Job summary
This is a unique opportunity to develop and be part of a new nursing team. Intermediate Care is a rapid response, integrated Nursing and Therapy service that works with the Community Nursing Teams to support patients at home.
You will be treating patients who are either at risk of admission to hospital or have just been discharged home. They require support, rehab and treatment, with a goal to either return to their usual level of function or to their new baseline.
The Nurses in Intermediate Care respond to 2hr referrals for the CNT and treat patients who have new nursing needs on discharge from hospital, as well as managing the nursing needs of patients on the team's caseload. You will also in-reach to the local hospitals to identify patients who could be supported in the community rather than in hospital.
The ideal candidate will be a confident, skilled Nurse with a passion for MDT working and keeping patients at home. You will have an interest in service development and quality improvement and be excited by the opportunity to integrate nursing within the team.
You will receive line management from the Nursing Team Lead, with clinical governance overseen by the Senior Community Matron. Clinical supervision is held regularly, jointly between all Community Sisters in the locality.
In return for your commitment and support to the team and patients, we will support your continued professional development with additional relevant training eg DN/prescribing qualifications etc.
Main duties of the job
Provide professional nursing skills and leadership within the team, supporting the Nursing and Therapy Team Leads in managing the team and caseload as required, ensuring safe and effective staffing levels and provision of resources for continuous service delivery and enhancing nursing practice.
Expert clinical management for patients with complex care needs, who are at risk of deteriorating health that may result in admission to hospital.
Using high-level patient-centred assessment skills for the health and wellbeing of patients with complex needs, to provide an excellent service in the community which includes:
- First point of contact for a patient, co-ordinating their care, anticipating and dealing with problems before they lead to exacerbations including thorough both nursing and holistic assessments, care and timely onward referral when appropriate.
- Palliative Care: symptom management including assessment of acute symptom onset, care for the patient and their family/carers and in accordance with national guidance on end of life care.
- Continuing care: appropriate, timely and complete referral to other agencies contributing to the delivery of the National Service Frameworks.
- Public health: health protection and promotion programmes that improve and reduce inequalities.
About us
Frimley Health NHS Foundation Trust provides NHS hospital services for around 900,000 people across Berkshire, Hampshire, Surrey and south Buckinghamshire.
As well as delivering excellent general hospital services to local people, we provide specialist heart attack, vascular, stroke, spinal, cystic fibrosis and plastic surgery services across a much wider area.
We have three main hospitals - Frimley Park in Frimley near Camberley, Heatherwood in Ascot and Wexham Park near Slough.
Our three core values, and the behaviors that support them, guide everything we do and set out what we expect of our staff in the way they treat patients, visitors, service users and each other, Committed to Excellence, Working Together and Facing the Future.
We are also proud to host the Defence Medical Group South East at Frimley Park with military surgical, medical, and nursing personnel working alongside the hospital's NHS staff providing care to patients in all specialties.
Job description
Job responsibilities
Undertake holistic assessments of patients on the caseload.
Complete assessments such as Purpose T, MUST/MUAC, wound assessments for all patients on the caseload.
Manage chronic wounds such as leg ulcers, pressure ulcers using best practice and NICE guidelines.
Manage short term wounds such as surgical wounds.
Manage patients with JVAC drains, lantern drains, pig tail drains and flushes when required.
Care for PICC lines and chemotherapy disconnections Full training will be given.
Care for other central lines such as Mid lines, portacaths Full training will be given.
Undertake the administration of intravenous antibiotics in the community, bolus or infusion.
Manage the caseload of patients requiring daily administration of Insulin, Dalteparin ensuring patients are also taught to self manage their long term conditions such as Diabetes.
Attend pressure ulcer panel to discuss patients who have developed a pressure ulcer whilst in the care of the community nursing team.
Share the learning from pressure ulcer panel with the team.
Ensure patients on the caseload have pressure relieving equipment in place or referred to the appropriate service for additional pressure relieving equipment for specialist items.
Liaise with the patients GP when needed and communicate effectively with the GP practice to build relationships with our GP colleagues.
Be part of the Integrated Care Team, attending weekly MDT meetings as allocated.
Be the patients advocate when needed.
Refer patients to safeguarding when required, understand the need for safeguarding patients in the community setting.
Ensure staff are completing their electronic records in line with policy and within the NMC guidelines.
To adhere to the NMC standards.
Maintain accountability for practice following the Nursing and Midwifery Council Codes of Professional Conduct and compliance with the FHFT Policies and Procedures.
Undertake regular and relevant CPD and maintain a portfolio of this for reregistration and revalidation.
Provide excellent end of life care to patients who wish to be cared for in their homes, ensuring communication and care is joined up with other services such as the local hospice.
Provide excellent palliative care and symptom management to the patients with a terminal diagnosis, sign posting, referring on to other services such as living well, local hospice, CNS.
Liaise with the tissue viability service, complete referrals to the TVN service for patients with chronic leg ulcers, pressure ulcers or other wounds that require the expertise of the TVN.
Liaise with the Diabetic CNS for patients on the caseload who require daily insulin administration or if their condition deems intervention from a Diabetic CNS.
Ensure all planned visits are allocated before 3pm daily, being part of the 3pm TEAMS call, asking for support with unallocated visits.
Ensure all patients on the caseload are RAG rated for clinical reasoning and allocated appropriately according to system pressures and patient needs.
Attend daily handover, challenging staff when required, ensuring visits are forward planned, treatment adjusted, onward referrals made and discharges are completed daily.
Review patients prior to discharge from hospital who have a new nursing need or need input from the Intermediate Care Team to support their discharge home.
In Reach to local hospitals to identify appropriate patients who could be supported within the community and to follow the patient journey for known community patients with a view to expediting their discharge.
Job description
Job responsibilities
Undertake holistic assessments of patients on the caseload.
Complete assessments such as Purpose T, MUST/MUAC, wound assessments for all patients on the caseload.
Manage chronic wounds such as leg ulcers, pressure ulcers using best practice and NICE guidelines.
Manage short term wounds such as surgical wounds.
Manage patients with JVAC drains, lantern drains, pig tail drains and flushes when required.
Care for PICC lines and chemotherapy disconnections Full training will be given.
Care for other central lines such as Mid lines, portacaths Full training will be given.
Undertake the administration of intravenous antibiotics in the community, bolus or infusion.
Manage the caseload of patients requiring daily administration of Insulin, Dalteparin ensuring patients are also taught to self manage their long term conditions such as Diabetes.
Attend pressure ulcer panel to discuss patients who have developed a pressure ulcer whilst in the care of the community nursing team.
Share the learning from pressure ulcer panel with the team.
Ensure patients on the caseload have pressure relieving equipment in place or referred to the appropriate service for additional pressure relieving equipment for specialist items.
Liaise with the patients GP when needed and communicate effectively with the GP practice to build relationships with our GP colleagues.
Be part of the Integrated Care Team, attending weekly MDT meetings as allocated.
Be the patients advocate when needed.
Refer patients to safeguarding when required, understand the need for safeguarding patients in the community setting.
Ensure staff are completing their electronic records in line with policy and within the NMC guidelines.
To adhere to the NMC standards.
Maintain accountability for practice following the Nursing and Midwifery Council Codes of Professional Conduct and compliance with the FHFT Policies and Procedures.
Undertake regular and relevant CPD and maintain a portfolio of this for reregistration and revalidation.
Provide excellent end of life care to patients who wish to be cared for in their homes, ensuring communication and care is joined up with other services such as the local hospice.
Provide excellent palliative care and symptom management to the patients with a terminal diagnosis, sign posting, referring on to other services such as living well, local hospice, CNS.
Liaise with the tissue viability service, complete referrals to the TVN service for patients with chronic leg ulcers, pressure ulcers or other wounds that require the expertise of the TVN.
Liaise with the Diabetic CNS for patients on the caseload who require daily insulin administration or if their condition deems intervention from a Diabetic CNS.
Ensure all planned visits are allocated before 3pm daily, being part of the 3pm TEAMS call, asking for support with unallocated visits.
Ensure all patients on the caseload are RAG rated for clinical reasoning and allocated appropriately according to system pressures and patient needs.
Attend daily handover, challenging staff when required, ensuring visits are forward planned, treatment adjusted, onward referrals made and discharges are completed daily.
Review patients prior to discharge from hospital who have a new nursing need or need input from the Intermediate Care Team to support their discharge home.
In Reach to local hospitals to identify appropriate patients who could be supported within the community and to follow the patient journey for known community patients with a view to expediting their discharge.
Person Specification
Qualifications
Essential
- RGN Qualification
- BSc in Nursing Studies or equivalent
Experience
Essential
- Minimum 4 years post qualifying experience
- Ability to work unsupervised
- Support patient and person-centred care
Desirable
- Community nursing experience
Knowledge
Essential
- Experience of care planning
- Experience of multi- professional working
- Ability to manage and prioritise workload.
Person Specification
Qualifications
Essential
- RGN Qualification
- BSc in Nursing Studies or equivalent
Experience
Essential
- Minimum 4 years post qualifying experience
- Ability to work unsupervised
- Support patient and person-centred care
Desirable
- Community nursing experience
Knowledge
Essential
- Experience of care planning
- Experience of multi- professional working
- Ability to manage and prioritise workload.
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
