. Innovative
81. Enthusiastic
82. Able to work alone