Job responsibilities
ROLE PURPOSE
To work closely with the
UCR clinicians and Clinical Lead as well as (ACPs) & Clinical Leads
for frailty, Community Nursing, Frailty GPs, Adult Social Care, community
services and the third sector to provide fast reactive services for patients to
support acute hospital admission avoidance where appropriate with a focus on
the 9 Common Critical Conditions- Falls; Decompensation of Frailty; Reduced
Function/Decondition/reduced mobility; Urgent equipment provision, Confusion /
Delirium, Palliative / EOL crisis support; Urgent Catheter Care, Urgent support
for diabetes; Unpaid Carer breakdown.
To provide advanced assessment and care planning, including
history taking and physical assessment for patients with frailty.
To work closely with the frailty GPs, Advanced Clinical
Practitioners & Clinical Leads for UCR & Frailty, adult social care and
the third sector carers and patients to assist in proactively identifying and
managing patients with frailty and supporting them and their carers in the
development and delivery of personalised care plans.
To provide strong holistic assessment and treatment planning
of patients with frailty, without direct supervision.
To work in conjunction with a wide range of clinical
colleagues and specifically, primary care and community teams and Social Care
professionals, leading and facilitating a patient or client focused,
co-ordinated case management approach across primary and secondary care for
people who are most vulnerable to, and at high risk of repeat admission to
hospital.
To participate in and influence efforts across health and
social services to shape multi-disciplinary pathways designed to support
patient choice, improve quality of life, promote self-management and assure
early intervention through the proactive provision of care in or as close to
the patients own home as possible.
The UCR clinician will work across the caseload and the
single point of access or (equivalent), using their clinical skills to identify
the needs of patients and the correct services to liaise with.
The UCR clinician will provide expertise within their
professional discipline, to the wider team.
Provide professional leadership within the team, supporting
the Clinical leads for UCR, and the Band 7 Team Leads in managing the team and
ensuring safe and effective staffing levels and provision of resources to
ensure continuous service delivery and enhancing clinical practice.
Advise on the promotion of health and prevention of illness
and provide information to individuals and groups to prevent disease, where
possible. Recognise situations that may be detrimental to health for example
housing, social and economic factors and refer to an appropriate agency and
liaise with members of the Community Care Team.
To provide case management using extended skills where
appropriately trained to avoid hospital admission and manage sometimes complex
clinical needs in the community setting.
To provide assessment of patients, using analytical and
judgment skills. To provide appropriate patient centred treatment using
evidence-based practice where-ever possible. Patients will present with acute
or chronic conditions and complex multi-system pathologies e.g. neuro,
respiratory conditions, orthopaedic rehabilitation and age-related
deterioration.
To devise effective, personalised plans of care for each
patient with specific therapeutic knowledge, recognizing him or her as an
individual. The plan of care, which has been developed in conjunction with the
patient, carer, and relevant others, should be outcome based and ensure
appropriate pathways of care and communication via liaison and referral to
other agencies as required.
The goals and objectives of any intervention are clearly
established and negotiated, and where appropriate can be assessed through use
of outcome measures/ objective markers.
To provide a holistic and therapeutic treatment programme or
where appropriate direct the intervention as necessary through UCR Band 5
Clinicians, Community Rehab Assistants, HCAs or other members of the
multi-disciplinary team.
DIMENSIONS
Act always with Compassion, and be committed to delivering
high quality care, using effective communication, clinical competence and
courage when needed.
Review effectiveness of clinical care provided ensuring that
patient safety is maintained, and care delivery meets the standards required by
the Trust and the Care Quality Commission.
Monitor the quality-of-care planning, implementation, and
evaluation to ensure optimum quality is maintained.
Maintain, uphold and follow the standards within the
NMC/HCPC code of conduct always ensure safe and effective delivery of patient
care.
To remain up to date and within guidelines for
revalidation/re-registration as always required by professional bodies.
Review effectiveness of clinical care provided ensuring that
patient safety is maintained, and care delivery meets the standards required by
the Trust and the Care Quality Commission.
Ensure that medicines in your area are handled and
administered according to
professional and organisational guidelines to ensure safety and
efficacy.
Inform your line manager of any concerns with patients,
relatives, visitors or staff that may compromise patient care & safety.
Develop and maintain constructive working relationships and
liaise effectively with all members of the multidisciplinary team so that
patients needs are met.
Communicate effectively with colleagues, patients, and
carers so that information is shared to meet patients needs.
Act as a role model in the promotion of person-centred
practice, and challenge practice, which is not person-centred, so that a
person-centred culture is maintained.
Keep updated with relevant clinical developments and use
knowledge to enhance standards of care.
Ensure that discharge and transfer planning for patients is
done in a proactive and interdisciplinary manner.
Practice, role model and promote safe and effective skills
in all aspects of clinical practice.
Practice, role model and promote safe and effective
recording in line with trust policies and professional standards.
Encourage a culture of patient wellness and coproduction
using a health coaching approach.
Encourage a culture of staff wellness and coproduction using
a health coaching approach.
Demonstrate, care, compassion, competence, effective
communication, courage and commitment with all patients and carers by using a
range of verbal and non-verbal communication skills to communicate effectively
in order to progress rehabilitation and treatment programmes. This may include
patients who have difficulties in understanding or communicating e.g. patients
who may be deaf, blind, have cognitive and/or behavioural problems, or who are
unable to accept their diagnosis or presenting condition.
Ensure that patients with palliative care needs (and their
families) have those needs met.
Demonstrate competence and confidence in clinical practice:
this includes all clinical procedures that are relevant/specialist to the
area.
Recognises own limitations in the provision of clinical care
and urgency of patients needs, referring to other healthcare professionals
accordingly and is accountable for his/her own action.
KEY RELATIONSHIPS
Mentoring, supporting and educating others.
Appropriately support the training, support and supervision
of the UCR and frailty teams, ensuring team training needs are met.
Assess and maintain the skills and competencies of Band 3s
and 4s within the team.
Support students in their learning and development.
Promote and contribute to an open reflective learning
culture.
Support the Clinical Leads to ensure new staff receive
proper induction so that they understand acceptable practice and standards.
Use reflective practice to analyse incidents and events and
to develop high quality care.
Ensure practice follows evidence-based practice and national
guidelines are followed.
Participates in setting standards and implementing other
quality initiatives.
Participates on working parties and groups at a local and
organizational level to aid in the development of professional practice this
will include embracing innovations and proposing changes to practice.
Actively participates in CSH Surrey developments related to
chronic disease management and targeted care, e.g. falls, diabetes, coronary
heart disease, stroke, dementia within CSH Surrey and across the boundaries of
health and social care/primary and secondary care.
Initiates policy and practice changes as a result of
incidents, audits and complaints.
STAFF LEADERSHIP AND MANAGEMENT
Provide management support for the team in partnership with
the Clinical Leads, Advanced Clinical Practitioners and Team Leads. This may
include annual leave management; sickness / absence management; performance
management, training and development, appraisals, incident and complaints
management.
Deputise for the Team Leads as required.
Proactively take part in talent management.
Proactive involvement in audit in response to identified
need.
Take an active role in UCR/Hub/Virtual Ward initiatives, in
order that your expertise can be used to benefit care.
Take an active role in promoting the interests and
philosophy of the UCR.
Ensure that equipment is used in the approved manner and is
kept in good condition so that resources are used effectively and efficiently.
Support the Clinical Leads & Team Leads to ensure
systems of risk assessment and management are in place and functioning
effectively.
Support junior colleagues in identifying and minimising
stress in a stressful environment, and through periods of change.
Demonstrate and role model expert practice: this includes
the ability to use independent judgement in issues where clear guidance is not
available.
Building and maintaining effective relationships with all
stakeholders.
Ensure effective management of own and team caseload.
To be able to undertake investigations as required.
