NursingNetUK

Detailed job description and main responsibilities

The post-holder is responsible for the ongoing assessment of care needs and the development, implementation, and evaluation of care. The post holder will carry out all relevant forms of care and will take responsibility for caseload holders in their absence. Professional/Ethical Practice

Ensuring that the community nurses within the team practice within a legal and ethical framework that adheres to The Code and local Trust Policies and Procedures.

Focusing resources to ensure equity of access for all individuals and groups within the locality.

Being personally accountable for professional and ethical actions and ensuring compliance with The Code.

Maintaining confidentiality, while communicating patient information, in such a way that preserves the dignity and privacy of the patient and family/carers.

Working in a non-judgmental anti-discriminatory way, with regard to cultural and religious beliefs of individuals and groups.

Ensuring that prior to any course of action involving individuals/groups has their informed consent.

Acting as an advocate for individuals and groups.

Bringing to the attention of team members when they are acting outside of the Code, Trust Policies and Procedures and identifying actions to rectify any professional issues. Patient Care Delivery/Communication

Developing, maintaining, and identifying problems with effective locality communication networks with other health professionals, statutory and voluntary agencies and helping to improve its effectiveness. To manage a caseload of patients with a broad range of complex and specialist needs, using evidence based and client centred principles to assess plan implement and evaluate interventions.

Accurately and timely recording of all care given to the patients and report any changes in the patient’s condition to the general practitioner or other members of the health/social care team and that may be used for investigations/serious incident reporting.

Attending and participate in staff meetings, MDT’s and other meetings as required.

Ability to verbally explain complex issues in formal situations such as investigations.

Ability to formally present and discuss to individuals and groups ideas and issues pertinent to Community Nursing.

Identifying and allocating responsibility for the assessment of particular client groups.

Having responsibility for the health assessment of adults within the population as their needs arise.

Using the knowledge and skills necessary to assess individuals and groups, identifying the multiple needs of the patient, family/carer providing holistic care taking into consideration cultural differences.

Working within the Community Division as a member of the integrated community nursing team, participating in activities, which address the health needs of the general population.

Providing and maintaining a high standard of skilled nursing care for patients in their homes, health clinics and Care Homes using an evidence-based model of care, that is consistent with NICE guidelines, within own scope of practice and legislation.

Ensuring that nursing procedures are taught to relatives/carers so that the care of the patients may be continuous over 24 hours, and guidance is given on carrying out all treatments.

Ensuring the changing needs of individuals and groups are identified timely and adjustments to programmes of care are made.

Promoting and maintaining optimum health by identifying, planning, and undertaking specific health promotional activities with identified individuals and target groups.

Following Merseycare NHS Foundation Trust guidelines in all suspected and confirmed emotional, sexual, and physical abuse.

Ensuring that concerns and identified potential risks are referred to the appropriate General Practitioner (GP)/Multidisciplinary team immediately.
Care/Caseload Management

Responsibility for the co-ordination in monitoring the care of patients with long term conditions, disease management and supporting clinical staff ensuring continuity and continuing care

Being responsible for the development of an annual caseload profile to identify the health needs and necessary resources to meet service needs, using the information to inform other professionals and to direct development of services.

Responsible for the setting of team objectives in conjunction with the Operational Lead.

Ensuring that all Human Resources policies are adhered to including the recruitment and employment of staff, the management of sickness absence.

Using own expertise and experience to present recommendations for service development.

Responsible for ensuring that all data relating to the patient activity of the team is input onto the information system accurately and on time as required by Trust policy.

Having delegated responsibility for budget management operating with constraints identified by management, and acts as an authorise signatory for goods and services.

Allocating work to make best use of the knowledge and skills of team members.

Having responsibility for ensuring that appraisals and PDPs are carried out within the team and the information collated.

Co-operating with Trust management and others in meeting statutory and local requirements of the Health and Safety Policy.

Identifying strategies aimed at minimising risks to staff, patients, clients, and others that use the health service.

Having the responsibility for accident/incident reporting.

Developing systems and processes that engage with users of the service ensuring services are designed to meet need.

Valuing the contribution that users of the service can make in shaping services.

Leading by example to inspire others with the values and vision for the present and future of Community Nurses nursing patients with long term conditions/acute disease management highlighting to individuals, the team, and the Trust the benefits of new ways of working

Having the ability to constructively challenge current working practices and overcome barriers during times of change.

District Nurse Team Leader Role:

To promote the attainment and maintenance of optimum health of patients who have long term conditions and acute disease management through predictive and proactive case management of an identified caseload of patients.

To formulate care plans that address the expressed health, social and cultural needs of the patient as an individual through working in partnership with the patient, the GP, specialist nurses and other stakeholder providers.

To promote patient centred care by integrating and co-ordinating the activities of the patient, relatives and carers, the individual practitioners, and teams in the provision of an efficacious management strategy for managing an individual’s long-term condition.

To ensure that appropriate information regarding the condition of the patient is known to the GP and other appropriate stakeholder providers, by the development and maintenance of effective systems of inter-agency, inter-disciplinary communications.

In liaison with Integrated Community Nursing Teams, Social Services and GPs, provide clinical leadership to nursing teams to enable them to develop approaches that address the needs of patients with complex long-term conditions and acute disease.

Support pathways for smooth transition between primary, secondary, and tertiary care for patients, particularly those who are newly diagnosed or whose symptoms are poorly controlled, by liaison with specialists within primary and secondary care. Making direct referral of patients for medical assessment and diagnostic procedures using the care pathways approach.

Inform the development of policies and procedures relevant to the care of people with long term conditions and acute diseases by co-operating and assisting in research programmes relating to the client group. Valuing the contributions that users of the service can make in reshaping services by developing systems and processes that engage those users meaningfully to ensure services are designed to meet expressed need.

Ensure services are delivered and sustained in line with NICE guidelines/local targets and understand principles of disease management by leading, motivating, educating, and developing colleagues and others.

Promote admission avoidance and early discharge by effective liaison with internal and external stakeholders. Personal/Professional Development

Participating in the setting of personal objectives with the Operational Lead through the job appraisal and clinical supervision processes.

Giving advice on professional issues relating to community nursing.

Managing changes to ensure the smooth transition of new ways of working.

Identifying and investigating poor quality practices within the team and suggesting and agreeing actions to rectify practice.

Complying with and fulfilling the objectives of the Community Division.

Maintaining and continually updating professional knowledge and skills.

Undertaking yearly appraisals with team members, identifying their training, educational and development needs.

Assisting in the induction programme for new staff to the Merseycare NHS Foundation Trust as appropriate.

Using own knowledge and skills to inform the future development of policies and procedures relevant to Primary/Community care and district nursing in particular.

Ensuring the competencies relating to the nurse prescribing competency framework are maintained and developed.

Ensuring that identified risks to service delivery are reported or acted upon i.e., working practices do not support effective practice.

Ensuring that quality standards of care are maintained using audit and other monitoring systems.