Senior Integrated Community Nurse

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 independence.To 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 care.To 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 times.In 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 care.Be 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 Educators.The 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 ofhospitalisation.To develop an individualised care plan with the patient, carers, relatives and health care professionalsbased on a comprehensive assessment of medical, nursing and social care needs.To 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 promotioninterventions.To 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 outcomes.To 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 (e.g. 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 health.To 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 task.To 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 process.To 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 service.To ensure that statutory requirements and directives of the NMC are promoted and adhered to and staffwork with their scope of practice.To promote a suitable learning environment for staff and students to enable individuals develop therequired competencies according to their role and needs of the service.To 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 transformationagenda.Report, 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 learning.Work 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 programme.To monitor and review the needs of the community clusters and prioritise as appropriate using effectivemanagement of resources.To 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 manager.To 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 serviceprovision.To 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 mentors.Manage 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 training.To 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 appropriate.To actively contribute to and participate in research, screening programmes and audits where appropriate.To 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 making.To facilitate the engagement of staff within the ICNT with the Listening into Action process in order toimprove the care provided to our patients.By effective role modelling promote effective communications within and between teams.Actively participate in team, cluster, directorate and other relevant meetings, working groups andcommittees.Ensure 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 groups.To inform the line manager of any changes in service need and assist where possible to address thechanging need..To motivate and lead the ICNT in developing a professionally accountable and responsible approach towork, by acting as an exemplar role model.

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