Job responsibilities
This role combines a practice development role with a clinical role in Bromleag Care Practice which is part of the Orpington Primary Care Network. The post holder will have
high visibility within the care homes using every opportunity to role model and empower care home staff, in addition to Primary care teams and other stakeholders, around
o recognition of frailty,
o enhanced communication with patients, their families and professionals
o expert symptom management.
The post holder will work as part of the wider interdisciplinary team at Bromleag Care Practice and any ongoing or initiated programmes of support for care homes to ensure a joined up, system wide approach.
The post holder will sit within the Bromley Community team and Bromleag Care Practice, supporting staff to develop skills around support and management of frailty using CASCADE and its capabilities as an integral way of working
The post holder will be expert at frailty recognition and be competent in frailty specific assessment to recognise holistic needs and plan, implement and evaluate care provision
The post holder will also be competent in the recognition of incremental change in a persons illness trajectory and support parallel planning, ensuring support to others to recognise progressive decline of a resident and understanding frailty triggers
The post holder will be expert in communication skills around goal setting and potentially end of life discussions including advance care planning understanding when, where and how to have and document these conversations
The post holder must have the skill set to undertake all aspects of the role including clinical practice (assessment and symptom management), sensitive interpersonal communication, teaching and coaching, quality, audit and management.
The post holder will take every opportunity to train and support Primary Care Colleagues, other stakeholders, registered nurses (RNs) and care workers in the care home through role modelling and informal teaching. Using facilitation, and when appropriate, will develop the skills of the RNs and health care assistants within the care home to provide individualised and quality care to those with advanced life-limiting illness and those approaching the end of life.
Support during the Primary care Teams undertaking Ward Rounds either in person or virtually
This will be achieved by;
1. Provision of professional clinical leadership to the Care Home teams, primary care and other stakeholders maintaining and further developing, high quality care
2. Using advanced clinical interventions with efforts to model and engage other stakeholders in this work
3. High level visibility and accessibility to the Primary care networks in Bromley on leading by example and empower staff in their professional development
4. Support strategic development of St Christophers services around its offer to care Homes
5. Welcome and support for professionals visiting, or learning within the services St Christophers provide to care Homes in Bromley
6. Support for the wider multi professional team, and its work to the benefit of patients and their families who reside in care Homes in Bromley
7. Quality assurance and improvement processes related to the work undertaken
1. To be an authoritative specialist in frailty and end of life care in Care Homes by using advanced clinical reasoning skills and evidence-based knowledge on assessment, pain and symptom management, psychological /spiritual/ social /practical and ethical decisions at the end of life and to work in partnership with patient and families, and a range of health professionals to improve their skills in these areas.
2. To be able to identify patients goals and help them (where possible) to achieve these.
3. To be professionally and legally accountable for all work undertaken and to practice at an advanced level of professional autonomy and accountability within St Christophers policies and the NMC Code
4. To undertake independent prescribing when necessary and to be professionally and legally accountable in accordance with St Christophers policy, the Code and the Royal Pharmaceutical Societys Competency Framework for Prescribers. This will include advising General Practitioners and others on appropriate medication provision.
5. Be cognisant of the use of User and Patient Related Outcome Measures (uPROMS) to measure the patient need and service response.
6. Develop excellent partnership working with external stakeholders e.g. Continuing Health Care, Local authority, Commissioners, Voluntary Sectors, local health care providers across Croydon ensuring the focus of high-quality end of life support to Care Home Teams
7. Ensure the systems and processes are in place to smoothly manage patient flows across all care settings.
8. Advise and support Care Home staff in delivering optimal care at home by initiating treatments such as managing CSCI pumps and subcutaneous fluids.
9. Initiate and manage complex communication with residents and their families including advance care planning discussions. Structure an interview using appropriate questioning; avoid jargon, using familiar language, at the residents own pace.
10. Demonstrate particular skills for communicating with residents with advanced dementia. Support care home staff in their communication skills. Anticipate barriers to communication, and act to work with care home staff to improve the communication skills and strategies of the team;
11. Document all discussions appropriately and create/update UCP record.
1. Develop objectives and key performance indicators in line with St Christophers strategic objectives
2. Collect and interpret data, providing reports on the performance/ development of the role
3. Develop mechanisms to ensure regular feedback from stakeholders and respond to any informal or formal feedback
4. Manage complaints, as requested to do so and feedback relevant information to external agencies
5. Assess risk and minimise threat to personal safety
1. Work closely with the multidisciplinary team providing support and care to the care Homes within Bromley. Co-ordinate and facilitate GSF meetings.
2. Communicate effectively at all levels of the organisation and across organisational boundaries demonstrating diplomacy and partnership working.
4. Work with the Care Director and Director of Quality and Innovation to ensure St Christophers complies with the CQC Standards of Care
5. Work closely with all services provided by St Christophers, using our resources effectively
6. Contribute to the leadership of the MDT meetings to facilitate the changes required to ensure efficient and high-quality care for all patients both at St Christophers and across Care Home settings
7. Attending regularly the EoL Steering Group meeting in Bromley ensure effective participation and completing all work / outputs from this meeting
1. Ensure any relevant Policies and SOPs are developed to support this project
2. Ensure compliance in areas of responsibility with key statutory and regulatory guidance related to safeguarding, deprivation of liberty, mental capacity and similar.
3. Proactively engage with leaders in Bromleag Care Practice and St Christophers Hospice across EoL care in Bromley to continually develop our service
1. Co-ordinate the multi professional team providing care in care Homes using knowledge of the team, to facilitate active sharing of expertise across disciplines. This include facilitating continuous improvement of care provision in ward rounds
2. Model a palliative care approach which promotes rehabilitation and self-management whenever possible using goal setting techniques
3. Be expert in delivering education and training sessions as required
4. Consistently draw on research and literature evidence base to influence practice and teaching and proactively seek opportunities to develop and perpetuate a culture where audit and research are integrated into practice
1. Coach and/or mentor individuals as appropriate including GP trainees and AHP trainees
2. Provide and support provision of a high-quality learning environment in line with ACP NMC guidance on Standards for student supervision and assessment.
3. Clinical oversight of clinical trainees as educational and/or clinical supervisor as agreed within the clinical team
4. Contribution to the nursing /AHP support of educational activity in the organisation, mentorship and collaboration with other disciplines to promote and facilitate effective interdisciplinary practice if required
5. Take a co-productive approach to the learning needs of care home staff
6. Recognise the emotional impact of caring for dying residents on care home staff and encourage self and team care strategies
7. Work with the ECHO facilitator to identify ACHPs ready to engage in the development of an ECHO Community of Practice
8. Work with Bromleag Care Practice in developing educational webinars for care home staff.
9. Work with care home managers to promote the use of Assessment tools and Patient reported outcome measures
10. Use a range of approaches to the facilitation of learning to deliver effective education and training to care home staff
11. Where possible introduce and demonstrate and encourage the use of the NAMASTE toolkit.
12. Identify learning evaluation strategies and ensure collection and analysis of data to ensure both improvement of own practice development role but also improvement of care home staff practice
13. Be a resource for care home managers and staff to access apprenticeships and vocational learning.
14. Undertake mandatory and statutory training as required
The post holder also provides professional supervision to staff across the organisation
Contributing to the development and review of the organisation wide care and support strategy, attending relevant meetings at the request of the Care Director or Medical Director
