Job responsibilities
You will be able to demonstrate your learning to new or less experienced employees and provide training to others.
Examples of clinical duties may include:
Participate in the review or case conference of individual patients and contribute to the evaluation and development of their discharge planning
Support /attend the MDT and daily Board rounds to work in accordance with current CHFT discharge policies
Identify using appropriate IT systems (Electronic Patient Records, Systm1), liaising with patients and/or carers relevant health and social care history including any existing services and which authority (Kirklees CCG, Calderdale CCG, Calderdale Council, Kirklees Council) is responsible for care provision
Having gained informed consent from the patient and/or carer share relevant information with wider MDT to facilitate appropriate care and discharge planning
In conjunction with the ward manager review all patients on the ward OR with the Discharge Sisters/Therapist all patients on the caseload and with the wider MDT identify those patients likely to require on-going health and social care support including care or support services.
Ensure all those involved in the current and onward care of the patients carryout their assessments and related activities in a timely manner; this will involve negotiation with other professionals including doctors, nurses and the wider MDT to obtain medically appropriately estimated dates of discharge (EDDs).
Meet regularly with ward manager and the Discharge sister/Therapist to ensure clinical delays are appropriately identified ( Right to Reside ), recorded and reported in line with legislation and local policy. Check each patients plan on the Transfer of Care ( TOC ) every day and update where necessary. Ensure EPR is updated relating to any work completed
Support the ward clerk in ensuring that transport has been arranged for the patients discharge as appropriate.
Escalate any delays in patient pathways to the Ward Manager and or Discharge Sister/Therapist as appropriate as described in the Discharge Policy
Prepare and co-ordinate patient information for weekly multi-disciplinary (MDT) meeting where they occur; ensure all relevant information is available and presented at the meeting.
Work in conjunction with the MDT, support the completion of comprehensive and relevant discharge documentation
Provide hands on assessment of needs relating to discharge and provision of low risk equipment such as walking aids, commodes, etc where this has been assessed as being required.
Work closely with the patients family and friends to ensure accurate information is recorded on EPR and that they are happy and confident to provide consent to other services
Carry out baseline assessment in relation to health and social care support, record those assessments and request simple services or alterations to packages of care for service users. Liaise with Gateway to Care and Single Point of Contact and social services directly where appropriate.
To develop an understanding and awareness of all the resources available to meet the needs of people in the community and to contribute to the assessment of patients and/or their families/carers identifying which resource can best meet their needs
Support the collation of any relevant statistical information which will help with developing or improving services for patients and/or carers.
To ensure that documented information is accurate, up-to-date and reflective of the departments involvement with individual service users and to use computerised records accordingly
This post will work over a 7 day service and therefore the post holder will be required to work weekends and bank holidays on a rota basis.
1. Formal knowledge and experience
Formal qualifications and experience expected of a new candidate (see person specification)
2. Supporting patients and service users
Supporting patients and service users and their families, and providing care throughout their care and care pathways
Will involve assessing for, ordering, and issuing basic equipment
Will involve discharge planning from services in conjunction with MDT and registered practitioners.
To support / lead on onward referrals to other health related teams within CHFT /external agencies
To undertake lone working (occasionally within a patients own home, which would be risk assessed prior to the visit) in line with CHFT Lone Working Policy.
To complete administrative duties and general patient care across departments as required
Will take part in manual and handling training and subsequently contribute to the moving and handling of patients
3. Clinical, technical and scientific roles and responsibilities
The underpinning knowledge and practice, support and interventions required of support staff to safely assist service users in meeting their optimum potential.
Determine a treatment and/or discharge plan for an individual following a needs-based assessment, taking into account both health and social care needs.
May require preparing and co-ordinating patient information regarding reason for admission/ referral, social history and current needs, to document this information accordingly and share with the MDT as required.
To work as part of the wider Health and Social Care Team / PCN linking with staff from the Acute Trust, Primary and Social Care
Carry out baseline assessment in relation to health and social care support, record those assessments and request simple services or alterations to packages of care for service users. Liaise with Gateway to Care and Single Point of Contact and social services directly where appropriate
4. Communication and information
The ability to communicate clearly, respectfully, and effectively using a range of methods written, verbal and non-verbal. Maintaining confidentiality and protection of data and overcoming physical, sensory, cognitive and language barriers to understanding.
Working in conjunction with the MDT, support the completion of the comprehensive and relevant discharge documentation /including onward referrals to other agencies
At times, demonstrating good negotiation, support and conflict resolution skills where there may be disputes surrounding a plan for discharge/ treatment or assessment
Supporting patients and relatives during stressful and emotional times
Work closely with the patients family and friends to ensure accurate information is recorded on electronic systems and that they are happy and confident to provide consent to other services
Ensuring compassionate care and excellent communication is at the forefront of all interactions and assessments
5. Safe and inclusive environments
The principles of equality, diversity and inclusion, safeguarding, protection, personal wellbeing and safety, along with the importance of duty of care and candour.
To ensure that documented information is accurate, up-to-date and reflective of the departments involvement with individual service users and to use computerised records accordingly
Ensure all relevant systems are regularly reviewed and updated to ensure safe care of all patients including safe discharge from services
Carry out duties with due regard to the Trusts Equal Opportunity Policy
6. Research and service improvement
Participation in research, audit, evaluation, and service improvement projects. Eg supervision, training, developments
Attend all mandatory training and be responsible for maintaining up to date additional training and responsibilities relevant to the post (e.g. medical devices, competency training etc)
7. Leadership
The importance of being a role model, identifying areas for self improvement and supervising others, and leading on patient safety, improvements and support for others.
Will take the responsibility for the training of others, including delivering training
8. Personal and professional values and behaviours
Understanding and demonstration of the values in the NHS Constitution and NHS People Promise, as well as self-development and personal wellbeing
Participate in regular supervision
Participate in an appraisal annually identifying, developing and agreeing your own development plan with your Line Manager using the Trust Appraisal
Comply with all Trust policies, procedures and protocols
Seek advice and support from Line Manager whenever necessary
Maintain professional conduct including appearance at all times
Be responsible for good time management and attendance.
Ensuring compassionate care and excellent communication is at the forefront of all interactions and assements
