Overview
The Westminster and Kensington & Chelsea Older Adults and Healthy Ageing Community Mental Health Teams are developing a new primary care pathway to provide early access to support for older adults who are experiencing mental health difficulties. In line with the mental health transformation agenda, the primary care pathway will focus on the integration and development of neighbourhood-based care alongside primary care, local authorities and third sector providers. Additionally, it will promote early identification and prevention of mental health problems in older age, early recognition of emerging cognitive, emotional and behavioural changes. Furthermore, the service will focus on early intervention, working proactively with community partners to provide interventions to meet needs, reduce risks and prevent escalation by supporting service users to remain well in the community, thereby reducing the need for secondary care interventions and admissions to hospital.
Main duties of the job
We are looking for two Older Adult Clinical Leads who will become an integral member of the management team providing support, managerial and clinical supervision. The post holders will take line management responsibilities for a small team which will include RMNs, Occupational Therapists and Support Workers, amongst others. They will have a vital leadership role, acting as a role model for others, in communicating, developing and maintaining relationships both within the team, wider Trust and PCNs they work within. This will include liaison and engagement with wider mental health and other services, to develop effective links, and understanding of pathways into and through services.
The postholders will be expected to have outstanding mental and physical health clinical skills in order to enable them to appropriately provide advice to Primary Care colleagues, guide and supervise staff at all levels. This role will involve the full assessment of mental health care needs of older adult patients in the community, providing a broad range of specialist psychosocial treatments as necessary. They will carry their own small caseload of clients and be expected to assess patients referred from a variety of clinical settings, acting as a resource and taking the lead in the management and delivery of services where appropriate.
Working for our organisation
The primary care pathways will sit within the Westminster and Kensington & Chelsea Older Adults and Healthy Ageing Community Mental Health Teams. These are well established dynamic multidisciplinary services providing mental health support to older adults in Westminster and Kensington & Chelsea with functional disorders and dementia. They are co-located with the Westminster City and Kensington and Chelsea Council mental health team, offering a holistic approach to care. The Westminster team is also involved in the CNWL Open Dialogue project, which promotes person-centred recovery-oriented care.
The teams operate using a case management, intervention-led and recovery-focused model, offering multidisciplinary assessments and interventions for service users with complex needs, as well as their families and carers. Regular multidisciplinary meetings facilitate case discussions, initial assessments, and reflective practice. A key feature of the services is the integrated older adults home treatment team, which delivers intensive support, crisis management, admission prevention, and helps ensure timely hospital discharges. The CMHT and HTT teams collaborate closely, offering a responsive and flexible service to meet the needs of service users. Coordination with older adults’ inpatient services allows smooth transitions of care.
Detailed Job Description And Main Responsibilities
* To be one of the OA clinical team leaders for primary care networks (PCNs), responsible for the clinical practice of the team and ensuring that priorities are met.
* To support the Service in the development of the primary care pathway which may include:
* Developing systems of engagement with key 3rd sector partners to identify and promote access to mainstream activities
* Creating systems which will provide a high standard of record keeping and documentation with adherence to Trust policy and an understanding of professional guidelines and application of confidentiality. These systems will ensure monitoring of referrals, assessments, allocation, caseloads and clinical review processes
* To line manage all junior staff in the PCN team irrespective of their registration.
* To ensure that clinical supervision is given to all staff in the team and to ensure that staff work to high standards of professional practice
* Carry out robust needs and risk assessments, as well as care planning in primary care environment.
* Provide access and /or deliver a broad range of psychosocial interventions for individual patients where needed.
* To be responsible for providing and receiving complex, sensitive, distressing and emotional information in relation to health issues where there are often barriers to acceptance
* To be mindful of the needs of individuals and families from a wide range of racial, cultural, sexual, religious and social backgrounds and, with service users and colleagues, co-produce innovative ways of communicating and working across language and cultural barriers
* Where appropriate, provide expert advice regarding the pharmacological management of mental health patients to non-mental health professionals, seeking clinical guidance from the designated Consultant Psychiatrist/GP in relation to any specific prescribing advice
* Attend relevant PCN multi-agency meetings and conduct specialist short-term intervention and mental state assessment for patients either as part of the transfer of care process or following request by primary care team
* To carry and care co-ordinate a small caseload and contribute to an assessment roster
* Provide advice to primary care to help prevent inappropriate referrals and provide support to patients and to find different ways of meeting their mental health needs
* Follow up on service users who do not meet the threshold for secondary care assessment and interventions
* Be required to work in conjunction with individual members of the primary care team, patients and carers to develop personalised safety plans
* Work within an agreed process for safe transfer of care from Older Adult Community Mental Health Teams to GPs that will ensure good clinical outcomes, access to appropriate advice, advocacy and support networks as well as rapid re-referral, when appropriate
* Work with colleagues to develop clinical expertise and high standards of professional practice
* Deliver care that is evidence based, reflecting current best practice and research, demonstrating clinical excellence and high standards of professional practice to other staff
* Demonstrate sound understanding of the legal and ethical issues in caring for people with a mental health condition. In particular, demonstrating sound understanding of the Mental Health Act (1983) and Mental Capacity Act and its use in a non-mental health settings.
* To work within the relevant legislative frameworks (e.g. Mental Health Act (1983) Mental Capacity Act (2005), Deprivation of Liberty Safeguards, Care Act 2014 etc). To ensure that team works within the relevant frameworks and policies for safeguarding vulnerable adults
* To demonstrate outstanding clinical competence both in relation to supervision of staff and direct face to face contact with service users
* To advise the manager regarding the delivery of PCN mental health services and be involved in identifying the resources needed in the team
* To ensure that the service works in co-ordination with other Community and Acute In-Patient services
* To develop an Open Dialogue pathway in PCNs if relevant to the borough.
Communication
In conjunction with the team manager:
* To work in partnership with the consultant psychiatrist in the primary care pathway to actively promote MDT working
* To work actively in partnership with service users and carers
* To engage directly with service users to ensure effective consultation regarding service standards and development
* To facilitate and enhance good team working and promote reflective practice
* To ensure the team maintains close liaison with all local agencies that support service users, including the Metropolitan Police Service, primary care and voluntary sector organisations
* To ensure good working links with any other agencies who may be involved in referring service users or providing services for them
* To disseminate professional developments and changes in policy or legislation, information regarding services and community resources, to ensure that staff utilise these services or developments for the benefit of service users
* To provide expert advice and consultation in professional matters relating to the postholder’s discipline, and to ensure that expert information and advice is available for the other disciplines in the team
* To attend liaison meetings with other teams and agencies, i.e. police, housing, learning disabilities etc
Training
In conjunction with the Team Manager:
* To ensure that all disciplines conform to the agreed operational policy
* To ensure that accurate case recording occurs regarding all aspects of the work undertaken with service users and that this is reflected in the teams database, and that administrative systems are updated whenever there is any adjustment in service
* To take an active role in care quality to ensure high standards
* To ensure team members have the competence to undertake the work of the team and to participate in delivering in-house training
* To ensure that the training, professional and legal requirements are met
* To coordinate and promote training for students on placement
* To ensure that forums are developed that facilitate: team development, cross disciplinary learning and communication between team members, clinical professional dialogue and staff support
* To engage in own professional development, including supervision and appraisals in line with best practice
* To adhere to the relevant professional’s Code of Ethics and Professional Conduct.
* To act as a practice placement assessor/educator for nursing/OT/social work students, attending all relevant meetings and liaising with colleges as appropriate.
Service Development
In conjunction with the team manager:
* To develop and implement the primary care pathway
* To take an active role in care quality forums / business meetings / engage with experts by experience and carer to inform the development and evaluation of the service.
* To ensure the service is “service user” centred, and they are treated with dignity, respect, courtesy and understanding
* To ensure that information regarding the work of the team is made available and relevant metrics are used to monitor the effectiveness of the service provided by the team and ensure adherence to standards agreed by CNWL
* To ensure professional standards of the team are maintained and developed
Person specification
Qualifications And Training
Essential criteria
* Professional qualification in mental health - Occupational Therapy, Mental Health Nursing (RMN) with current NMC/HCPC registration
* Attained at least Level 2 Maths and English (equivalent to GCSE grade 9-4 (A*-C))
* Attendance at specialist courses relevant to the post (e.g. MBT or DBT, Trauma Informed Care, Group Approaches, motivational interviewing, complex emotional needs)
* ENB 988 or equivalent training or equivalent for OT candidates
Desirable criteria
* Educated to degree or Diploma level with other courses relevant to primary care mental health services e.g. CBT, Brief Solution Focussed Therapy etc.
* RGN/physical health qualification
* Evidence of recent and on-going relevant further professional development
* Open Dialogue Practitioner or willingness to train
Experience
Essential criteria
* Extensive experience of working with older adults/ those with complex physical and mental health needs including: assessment and therapeutic interventions and/or working with carers and/or delivering therapeutic group interventions and/or working in MDTs and Work in multi-cultural settings
* Relevant experience of working in the NHS, primary care, outreach work and community setting.
* Work with older adults with enduring mental health problems
Desirable criteria
* Evidence of experience in a Band 6 position or equivalent
* Experience of teaching/training in a formal or informal setting
* Experience of working with service users with drug and alcohol misuse issues
Knowledge
Essential criteria
* Comprehensive knowledge and understanding of UK health care systems and structures: staffing, roles and responsibilities, the role of hospitals, primary care and community care.
* Excellent knowledge of mental health and physical health conditions affecting older adults, including assessment and intervention models.
* Experience in using standardised measures for cognition and mood (e.g. ACE 3; MOCA, GDS, Core 10)
* Team/self-management and organisation skills that enable a number of complex activities and clinical work to be undertaken, revising and adjusting these according to the needs of individual patients and the service
* Knowledge of counselling skills/cognitive behavioural skills, psychosocial interventions
* Knowledge of recovery approaches as used with those with mental health conditions
Operational
Essential criteria
* Computer literate
* Use IT packages – word processing, e-mail and internet, Excel and Access
Desirable criteria
* Experience in using SystmOne
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