Job summary

This role provides specialist nursing support to primary care and community teams within the Hounslow community diabetes service for adults with type 2 diabetes predominantly, and patients with type 1 diabetes in special circumstances.

The service provides level 3 intermediate advisory care for patients with complex diabetes and for colleagues to joint care planning supported by a weekly consultant-led MDT meeting. The MDT is open to the wider healthcare community to present their patients and is attended by IAPT representative. Currently the service is working with the local primary care network (PCN) to implement integrated care.

The post holder will have the opportunity to hold a short-term caseload with step up and step-down clinics to optimise patients' health outcomes and support self-management in patients with complex needs. Structured education (X-PERT) is provided for patients as well as educational support for health care professionals which is central to the role.

Main duties of the job

• The post holder will work effectively as a member of the multidisciplinary team, primary care colleagues, secondary care, social care agencies and community teams to improve holistic health outcomes for patients with diabetes
• Provide specialist care, advice, and support to jointly support the development of integrated working with Primary Care Networks (PCN) for adults with type 2 diabetes predominantly, and patients with type 1 diabetes in special circumstances
• Provide joint in-practice primary care-based clinic sessions for complex patients in GP practices
• Triage and audit referrals to the service and provide relevant service and evidence-based feedback to referrers to provide timely care to patients
• Liaise with community nursing teams and allied health care professionals across Hounslow specific to supporting specialist diabetes within patient care plan; Contribute to the domiciliary service across Hounslow and do joint visits with Primary Care/HRCH staff in patients own homes and residential care homes
• Contribute to the training and education of practice nurses, community nurse teams and nursing home staff relating to delivery of personalised diabetes care

About us

Community healthcare is unlike any other part of the NHS. It's personalised care that helps people to retain their independence. It's the NHS at its best and the difference you make is truly tangible. Our colleagues often describe us as a family, and we know how important that sense of belonging and support is when you start a new job. It's simple - happy, engaged staff provide better services.

In 2018, we were named'Best Place to Work for Employee Satisfaction'by the Nursing Times. The same year, we won the Workforce category at the HSJ Awards. In the latest NHS Staff Survey results 2020, we had the best response rate amongst community trusts nationally.

We are the top community trust in the country on the theme Quality of care for the third year. We had the highest percentage of staff who felt they are able to deliver the care they aspire to and are satisfied with the quality of care they give to patients or service users.

Infection Control

As an NHS Trust we strongly encourage and support vaccination uptake as this remains the best line of defence against COVID19.

Job description

Job responsibilities

• Recognise and work within own competence and professional code of conduct as regulated by the NMC
• Work with other health care professionals to support patients to achieve diabetes self-care skills, monitor, manage and treat patients referred with Type 2 diabetes, in line with national and local policies and practice needs
• Triage and audit referrals to the service and provide relevant service and evidence-based feedback to referrers to provide timely care to patients
• To support complex patients identified in MDT and primary care locality clinics to manage patients effectively within a step up / step down model of care according to their needs
• Assess, plan, implement and evaluate individual treatment plans for patients referred with diabetes nurse led clinic and work with patient to facilitate lifestyle adjustments in response to their diabetes and circumstances, including urgent referral to acute care.
• Support and motivate patients to adopt healthier lifestyles and self-management of Diabetes specific to individuals personal needs, health, and religious beliefs.
• Be responsible for providing and documenting telephone and email advice to Primary Care and other healthcare professionals and integrated services
• Be able to impart highly complex information, requiring highly developed communication and reassurance skills to empower patients to self-care and cope with complications associated with diabetes
• To understand the combined impact of all the patients conditions on their health and social care needs in order to improve health outcomes and quality of life
• To hold or work towards recognised non-Medical (NMP) Prescriber qualification and prescribe to agreed protocols and policies
• Review medication for therapeutic effectiveness, alongside primary care staff, patient and carers to ensure individualized optimal management in accordance with evidence-based practice and national and local practice protocols
• Provide information and advice on medication prescribed to patients and non-specialist staff on medication regimens, side-effects and interactions
• Support X-Pert Structured Education Programmes across HRCH Diabetes service
• Produce accurate, contemporaneous, and complete records of patient consultation, consistent with legislation, using patient information systems in accordance with departmental and organisational policies and procedures

• Prioritise, organise, and manage own and others workload in a manner that maintains and promotes quality and respectful teamwork
• Work collaboratively within the wider team according to NSF, NICE guidelines and evidence-based practice
• Contribute to the assessment of the effectiveness of care delivery of the nursing team through peer review, benchmarking and formal evaluation
• Participate in shared learning across the service and wider organisation
• Assist in the implementation of service policies and assess the impact of these on care delivery
• Work within policies regarding family violence, vulnerable adults and children, substance abuse and addictive behavior, and refer as appropriate
• To have a thorough understanding of the current National NSF standards, diabetes UK and NICE guidelines relevant to the specialty in order to improve practice and health outcomes where appropriate
• Ensuring compliance with the clinical supervision requirement
• Support audit outcomes of care against accepted national and local standards (e.g Core National Diabetes Audit)
• Contribute to maintaining the safe and smooth running of the diabetes specialist service
• To plan and implement improvements on continuity of care by establishing and maintain links across primary and secondary care interface.
• To be responsible for specific clinical equipment about health and safety, infection control, quality control and ordering.
• Prioritise on the demands of the service and plan personal annual objectives within appraisal process
• To act as change agent and innovator, planning, instigating, and evaluating change
• To contribute to the National Audit Plan as required
• Contribute to annual development of service audit for the year to evaluate the quality of the work of self and the team, implementing improvements where required
• Manage patient complaints, and identify learning from clinical incidents and near-miss events utilising a structured framework (eg root-cause analysis and reflective practice)

Person Specification

Experience

Essential

• Minimum 2 years recent post registration diabetes experience
• Experience in nurse-led management of long-term conditions

Desirable

• At least 2 years recent primary and community nursing experience
• Team leader experience

Skills and Abilities

Essential

• Able to demonstrate a commitment to the HRCH values (Care, Respect, Communication)
• Clinical leadership skills for autonomous practice and coaching others
• Excellent communication skills, both written and verbal
• Teaching and mentorship experience in a clinical setting to multidisciplinary team members

Desirable

• Line management skills and /or training

Knowledge

Essential

• Competency in the management of patients with diabetes
• Knowledge of health promotion and behavioural change strategies
• Knowledge of clinical governance issues in community and primary care

Desirable

• Awareness of national and local public health issues

Qualifications

Essential

• Registered Nurse
• Relevant Nursing or Health Degree

Desirable

• Mentor / teaching qualification
• Independent nurse prescribing qualification or willing to working towards this

Any attachments will be accessible after you click to apply.

779-NA-5203149-PB-Y-A