Job summary
Integrated Care Lead North - 12 Month Maternity Cover. (Based at Martham or Yare House)
East Coast Community Healthcare CIC (ECCH) is commissioned to provide Community healthcare services to our local community, this role is central in ensuring optimum patient outcomes and developing effective relationships with staff from other organisations and local health care providers.
This is an excellent role to develop and transition your clinical and leadership skills. You'll be a core member of the PCH leadership team and advocate for the "four teams one service approach" to delivering high-quality outcomes and patient experience.
We are seeking an Allied Health Professional or Registered Nurse (Adult) or Social worker to lead and manage the reablement element of our Primary Care Home, in order to deliver high quality community health care to the population of Gorleston & Great Yarmouth . The role is for you if you have an open mindset, collaborative leadership style and are excited by the opportunities for improved patient care working in in a holistic way within our teams and with partners.
Previous experience of providing health care in the community, rapid response, case management and people management would be beneficial. We will support the right candidate to transfer existing knowledge and skills as a registered AHP/Nurse working in a different care environment.
Main duties of the job
The role requires a high level of autonomy as the Integrated Care Lead for the PCH you will be coordinating complex packages of healthcare, overseeing the delivery of reablement care by the multidisciplinary team, supporting the PCH response for Admission Avoidance, providing line management to a number of clinical employees.
You will have oversight of the health connectors colleagues and participate within the virtual rooms for facilitated early discharges when required.
You will be working in close collaboration with the Lead Nurse, Lead Therapist, Community Matrons and Locality Lead to provide clinical leadership within the PCH. Confidence is needed to provide the team with support and guidance regarding patient care, staff development and delegation. Close links are developing with the acute and community hospitals to ensure care is provided in the best place for the patient and as an Integrated Care Lead you will be at the forefront of integration and development of these changes. This will include oversight of the assessment of patients suitable for discharge from the acute hospital.
The PCH is commissioned to provide a 24/7 service. The core shift is currently 08:30 to 16:30 hours. Applicants may be required to participate in working other shifts as part of the role including weekend and bank holiday working on a rotational basis.
This role is full time but a minimum of 0.8 FTE would be considered.
About us
ECCH is a well established health care provider and has been successfully delivering NHS care within the community since 2011. We provide a range of NHS, community health and social care services predominantly across the easterly region of the Norfolk/Suffolk borders.
We are aligned to NHS terms and conditions, and offer many employee benefits, to find out more about us visit our website - www.ecch.org. We are a social enterprise and staff owned organisation which means staff can opt to be shareholders and have a real say in how ECCH is run and evolves to deliver healthcare for the future.
At the heart of our ambition, we work in partnership with and for the community to become the provider and employer of choice for community healthcare.
The Primary Care Home (PCH) is a multidisciplinary team working closely with GP's and other community partners to provide an excellent standard of person centered care to adults in their own homes, or residential care settings, supporting patients to self manage whenever possible. The service uses SystmOne as a clinical IT system to support mobile working.
We encourage you to apply as early as possible as this job may close earlier than the advertised closing date once enough applications have been received.
AI
We welcome strong applications and understand AI may support them. However, applicants must declare any AI use. By applying, you confirm all details reflect your own skills, knowledge, and experience truthfully.
Job description
Job responsibilities
We Listen, We Learn,
We Lead
-
Contribute to, support and promote ECCHs, strategic direction,
values and culture in relation to Reactive services.
-
Discuss all treatment options with sensitivity,
knowledge and expertise and to act as a patient advocate when appropriate,
respecting patient confidentiality with privacy and respect for diverse
cultural backgrounds and requirements.
-
Understand and support the achievement of ECCH
business plan objectives and performance targets for team and self, and
initiate and participate in screening and needs assessment as required.
-
Identify the potential for service developments, risk
and deficits and inform line manager making recommendations based on specialist
knowledge and experience.
-
Provide leadership and ensure effective management of
integrated teams, including rehabilitation support workers and paramedic teams
through identified and those providing a Reactive response.
-
Plan and organise a range of complex integrated
multidisciplinary coordination in a wide range of settings to ensure best
practice is delivered across the designated area of responsibility and the
wider community.
-
Provide clinical leadership within the integrated care
coordination team including Primary, Social Care, and all other provider
organisations to ensure high standards of care to patients the avoidance of
unnecessary admission to secondary care.
-
Through effective leadership, planning and
coordination; be a key enabler for establishing integrated care teams both
practically and behaviourally.
-
Work with the Primary Care Home leadership team
(Locality Leads) to design, implement and review pathways and guidelines to
support health care professionals in establishing patients to access
evidence-based therapies.
-
Develop systems to monitor, evaluate and audit service
quality in order to meet nationally and locally set targets and report to
Locality governance groups.
-
Effectively communicate at all levels of the
organisation and wider stakeholder, including a variety of health
professionals, users and carers, to provide the best health outcomes.
-
Maintain high levels of performance for service area
and ensure that goals and objectives are monitored effectively to ensure
quality outcomes are developed and maintained.
-
Provide leadership and manage stakeholder
relationships effectively within service area and ensure teams and individuals
are supported when faced with opposition or when working under conditions or
pressure.
-
Identify potential service developments, risks and
deficits and discuss with line manager, making recommendations based on expert
knowledge to enhance the capacity and quality of community care.
-
Monitor and maintain standards / provide benchmarking
data within service area to allow comparison with other healthcare providers.
-
Participate in teaching and clinical supervision with
primary care home team and other provider staff as required.
-
Critically evaluate research findings, national
guidelines and implement changes in clinical practice as appropriate.
-
Signpost patients, families, and carers to tailored
education programmes, advice and support that may precipitate symptoms of acute
exacerbation of underlying conditions or illness and include lifestyle changes
that would be advantageous to health.
-
Be responsible for participating and maintaining a
learning environment and maximise opportunities for education and development
in the clinical area to enhance individual development and performance in the
delivery of high standards of care.
My Accountability,
My Responsibility
-
Take responsibility for own personal and professional
development; maintain competence, knowledge and skills commensurate with role.
-
Using a standardised approach but with a high degree
of professional autonomy and accountability, work with Health, Social Care,
Voluntary and other health providers and agencies, to provide patients with
complex needs a single plan of care co-produced with the patient.
-
Responsible for ensuring effective patient/case
tracking within the local health system; provide baseline health data for
receiving teams to support integrated, coordinated care. To include
facilitation of Community Led discharge processes.
-
As Care Coordination Lead, ensure high visibility and
be accessible to patients, families and carers and be seen as being in charge
of their care.
-
Use assessment tools/skills that will ensure an
appropriate level of nursing or therapeutic intervention so that patients who
present with highly complex needs are timely referred to the appropriate
specialist.
-
Be wholly accountable for practice taking every
reasonable opportunity to sustain and improve knowledge and professional
competence and, ensure that all aspects of professional behaviour as required
within professional code are followed at all times.
-
Maintain legible, accurate and contemporaneous patient
records in accordance with ECCH Policy; the Nursing and Midwifery Council and
Health and Care Professionals Council standards for record keeping.
-
Assist with the investigations of complaints,
participate in the risk management process, critical incident reporting,
evaluation, dissemination and change in practice.
-
Be responsible for understanding, following and
implementing ECCH policies and procedures, and influencing working practices to
support this accordingly.
-
Contribute to the clinical governance agenda through
participation in clinical risk assessment and management, clinical audit.
-
Create an environment conducive to effective working,
respecting and supporting staff to deliver high quality clinical services.
-
Ensure a high standard of record keeping is achieved
in line with ECCH and professional standards.
-
Take responsibility to ensure compliancy with Health
and Safety Policy, Fire and Environmental Waste Regulations.
Respect
Our Resources: People, Time and Money
-
Take responsibility for the cost-effective management
and safe use of expensive and highly complex equipment, provide recommendations
for effective use of resources and contribute to the effective delivery of cost
improvement planning.
-
Analyse, interpret, compare and contrast complex
information, service requirements and options ensuring the effective approaches
to service delivery and team working within service area.
-
Evaluate the impact of Health Coaching programmes
designed for patients and carers, to ensure that they provide the necessary
knowledge and skills to gain independence, safely manage changing circumstances
and plan for unavoidable progression of conditions.
Work Together, Achieve Together
- Working with partners in Primary and Social care to
support a model of care which identifies and case manages those patients
needing complex chronic disease management or palliative care supporting the
needs of the local community.
-
Negotiate and agree with the patient carers and other
healthcare professionals, individual roles and responsibilities with actions to
be taken and outcomes to be achieved, referring on to other services or
professionals as appropriate.
-
Work in partnership with the patients to empower them
to make informed choices about their healthcare and support choices about end
of life care.
-
With peers, and under the supervision of the Locality
Lead, establish local networks in partnership with other health and social
professionals/agencies and national links with other generalists in order to
develop protocols according to national and local guidelines for the safe and
effective provision of a community nursing services.
-
In partnership with Primary Care colleagues provide
seamless care pathway for patients who occupy the Beds with Care.
-
Work with partners in nursing and residential care to
improve the health outcomes of the residents and so prevent unnecessary
hospital admissions or extended in- patient care episodes.
-
Provide professional expertise and clinical leadership
within service area, acting as a resource to other professionals internally and
outside ECCH, concerning clinical caseloads to ensure continuous service
provision, high levels of communication and effective inter-professional
working.
-
Work with ECCH Colleagues, and other partner agencies
and stakeholders including the acute trust to contribute to the development and
delivery of new innovative models of service delivery, ensuring a leading edge
approach to service development in-line with evidence based practice.
-
All roles within East Coast Community Healthcare CIC
(ECCH) require staff to demonstrate our Values and Signature Behaviours in the
care and service they provide to patients, service users, stakeholders and
colleagues. All members of staff should consider these as an essential part of
their job role.
-
Our Values
outline the core behaviours that we can all achieve and are summarised as an
acronym within the word CARE.
These stand for: Compassion, Action, Respect and Everyone.
-
Underpinning our
Values are our Signature Behaviours which highlight by taking the right actions
we continue to build a strong culture.
Our four Signature Behaviours are: Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together.
Job description
Job responsibilities
We Listen, We Learn,
We Lead
-
Contribute to, support and promote ECCHs, strategic direction,
values and culture in relation to Reactive services.
-
Discuss all treatment options with sensitivity,
knowledge and expertise and to act as a patient advocate when appropriate,
respecting patient confidentiality with privacy and respect for diverse
cultural backgrounds and requirements.
-
Understand and support the achievement of ECCH
business plan objectives and performance targets for team and self, and
initiate and participate in screening and needs assessment as required.
-
Identify the potential for service developments, risk
and deficits and inform line manager making recommendations based on specialist
knowledge and experience.
-
Provide leadership and ensure effective management of
integrated teams, including rehabilitation support workers and paramedic teams
through identified and those providing a Reactive response.
-
Plan and organise a range of complex integrated
multidisciplinary coordination in a wide range of settings to ensure best
practice is delivered across the designated area of responsibility and the
wider community.
-
Provide clinical leadership within the integrated care
coordination team including Primary, Social Care, and all other provider
organisations to ensure high standards of care to patients the avoidance of
unnecessary admission to secondary care.
-
Through effective leadership, planning and
coordination; be a key enabler for establishing integrated care teams both
practically and behaviourally.
-
Work with the Primary Care Home leadership team
(Locality Leads) to design, implement and review pathways and guidelines to
support health care professionals in establishing patients to access
evidence-based therapies.
-
Develop systems to monitor, evaluate and audit service
quality in order to meet nationally and locally set targets and report to
Locality governance groups.
-
Effectively communicate at all levels of the
organisation and wider stakeholder, including a variety of health
professionals, users and carers, to provide the best health outcomes.
-
Maintain high levels of performance for service area
and ensure that goals and objectives are monitored effectively to ensure
quality outcomes are developed and maintained.
-
Provide leadership and manage stakeholder
relationships effectively within service area and ensure teams and individuals
are supported when faced with opposition or when working under conditions or
pressure.
-
Identify potential service developments, risks and
deficits and discuss with line manager, making recommendations based on expert
knowledge to enhance the capacity and quality of community care.
-
Monitor and maintain standards / provide benchmarking
data within service area to allow comparison with other healthcare providers.
-
Participate in teaching and clinical supervision with
primary care home team and other provider staff as required.
-
Critically evaluate research findings, national
guidelines and implement changes in clinical practice as appropriate.
-
Signpost patients, families, and carers to tailored
education programmes, advice and support that may precipitate symptoms of acute
exacerbation of underlying conditions or illness and include lifestyle changes
that would be advantageous to health.
-
Be responsible for participating and maintaining a
learning environment and maximise opportunities for education and development
in the clinical area to enhance individual development and performance in the
delivery of high standards of care.
My Accountability,
My Responsibility
-
Take responsibility for own personal and professional
development; maintain competence, knowledge and skills commensurate with role.
-
Using a standardised approach but with a high degree
of professional autonomy and accountability, work with Health, Social Care,
Voluntary and other health providers and agencies, to provide patients with
complex needs a single plan of care co-produced with the patient.
-
Responsible for ensuring effective patient/case
tracking within the local health system; provide baseline health data for
receiving teams to support integrated, coordinated care. To include
facilitation of Community Led discharge processes.
-
As Care Coordination Lead, ensure high visibility and
be accessible to patients, families and carers and be seen as being in charge
of their care.
-
Use assessment tools/skills that will ensure an
appropriate level of nursing or therapeutic intervention so that patients who
present with highly complex needs are timely referred to the appropriate
specialist.
-
Be wholly accountable for practice taking every
reasonable opportunity to sustain and improve knowledge and professional
competence and, ensure that all aspects of professional behaviour as required
within professional code are followed at all times.
-
Maintain legible, accurate and contemporaneous patient
records in accordance with ECCH Policy; the Nursing and Midwifery Council and
Health and Care Professionals Council standards for record keeping.
-
Assist with the investigations of complaints,
participate in the risk management process, critical incident reporting,
evaluation, dissemination and change in practice.
-
Be responsible for understanding, following and
implementing ECCH policies and procedures, and influencing working practices to
support this accordingly.
-
Contribute to the clinical governance agenda through
participation in clinical risk assessment and management, clinical audit.
-
Create an environment conducive to effective working,
respecting and supporting staff to deliver high quality clinical services.
-
Ensure a high standard of record keeping is achieved
in line with ECCH and professional standards.
-
Take responsibility to ensure compliancy with Health
and Safety Policy, Fire and Environmental Waste Regulations.
Respect
Our Resources: People, Time and Money
-
Take responsibility for the cost-effective management
and safe use of expensive and highly complex equipment, provide recommendations
for effective use of resources and contribute to the effective delivery of cost
improvement planning.
-
Analyse, interpret, compare and contrast complex
information, service requirements and options ensuring the effective approaches
to service delivery and team working within service area.
-
Evaluate the impact of Health Coaching programmes
designed for patients and carers, to ensure that they provide the necessary
knowledge and skills to gain independence, safely manage changing circumstances
and plan for unavoidable progression of conditions.
Work Together, Achieve Together
- Working with partners in Primary and Social care to
support a model of care which identifies and case manages those patients
needing complex chronic disease management or palliative care supporting the
needs of the local community.
-
Negotiate and agree with the patient carers and other
healthcare professionals, individual roles and responsibilities with actions to
be taken and outcomes to be achieved, referring on to other services or
professionals as appropriate.
-
Work in partnership with the patients to empower them
to make informed choices about their healthcare and support choices about end
of life care.
-
With peers, and under the supervision of the Locality
Lead, establish local networks in partnership with other health and social
professionals/agencies and national links with other generalists in order to
develop protocols according to national and local guidelines for the safe and
effective provision of a community nursing services.
-
In partnership with Primary Care colleagues provide
seamless care pathway for patients who occupy the Beds with Care.
-
Work with partners in nursing and residential care to
improve the health outcomes of the residents and so prevent unnecessary
hospital admissions or extended in- patient care episodes.
-
Provide professional expertise and clinical leadership
within service area, acting as a resource to other professionals internally and
outside ECCH, concerning clinical caseloads to ensure continuous service
provision, high levels of communication and effective inter-professional
working.
-
Work with ECCH Colleagues, and other partner agencies
and stakeholders including the acute trust to contribute to the development and
delivery of new innovative models of service delivery, ensuring a leading edge
approach to service development in-line with evidence based practice.
-
All roles within East Coast Community Healthcare CIC
(ECCH) require staff to demonstrate our Values and Signature Behaviours in the
care and service they provide to patients, service users, stakeholders and
colleagues. All members of staff should consider these as an essential part of
their job role.
-
Our Values
outline the core behaviours that we can all achieve and are summarised as an
acronym within the word CARE.
These stand for: Compassion, Action, Respect and Everyone.
-
Underpinning our
Values are our Signature Behaviours which highlight by taking the right actions
we continue to build a strong culture.
Our four Signature Behaviours are: Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together.
Person Specification
Skills and Knowledge
Essential
- Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software with proven ability to problem solve
- Evidenced high standards of leadership and people management skills
- Evidenced experience of negotiating and influencing skills
- Excellent interpersonal skills, including communication with different stakeholders
- Ability to travel throughout the locality in accordance with role requirements. Advanced communication skills
Qualifications
Essential
- BSc in Nursing Practice or equivalent, or Allied Health Professional degree level qualification
- Professional registration with Nursing and Midwifery Council (NMC) or Health Care Professions Council (HCPC)
- Leadership/ management qualification or willing to undertake
Desirable
- Masters level study or working towards a masters level qualification in a relevant field
- Health Coaching Programme
Experience
Essential
- Evidenced and relevant experience of working in a community clinical role at a management/supervisory level
- Evidence of partnership working with other care agencies
- e.g. Social care Services/voluntary sector/primary care
- Evidence of managing team(s) and individuals to a high standard of performance. Including absence, appraisal, performance and conduct (disciplinary) processes
Desirable
- Experience of team leadership.
- Experience of Coordinating multidisciplinary integrated care for patients
- Experience of complaint investigation
- Project management experience
- Experience of facilitating clinical supervision
- Experience of audit
Personal Attributes
Essential
- Ability to embrace our Culture, Values and Signature Behaviours:
- (Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together)
- Willingness and ability to work across different sites and travel to alternative sites and across the community as required
- Flexible team orientated approach to work
- Passion and enthusiasm to deliver person centred care Self-motivated and solution focused
- Commitment to lifelong learning
Person Specification
Skills and Knowledge
Essential
- Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software with proven ability to problem solve
- Evidenced high standards of leadership and people management skills
- Evidenced experience of negotiating and influencing skills
- Excellent interpersonal skills, including communication with different stakeholders
- Ability to travel throughout the locality in accordance with role requirements. Advanced communication skills
Qualifications
Essential
- BSc in Nursing Practice or equivalent, or Allied Health Professional degree level qualification
- Professional registration with Nursing and Midwifery Council (NMC) or Health Care Professions Council (HCPC)
- Leadership/ management qualification or willing to undertake
Desirable
- Masters level study or working towards a masters level qualification in a relevant field
- Health Coaching Programme
Experience
Essential
- Evidenced and relevant experience of working in a community clinical role at a management/supervisory level
- Evidence of partnership working with other care agencies
- e.g. Social care Services/voluntary sector/primary care
- Evidence of managing team(s) and individuals to a high standard of performance. Including absence, appraisal, performance and conduct (disciplinary) processes
Desirable
- Experience of team leadership.
- Experience of Coordinating multidisciplinary integrated care for patients
- Experience of complaint investigation
- Project management experience
- Experience of facilitating clinical supervision
- Experience of audit
Personal Attributes
Essential
- Ability to embrace our Culture, Values and Signature Behaviours:
- (Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together)
- Willingness and ability to work across different sites and travel to alternative sites and across the community as required
- Flexible team orientated approach to work
- Passion and enthusiasm to deliver person centred care Self-motivated and solution focused
- Commitment to lifelong learning
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Employer details
Employer name
East Coast Community Healthcare CIC
Address
East Coast Community Healthcare
Morton Peto Road
Great Yarmouth
Norfolk
NR31 0LT
Employer's website
https://www.ecch.org/ (Opens in a new tab)
