Specialist Neighbourhood Nurse
2 months ago
Job summary
The role of the Specialist Neighbourhood Nurse is to support both the practice staff and members of the Neighbourhood Team to identify and support people to reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community.
To work dedicated hours to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team to achieve the following objectives:
To be a pro-active member of the Integrated Neighbourhood Team, the practice and Four Counties Primary Care Networks. To pro-actively engage with people deemed to be at risk of hospital admission or health deterioration. To proactively engage with frequent fliers those attending A&E and utilising OOH services. To pro-actively engage with Home First Teams to reduce length of stay in acute hospital settings. To pro-actively engage with people living in care home settings. To be the key contact within the GP Practice environment.Neighbourhood Working is a new way of strengthening and redesigning community services for a local population. It empowers people and communities to take an active role in their health and wellbeing, with greater choice and control over the care they need. It also supports the improvement, integration, and personalisation of services in Lincolnshire.
Main duties of the job
What you will do
Act as a point of contact between the GP Practice Team, Neighbourhood Team, people and their careers. Develop and maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team/Primary Care Network. Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health need and support. Support the early identification of those with life limiting conditions including those with palliative and end of life symptoms and conditions in order that they are supported to achieve a good end of life experience. Work with Neighbourhood Team colleagues to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support. Communicate the care plan to the GP and any other members of the Neighbourhood Team involved in the persons care and upload to the relevant records.
About us
LAKESIDE HEALTHCARE is changing the face of primary care provision in England. We are bold, adventurous and ambitious and determined to thrive in uncertain times. We are the largest true partnership in the NHS and operate from various sites across the East Midlands. We serve the healthcare needs of over 170,000 patients across Northamptonshire, Lincolnshire & Cambridgeshire. Joining our team presents an opportunity to be part of a large organisation that is changing the way primary care is delivered today.
Living and breathing our values at Lakeside Healthcare
Caring & Respect: Simply put we genuinely care about people: working together for our patients and our teams, our patients come first in everything we do. We strive to ensure we connect and respond to all needs with compassion, care and respect to improve the lives and wellbeing of the communities we serve.
Teamwork & Quality: In all areas of our business we network, collaborate and learn from our Patients, Stakeholders and each another to ensure we are always striving to improve, making the right and best decisions to provide the best service.
Job description
Job responsibilities
The role of the Specialist Neighbourhood Nurse is to support both the practice staff and members of the Neighbourhood Team to identify and support people to reduce the risk of unplanned hospital admissions and to effectively support those individuals in the community.
To work dedicated hours to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team to achieve the following objectives:
To be a pro-active member of the Integrated Neighbourhood Team, the Practice and Four Counties Primary Care Networks. To pro-actively engage with people deemed to be at risk of hospital admission or health deterioration. To proactively engage with frequent fliers those attending A&E and utilising OOH services. To pro-actively engage with Home First Teams to reduce length of stay in acute hospital settings. To pro-actively engage with people living in care home settings. To be the key contact within the GP Practice environment.General Duties
Act as a point of contact between the GP Practice Team, Neighbourhood Team, people and their careers. Develop and maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team/Primary Care Network. Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health need and support. Support the early identification of those with life limiting conditions including those with palliative and end of life symptoms and conditions in order that they are supported to achieve a good end of life experience. Liaise with primary, secondary and specialist care services as required. Work with Neighbourhood Team colleagues to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support. Provide these cohorts of people signposting to identified services to maintain their independence and improve their health and well-being. Visit people in community, home, or care home settings to assess and discuss their care needs involving carers as appropriate. Implement personal care plans for individual people, ensuring preventative actions are detailed to support the appropriate use of services. Communicate the care plan to the GP and any other members of the Neighbourhood Team involved in the persons care and upload to the relevant records. Ensure that identified people receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant members of the Neighbourhood Team. Work with patient, carers and the Neighbourhood Team to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions. Liaise with other agencies to ensure timely and appropriate engagement as required. Support people to access community care assessments as well as carers assessments. Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make. Identify unpaid carers and direct them to access services as appropriate to provide them with support. Identify when urgent action or a step up in care is required and promptly alert the relevant member of the Neighbourhood Team, highlighting any safety concerns. Follow up on communications from out of hospital and in-patient services regarding changes in condition of people to support the practice to respond proactively to potentially unmet needs. Undertake visits or telephone contact to manage people on the Specialist Neightbourhood Nurse case load following any unplanned hospital admissions where appropriate. Participate in Practice multi-disciplinary meetings to discuss people actively being managed by the Neighbourhood Team and any other people from the Specialist Neightbourhood Nurse case load needing discussion. To attend Neighbourhood Team MDT meetings plus any other meetings. Updates between meetings to be shared with the Neighbourhood Team colleagues. Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role entering notes onto SystmOne using agreed read codes. To run regular patient searches using SystmOne to have an up-to-date record of progress of achievement of Key Performance Indicators in line with practice-based recording and reporting requirements. Support the Practice Managers in providing KPI reports for submission as requested. Work with Four Counties Primary Care Networks, Neighbourhood Team and other agencies to support and further develop this role.Health and Safety - It is the responsibility of the individual to work in compliance with all current Health and Safety legislation and the Practice Health and Safety Policy. To attend any training requirements, both statutory and mandatory, in line with the legal responsibility to comply with the Health and Safety at Work Act 1974.
Data Protection and Confidentiality All employees are subject to the requirements of the Data Protection Act 1998 and must maintain strict 5 confidentiality in respect of patient, client and staff records.
Smoking and Health The organisation has a no smoking policy throughout its premises, including buildings and grounds.
Equality and Diversity The organisation is committed to promoting equal opportunities to achieve equity of access, experience and outcomes and to recognising and valuing peoples differences. This applies to all activities as a service provider and as an employer.
Information Management and Technology (IM&T) All staff are expected to utilise the relevant national and local IM&T systems necessary to undertake their role.
Flexible Working The organisation is committed to offering flexible, modern employment practices, which recognise that all staff need to strike a sensible balance between home and work life. All requests to work flexibly will be considered.
Clinical Supervision It is mandatory for all professionally qualified staff and clinical support staff to actively participate in clinical supervision as an integral part of their professional development for a minimum of four sessions per year. Clinical Supervision will be monitored via an annual appraisal and 1-1s with line manager.
Reasonable Adjustments The organisation is seeking to promote the employment of disabled people and will make any adjustments considered reasonable to the above duties under the terms of the Equality Act 2010 to accommodate a suitable disabled candidate.
The role contains the following responsibilities:
To maintain registration with the NMC/HCPC or other professional body. To adhere to the NMC/HCPC Code or other relevant professional code. To support training and development. To maintain personal professional competency and appropriate development. To carry out the duties and responsibilities of the post in accordance with the K2 Federation Policies including duty of candour and whistleblowing. Required to comply with all relevant national and local statutory and mandatory requirements including Health and Safety, Infection Control, Safeguarding, Information Governance, Research Governance and Equality and Human Rights. The post holder will work in an environment where individual differences and the contributions of all staff are recognised and valued. All employees, people, carers and the public are entitled to be treated with dignity and respect and no form of discrimination, intimidation, bullying or harassment will be tolerated.This Job Description is not an exhaustive list and will be reviewed in the light of changed needs and organisation development. Any changes will be discussed with the post holder who will be required to carry out other duties appropriate to the grade and scope of the post.
The post will involve regular travel locally and regionally on occasion and the post holder may be required to undertake occasional evening or weekend work.
Person Specification
Qualifications
Essential
Registered Health or Care Professional. Post graduate study in health-related studies relevant to long term conditions or equivalent experience. Evidence of continuing professional development. Post registration teaching qualification or willingness to undertake.
Experience
Essential
Experience of dealing with people with long term conditions. Evidence of ability to work autonomously. Evidence of working within a multidisciplinary team. Evidence of teaching or mentorship. Evidence of complex case management and multiagency working.We have other current jobs related to this field that you can find below
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