Our vision is for the people of Croydon to experience well-co-ordinated care and support in the most appropriate setting, which is truly person-centred and helps them to maintain their independence.
Living Independently For Everyone (LIFE) is an integrated service with NHS health and local authority social care that aims to provide rehabilitation, reablement and recovery support to patient's in the community, in their own homes or in the intermediate care bed setting.Main duties of the job
To work in collaboration with the discharge teams at the hospital to identify patients suitable for intermediate care, to support early safe discharges and prevent readmission to hospital including premature admission to long-term care. To take lead responsibility for overseeing the nursing care of patients on the LIFE caseload in the community and for patients admitted to the intermediate care beds including screening referrals and new admissions.
To lead and provide support into the wraparound service, early supported discharge and multidisciplinary meetings.
To work in partnership with the intermediate care service therapists and support workers, community nurses, specialist nurses, the multidisciplinary team and our partners within the integrated organisation to ensure the provision of the highest quality of assessment and interventions.
To Provide effective evidence-based nursing care, rehabilitation and social support to patients in their own homes and intermediate care beds.About us
Croydon Health Services NHS Trust provide hospital and community services from a number of community and specialist clinics throughout Croydon.
These include:o Croydon University Hospital o Purley Hospital o The Sickle Cell and Thalassaemia Centre in Thornton Heath o Community bases at Purley, Sanderstead, New Addington, Broad Green, Woodside o A minor injuries unit in New Addington The Trust was formed on 1st August 2010 through the integration of Croydon Community Health Services and Mayday Healthcare NHS Trust. Around 3,500 staff provide services for a population of over 360,000 people who are relatively young with a high level of ethnic diversity.Our Vision:Excellent integrated care for you and your family, when and where you need itOur 5 key 'Here for you' promises to the people of Croydon are:o You feel cared for by helpful and welcoming staff o You feel in safe hands with highly professional staff o You feel confident in your treatment from skilled teams of compassionate clinicians o You feel we value your time with convenient appointments, minimal waiting and care closer to homeo You feel it's getting better all the time as we continue to improve our services
We are one of 17 Trusts in the country who have been accepted as national pioneers on staff engagement and empowerment, through the adoption of Listening into Action as a new way of working. The approach we are taking to Listening into Action is new and different.Job descriptionJob responsibilities Main duties and responsibilities
- To support in the discharge process, to ensure that they are able to access the intermediate care beds and community service appropriately, in the right place at the right time.
- Hold a caseload of patients and work across health and social care to prevent avoidable, unplanned hospital admission.
- Prevent the inappropriate admission of patients to hospital or to long-term placement.
- Be responsible for care planning and support delivery of care for people at home or in the intermediate care beds in partnership with their carers, other members of intermediate care, the staff of the intermediate care bed establishment and primary care teams.
- Provide expert clinical advice and support with regard to complex hospital discharges.
- Support and lead the multidisciplinary meetings within the wraparound service for early supported discharge.
- Facilitate the early discharge of patients from hospital.
- Provide clinical leadership for the nurses providing care to intermediate care patients.
- Enable patients admitted to the caseload to achieve their full potential in terms of independent living and promote self-care.
- Assess accurately and prescribe a range of equipment and minor adaptations and to be responsible for the safe and competent use of equipment, through teaching and supervision of practice.
- Participate in the rapid response service weekend working arrangements to cover the service needs on a rotational basis.
- Be accountable for the development, monitoring and maintenance of the standards of nursing care delivered to intermediate care patients by closely monitoring the clinical performance and competencies of the nursing support staff delivering the care in partnership with Clinical Nurse Trainers.
- Work in partnership and collaboration with the complex care team/Integrated Care Network (ICN) to ensure the co-ordination of patients who require case management.
- Provide professional leadership and direction to the nurse delivering the care to intermediate care patients, acting as a resource and role model at all times.
- Working in partnership and collaboration with the Clinical Governance leads to ensure practice is evidence-based guidelines and policies are developed, monitored and implemented across the service.
- To develop, monitor and evaluate patient pathways to ensure cost effective, quality care is delivered for all patients.
- To support the operational management of intermediate care and community nursing including the leadership, performance management and development of support work staff.
- Work in partnership with the operational managers / LIFE Team leads and senior therapists to develop the LIFE team service.
- Ensure that nursing is represented in multidisciplinary team meetings.
- Manage a caseload of patients requiring case management within Trust policies, guidelines and standards.
- To be responsible for the development and implementation of evidence based practice within the LIFE service.
- In collaboration with the Operational Managers and senior therapists, take responsibility for recruitment and retention of staff within the LIFE service.
- To identify and manage risk, this includes clinical incidents and near misses.
- To work with the line manager to ensure adequate cost-effective resources are available and maintained (e.g. equipment and staff).
- To have an understanding and awareness of the LIFE team budget.
- To be actively involved in any projects/developments and where appropriate to represent the community nursing service at board level.
- To maintain a high professional profile for LIFE within the integrated organisation.
- To be accountable for the delivery of care given to patients admitted to the LIFE service. This will include supervising the practice of qualified and unqualified staff within the LIFE service who are responsible for the independent assessment, diagnosing, planning, implementation and evaluation of care, and to ensure that the management of each patients care is delegated to the most appropriate, competent staff member.
- To refer to, liaise and work in collaboration with the multidisciplinary team, integrated care colleagues and other services/agencies to ensure that the immediate and longer term needs of patients admitted to the caseload are appropriately met.
- To undertake nurse prescribing and administer prescribed medications where appropriate to ensure and advise for the safe storage of these, liaising with other professionals as appropriate (e.g. pharmacists).
- To keep accurate and up to date records jointly produced with patients, in accordance with integrated organisations and NMC policies and guidelines.
- To attend case conferences and actively contribute to any subsequent discharge/future care planning.
- To work within the policies and guidelines set out by Croydon Health Services NHS Trust, the NMC code of professional conduct, and other relevant codes and/or guidelines.
- To ensure confidentiality on all matters relating to both patients and information obtained during the course of employment in accordance with the organisations policies.
- To ensure that equipment used during the course of work is stored, maintained and used in accordance with the manufacturers and trust guidelines related to medical devices.
- To provide nursing input within the LIFE service for a specific area of clinical practice relevant to the caseload this will include working with members of the multidisciplinary team to develop practice where appropriate.
- To deliver evidence-based, skilled nursing care in the patients home and intermediate care bed establishments this will include health promotion. To ensure that other team members also deliver clinically effective care.
- To work collaboratively with the line manager and practice development nurses to meet organisations clinical governance agenda to actively contribute in this process.
- To actively encourage and facilitate choices for people regarding promotion of their independence and to ensure other team members do the same.
- To provide specialist intermediate care nursing advice to other health care professionals and agencies.
- To be proactive in managing own caseload of community and intermediate care bed-based patients.
- Work with staff, team leaders and other people with key roles in intermediate care and be responsible for, prioritise and co-ordinate the nursing of intermediate care patients.
- To deputise for the Line manager.
- To performance manage, supervise and support the caseload holders in managing their caseloads and with their line management responsibilities.
- To develop, monitor and evaluate staff objectives, personal development plans in accordance with the organisations KSF Performance Management framework.
- To monitor, appraise and supervise the performance and practice of staff within the intermediate care service both directly and indirectly as appropriate this will include bank and agency staff.
- To communicate and work in partnership with patients, colleagues and other agencies, receiving, presenting and interpreting complex and sensitive information.
- To monitor and review the needs of the intermediate care service and prioritise as appropriate using effective management of resources.
- To work in partnership with the line manager and senior therapists to achieve locally agreed business plan, objectives and activity targets.
- To effectively manage change in order to implement organisational development.
- To ensure that off duty rotas are planned appropriately so that the needs of the service can be met and to manage any resource implication related to this and to inform the line manager.
- To ensure record keeping documentation and electronic recordings are up to date and well maintained in accordance with Trust policies, guidelines and standards.
- To undertake regular caseload analysis in order to target health needs and reduce inequalities in service provision.
- To keep self-up to date on clinical and professional developments in line with NMC, revalidation and evidence based practice to share knowledge with other team members where appropriate.
- To work with the practice development nurses to provide clinical supervision and to develop training programmes for the staff delivering care to intermediate care patients where appropriate (e.g.) to enable team members to develop new skills to meet a change in the needs of the patients on the caseload.
- To work with the pre-registration facilitator in planning and providing appropriate learning experiences for students and others allocated to the team for clinical placements.
- To actively contribute to and participate in research and screening programmes where appropriate.
- To utilise research findings and evidence-based practice to inform clinical decision making.
N.B. This job description is a reflection of the current position and may change in emphasis or detail in light of subsequent service or professional developments.Person SpecificationEducation, Qualifications & TrainingEssential
- To ensure that any managerial, professional practice and service developments are implemented effectively within the team.
- To actively contribute to the development and implementation of the locality clinical governance plan and objectives.
- To actively contribute to developing guidelines, policies and protocols relevant to the practice of the team and community nursing. This will include participating in relevant steering groups.
- To inform the line manager of any changes in service need and assist where possible to address the changing need.
- To participate in recording of relevant information for monitoring contact activity, evaluating team activities and other data required.
- To motivate and lead the LIFE service in developing a professionally accountable and responsible approach to work by acting as an exemplar role model.
- Nursing qualification
- Current NMC registration
- Other appropriate post registration qualification relevant to band 7 role (e.g. District Nursing, Advanced Practitioner)
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