Senior Integrated Community Nurse

Job summary

This post holder will be responsible for improving, maintaining and monitoring the Community NursingService, to ensure that patient care is delivered to the standards detailed in the PerformanceManagement Framework and Nursing Strategy. This will be achieved through leadership, the promotionof advanced clinical skills and the performance management of the caseload holder /District Nurse actively provide case management for patients with complex long-term conditions or who are highintensity users of secondary care, to prevent hospital admissions, to achieve a reduction in 'length ofhospital stay' and enable independence. This will include collaboration with the Rapid Response Serviceand stakeholders in the local health economy

Main duties of the job

Senior Integrated Community Nurse Band 7

Must have a valid license and access to a vehicle

Norbury Health Centre Health Centre

We require a full time Senior Integrated Community Nursing Sisters to work within our Community Nursing Teams to provide leadership and caseload management to patients in their own homes.

The post holder will be responsible for improving, maintaining and monitoring care provided within our newly reconfigured service. This will include working in partnership with Croydon Outcome Based Commissioning Alliance, part of the Integrated Care Network.

The ideal candidate will be a Registered Nurse with a Specialist Practice and teaching Qualification as well as experience of managing patients with complex nursing applicants should have a clean UK driving license and car for work purposes.

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 Vision:"Excellent integrated care for you and your family, when and where you need it"Our 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 description

Job responsibilities

MAIN DUTIES AND RESPONSIBILITIESTo provide a comprehensive assessment of the physical, psychological and social care needs of patientsand their main care providers followed by the instigation of an appropriate care package that maximiseshealth and wellbeing and promotes take overall responsibility for the ongoing co-ordination of complex care packages including for thosepatients requiring facilitated discharge form hospital, or other places of care, hospital avoidance and ongoing provide advanced, effective evidence based nursing care and case management to patients withmoderate and highly complex care needs, in a variety of community settings ensuring patient safety,patient experience and patient outcomes are optimised and patients are free from harm.

4To provide professional leadership, and direction to the integrated community nursing teams within thecluster, acting as a resource and role model at all the absence of the Cluster Matron be responsible for Cluster management and escalate issues thatcannot be resolved locally to the identified Cluster Matron allocated to provide professional support.

Lead and participate in transformation of community nursing services in order that it can manage theincreasing demands and move to a fully integrated service in line with the accountable provider alliance(APA) model of accountable for the development, monitoring and maintenance of the standards of nursing caredelivered, by closely monitoring the clinical performance and competencies of the caseload holders /districtnurses in the ICNT; in partnership with Practice senior integrated Community Nurse will be involved with the ICN Multi-Agency GP Huddles. This isworking closely with the GP networks within Croydon to ensure patients who are medium high risk areidentified quickly and are proactively case managed by one or more members of the MAWS team.Activity ensure the effective and efficient use of resources available including taking responsibility for thecare and safe keeping of equipment issued for personal, team and/or patient use. Ensure delivery of aservice that is responsive, high quality, value for money and achieves key performance indicators andpatient outcomes.ClinicalTo use advanced clinical decision making skills, physical assessment skills and expert knowledge toassess the physical and psychosocial needs of patients on the caseload in order to identify earlysymptom exacerbation in order to instigate treatment promptly, and therefore reduce the chance develop an individualised care plan with the patient, carers, relatives and health care professionalsbased on a comprehensive assessment of medical, nursing and social care order investigations as necessary and to instigate therapeutic treatments based on best availableevidence in order to improve health outcomes and to provide expert clinical care and health work in collaboration with GPs; consultants in elderly care, Nurse Consultants and other health andsocial care colleagues to determine diagnosis; provide specialist assessment, to establish appropriatecare planning, treatment and prescribe within Nurse prescribing and independent or supplementary formulary and initiate medicinesreview with colleagues to improve patient outcomes. Advice patients and staff on the safe storage andadministration of medication, liaising with other professionals as appropriate ( pharmacists).To regularly monitor / review the patients care plan and condition to increase independence and to identifychanges in condition to reduce the need for inappropriate hospital admission and to facilitate dischargefrom the caseload.

5Provide information and support to patients, relatives and other carers that promote and optimisepositive health and to undertake health promotion and disease prevention activities such as fluimmunisation, advice on stopping smoking, dietary advice and foot be accountable for the delivery of safe effective care provided to patients admitted to the ICNT. Thiswill include the coordination prioritisation and delegation of care to the most appropriate, competent staffmember.ManagerialTo be accountable for the delivery of safe effective care provided to patients admitted to the ICNT. Thiswill include the coordination, prioritisation and delegation of care to the most appropriate member of theteam who is competent to undertake the delegated work collaboratively with the line manager, Practice Educators and other ICNT team leaders to meetthe organisations clinical governance agenda and to actively contribute in this work in partnership and collaboration with the Clinical Governance leads to ensure practice is evidencebased; guidelines and policies are developed, monitored and implemented across the ensure that statutory requirements and directives of the NMC are promoted and adhered to and staffwork with their scope of promote a suitable learning environment for staff and students to enable individuals develop therequired competencies according to their role and needs of the develop, monitor and evaluate staff objectives, personal development plans in accordance with theorganisations KSF Performance Management Framework.Organise appropriate ICNT management and performance meetings to disseminate information to theteam and to keep staff informed on their teams performance and the Organisations , investigate, review and monitor complaints and clinical incidents and undertake clinical audit inconjunction with Cluster Matrons, governance and performance leads and work collaboratively to developstrategies around prevention of future occurrences and shared with clinical, pathway and professional leads to develop and re-design care pathways with otherpartners and to implement best practice and ensure maximum utilisation of available resourcesLead on recruitment and selection initiatives and the subsequent employment and induction of new staffand contribute to the trust wide workforce development monitor and review the needs of the community clusters and prioritise as appropriate using effectivemanagement of ensure that off duty rotas are planned appropriately so that the needs of the service can be met and tomanage any resource implication related to this and to inform the line keep accurate and up to date records jointly produced with patients, in accordance with the integratedorganisations and NMC policies and guidelines

To undertake regular caseload analysis in order to target health needs, and reduce inequalities in manage complaints promptly according to the Organisations Policy in collaboration with ClusterMatrons and Head of Service.Professional DevelopmentFacilitate the learning placement for students on post-initial qualification/advanced learning programmesidentifying appropriate all aspects of performance, development and training of staff in line with Trust policies, ensuringthat systems are in place to ensure that all staff within remit have an annual appraisal and personaldevelopment plan and attend annual mandatory refresher keep self up to date on clinical and professional developments in line with NMC revalidation processand evidence based practice; to share knowledge with other team members where actively contribute to and participate in research, screening programmes and audits where utilise research findings and evidence based practice to inform clinical decision making.Service and Practice DevelopmentTo support staff engagement by encouraging team members to be involved in shaping and influencingservice delivery and ensuring that the contributions and perspectives of all staff are heard, valued andinfluence management decision facilitate the engagement of staff within the ICNT with the Listening into Action process in order toimprove the care provided to our effective role modelling promote effective communications within and between teams.Actively participate in team, cluster, directorate and other relevant meetings, working groups that directorate, professional practice and service developments are implemented efficiently andeffectively within the team..Actively contribute to developing guidelines, polices and protocols relevant to the delivery of care withinthe ICNT. This will include participating in relevant steering inform the line manager of any changes in service need and assist where possible to address thechanging motivate and lead the ICNT in developing a professionally accountable and responsible approach towork, by acting as an exemplar role model.

Person Specification

Education and Qualification

Essential

Mentorship Qualification Successful study at 1st degree level Willingness to undertake relevant modules at Masters level. Nurse prescriber Willingness to undertake Independent (V300) prescribing study. Advanced practitioner qualification or Community nursing qualification DN, HV, Practice nurse

Experience

Essential

Significant experience working as a qualified District Nurse. HVOP or Community Matron Experience of managing conflict with a team Experience of caseload management Experience managing staff within a team, resources and workload, effective use of team skill mix, appropriate delegation of patient care, supervision of junior staff Experience identifying learning needs and line management experience or demonstrates the ability to be a line manager

Relevant Knowledge and Awarene

Essential

Understanding of current issues, policies and frameworks affecting primary care practice and district nursing practice based commissioning, community matron and Health care closer to home Understanding of professional and personal accountability and responsibility in line with NMC Code of Professional Conduct. Knowledge of management strategies and leadership styles

Skills, Abilities and Aptitude

Essential

Ability to deliver evidence based care that is responsive to the needs of patients and carers and that is negotiated in partnership with service users Ability to carry out concise, comprehensive patient assessments, prescribe appropriate nursing care, delegate implementation of care appropriately, and evaluate outcomes Ability to assess the needs of the caseload and to prioritorise and manage the resources.

Other Factors

Essential

Car driver, current UK licence and access to car for work purposes Able to work flexibly including unsocial hours Evidence of having met revalidation requirements

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