The post holder needs to work effectively as a member of the team; to assist in planning and implementing the care plans and treatment programmes as agreed with the service user and carers, under the guidance of the Clinical Lead/Health care professionals and stakeholders. This includes remote monitoring of vital signs for patients on TeleHealth and escalating to clinicians, people involved in the care and stakeholders as appropriate in a timely fashion. Our mission is to make a positive difference to people's lives by improving the quality of life for all we serve. Our values are: We Care, We Respect, We are Inclusive - so we are looking for people who live and breathe these qualities when supporting service users and carers, and in their relationships with colleagues in the Trust and our partner organisations.
* Following the direction and supervision of the Clinical Lead/Health Care Professionals to carry out assigned tasks and duties to assist with the physical, emotional and social care of the patients.
* To work in a sensitive, enabling manner always taking into account the need for sensitivity of the diverse population found within the borough of Newham. The ultimate goal of the service is to facilitate discharges, avoid hospital admission and ensuring continuity of services in the community where appropriate and possible.
* To monitor patient progress as defined by treatment aims identify trends that indicate a deterioration in health and that the appropriate action of alerting the Clinical Lead / HCP or GP.
* To work the shifts, inclusive of weekends deemed necessary to provide the service.
Health and Social Care Service
* Work collaboratively with colleagues in Primary care to actively seek out patients who will benefit from Telehealth and coordination to avoid unplanned hospital admissions, reduce the length of hospital stays and support and promote independence at home and facilitate discharges as appropriate
Support including self-management
* Support patients to be as independent as possible by facilitating range of self-management strategies i.e., available from other sectors.
* Support GP's to establish effective working relationships with patients, their families and carers. This will include promoting individual rights and recognising and respecting their contributions to care planning and delivery.
* The person needs to form professional relationships with clients, and communicate with them in a way that respects their views, autonomy and culture and provide an integrated care approach.
* The individual needs to be able to liaise with relatives, carers, medical staff, allied health staff and those within the multidisciplinary team to obtain or feedback information relating to the patient's care.
* To be able to contribute towards the teams' vision and attend meetings and events to promote the service
* Person must understand and apply the need for confidentiality in all aspects of patient interactions.
* Person needs to be legally accountable for all aspects of own work.
* Person needs to use clinical knowledge and life skills to build up a rapport with the clients, to engage with them and motivate them to engage with their own care.
Knowledge
* Being aware of national and local policy that impacts upon the health and well-being of patients with complex chronic conditions.
* Working with the multi-disciplinary team promoting self-care for patients with long term conditions.
* Working with patients and their families to plan for and improve last years of life care, ensuring that choices are reflected in personalised care plans
Administration
* The person needs to ensure confidentiality of client information is maintained.
* The person needs to ensure to adhere to data governance including documentation
* The person needs to take responsibility for the maintenance of equipment used within the clinical setting and to report any malfunction or damage.
* The person needs to attend service/team meetings as requested and participate in clinical governance and service improvement work, including audit activity or special projects as applicable.
* The individual has a responsibility to contribute to the smooth running of the service and play an active part as a team member.
Management and Record Keeping
* Person needs to maintain legible, accurate, contemporaneous clinical records.
* Ability to understand and employ a set of non-specific skills to meet the psychological needs of service users with mental health needs through care planning and risk management strategies.
* The individual needs to use strategies to overcome barriers to understanding when communicating with clients who do not have English as a first language, or those who have difficulty understanding or expressing themselves clearly, due to stroke or dementia illness.
* The person needs to able to work without direct supervision in the implementation of programmes of care in order to meet prior agreed goals; evaluate the effectiveness of intervention, and, make any changes in consultation with senior members of team
Education and Supervision Responsibilities
* The individual needs to attend regular supervision sessions with their identified mentor.
* The person needs to participate in the individual performance review system. To contribute to identification of training needs and the development of a personal development plan to address these.
* The person needs to keep a record of learning from training and development activities, and develop evidence of their competence within the job.
* The person needs to attend relevant course/study days and to share information gained or skills learnt with other staff within the service.
* The individual needs to be aware of, and comply with Community Health Newham and East London Foundation Trust policies and procedures, following the induction process
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