Community Health Nurse

The Neighbourhood Teams Charge Nurse/Community Sister will be responsible for delivering skilled nursing care to patients in the community setting, including assessing, planning, implementing, and evaluating care for patients and managing unpredictable situations flexibly and responsively.

The successful candidate will have the flexibility and skill set to work across planned and crisis pathways, supporting patients to remain well in their own homes or long-term place of residence and/or prevent hospital admission.

Key responsibilities include:

• Adapting and providing a wide range of nursing care in home and community-based settings.
• Being accountable for assessing, planning, implementing, and evaluating care for patients and managing unpredictable situations flexibly and responsively.
• Delivering skilled nursing care to patients in the community setting, including recording and monitoring a patient's clinical observations, wound care management, palliative care, IV cannulation, intravenous medications, urinary catheterisation, and obtaining bloods for diagnostic purposes.
• Managing caseloads, coordinating care, whether anticipated or unscheduled, with individuals and their families, through acute illness, long-term and multiple health challenges, and at the end of life.
• Leading and managing a team to deliver care in the home and community.
• Participating with the training of learners.
• Working in an integrated and partnership way with primary, secondary, social care, the independent and voluntary sector, and others to improve the health and care of individuals, families, and communities, particularly the most vulnerable.

The successful candidate will have a broad range of specialist nursing clinical expertise that supports high-quality person-centred care for the caseload population in a variety of community settings.

They will use appropriate physical and clinical examination skills to undertake the assessment of individuals with complex healthcare needs or those presenting with more acute illnesses, using a range of evidence-based assessment tools and consultation models.

They will assess the health-related needs of families and other informal carers, developing therapeutic relationships and using creative problem-solving that enables shared decision-making for the development of care plans, anticipatory care, and delivery of care packages.

They will supervise the delivery of person-centred care plans by the team, ensuring regular evaluation of care and develop systems to support staff interventions and care quality.

They will support all staff to use tools to identify changes in health status and maximise the skills of the nursing and support team to support complex assessment where the patient is showing signs of deteriorating health or new symptoms.

They will assess when additional expertise is necessary and make objective and appropriate referrals, whilst maintaining overall responsibility for management and co-ordination of care.

They will ensure clear lines of accountability with respect to delegation, supervision, and mechanisms for the assurance of clinical and care governance, including antimicrobial stewardship.

They will promote the mental health and well-being of people and carers in conjunction with mental health professionals and GPs, identifying needs and mental capacity, using recognised assessment and referral pathways and best-interest decision-making and providing appropriate emotional support.

They will work in partnership with individuals, formal and informal carers, and other services to promote the concept of self-care and patient-led care where possible, providing appropriate education and support to maximise the individual's independence and understanding of their condition(s) in achieving their health outcomes.

They will analyse and use appropriate approaches to support the individual's health and well-being and promote self-care in addressing their short- or long-term health conditions.

They will explore and apply the principles of effective collaboration within a multi-agency, multi-professional context, facilitating integration of health and social care and services, ensuring person-centred care is co-ordinated and anticipated across the whole of the person's journey.

They will demonstrate advanced communication skills, engaging and involving people and their carers that foster therapeutic relationships and enable confident management of complex interpersonal issues and conflicts between individuals, carers, and members of the caring team.

They will prescribe from the appropriate formulary relevant to the type of prescribing being undertaken, following assessment of patient need and according to legislative frameworks and local policy.

They will demonstrate a see-and-treat approach to patient care.

They will contribute to public health initiatives and surveillance, working from an assets-based approach that enables and supports people to maximise their health and well-being at home, increasing their self-efficacy and contributing to community developments.

They will lead, support, clinically supervise, manage, and appraise a mixed skill/discipline team to provide community nursing interventions in a range of settings to meet known and anticipatory needs, appraising those staff reporting directly whilst retaining accountability for the caseload and work of the team.

They will manage the staff nurse team within regulatory, professional, legal, ethical, and policy frameworks, ensuring staff feel valued and developed.

They will facilitate an analytical approach to the safe and effective distribution of workload through delegation, empowerment, and education, which recognises skills, regulatory parameters, and the changing nature of district nursing, whilst establishing and maintaining the continuity of caring relationships.

They will lead, manage, monitor, and analyse clinical caseloads, workload, and team capacity to assure safe staffing levels in care delivery, using effective resource and budgetary management.

They will manage and co-ordinate programmes of care for individuals with acute and long-term conditions, ensuring their patient journey is seamless between mental and physical health care, hospital and community services, and between primary and community care.

They will collaborate with other agencies to evaluate public health principles, priorities, and practice and implement these policies in the context of the district nursing service and the needs of the local community.

They will participate in the collation of a community profile, nurturing networks that support the delivery of locally relevant resources for health improvement and analysing and adapting practice in response to this.

They will articulate the role and unique contribution of the service in meeting healthcare needs of the population in the community and the evidence that supports this in local areas.

They will ensure all staff are able to recognise vulnerability of adults and understand their responsibilities and those of other organisations in terms of safeguarding legislation, policies, and procedures.

They will use knowledge and awareness of social, political, and economic policies and drivers to analyse how these may impact on district nursing services and the wider healthcare community.

They will participate in clinical supervision on a regular basis with a designated person.

They will be aware of and act in accordance with Trust Clinical Standards and Guidelines and the NMC Code of Conduct and Guidelines.

They will contribute to the development, collation, monitoring, and evaluation of data relating to service improvement and development, quality assurance, quality improvement, and governance, reporting incidents and developments related to district nursing, ensuring that learning from these, where appropriate, is disseminated to a wider audience to improve patient care.

Person Specification

Personal Attributes

Essential

• A current driving licence and access to a car during the working day is essential (reasonable adjustments will be considered for any applicants who are unable to drive due to a disability).
• Experience of working with older people in a nursing/rehabilitation setting.