Job responsibilities Main Duties & Responsibilities Key Areas of Responsibility To respond to unplanned care and prevent admission to hospital. To assess, prescribed and deliver care packages for patients, e.g. with long term conditions, palliative care and rehabilitation needs, to achieve quality of life and independence where possible. To work within the integrated team to facilitate early discharge from hospital To work within the integrated team to prevent unnecessary admission to Hospital. To work with all health care professionals, and statutory/non statutory agencies to provide a seamless, integrated service to our service users. Engage with mobile working. MAIN RESPONSIBILITIES Clinical The post holder will need to: Assess, plan, implement and evaluate all aspects of patient care, and develop care plans, using clinical reasoning skills, which may need to be delivered from a range of options. Following a holistic assessment, devise an individualised, evidence-based care programme for each patient, modifying it as required. Assess patients holistic needs, communicating complex and sensitive information to patients and carers as to their assessment, diagnosis, prognosis and treatment plan. Where there are barriers to understanding, such as hearing impairment, mental capacity impairment and other difficulties in comprehension, explanations require adjustments in order to gain understanding, consent and concordance. Be required to use tact and persuasive skills in order to gain the patients co-operation in their care management plan. Liaise with GPs, Social Services, inpatient teams, other allied health care professionals and the voluntary sector to ensure identified needs are met and care co-ordinated appropriately. Be aware of assistive technology and utilise where appropriate. To participate in multi-disciplinary/multi-agency meetings as appropriate, e.g. Gold Standard Framework. Ensure own caseload is planned and prioritised according to service targets and patient need. To manage and maintain all areas if intravenous therapy delivery including peripherally inserted central catheter (PICC lines) Ensure patient held records are completed for each visit, and that SystmOne inputting is completed on a daily basis. Demonstrate dexterity and co-ordination when using specialist equipment and fine tools, advanced sensory skills, manual and mobilising skills. Contribute to the requisitioning of supplies and equipment through electronic ordering systems. Ensure informed consent is obtained prior to initiating interventions. Will be exposed to bodily fluids, infected material, blood products on a daily basis, therefore must utilise universal precautions and adhere to infection control policies. Professional The post holder will: Actively contribute to multidisciplinary team meetings and other meetings where appropriate. Support all team members within the integrated team, respecting them, their roles and contributions. Be responsible for safe use and maintenance of equipment and supplies. Remain accountable for own professional actions as determined by the professional bodies. Provide advice / training to less experienced staff and supervise / support other staff and students where appropriate; contributing to the induction process for new staff/students. Comment on draft policies. Maintain own continuous professional development Ensure own workload is planned and prioritised Be accountable for work delegated to others within the team, ensuring staff are competent to undertake delegated work. Attend in-house training as required to develop current job role. Demonstrate leadership skills within own competence Organisational The post holder will: Follow Trust policies, and local procedures, and use discretion in interpreting them according to the setting and circumstances. Undertake mandatory training as required. Participate in a Personal Development Review process. Undertake Personal Development Plans for more junior staff members. Be aware of Trusts behaviour framework and ensure behaviours are embedded in role. Ensure Trusts behaviour framework is utilised when managing and supervising staff, and that behaviours are embraced and embedded within the team. Take part in clinical supervision as per Trust Policy. May be required to demonstrate own duties to students, new starters and/or less experienced staff. Provide mentorship for students undertaking pre/post registration course. Ensure absence reporting is undertaken as determined by Team Leader and Trust Policy. Contribute to clinical audit as required. Complete the staff survey as required. Complete risk assessments and incident forms as required