NursingNetUK

Swydd ddisgrifiad a phrif gyfrifoldebau manwl

To work as an accountable and autonomous practitioner working to pro-actively monitor and anticipate changing phase of illness and health and social care needs of Adults with serious mental illness.

To ensure delivery of a person centred approach, “What matters to me” to all patients that enables individuals to achieve their optimum physical, psychological and social wellbeing.

To provide a timely response to referrals and be responsible for advanced clinical care using comprehensive, evidence based, holistic assessment.

Promoting high quality standards and cost effectiveness in all aspects of care delivery.

Act as an autonomous practitioner, working with a caseload of people referred to them in a manner which demonstrates an enhanced knowledge base and advanced clinical skills and competencies.

Improve clinical outcomes for patients by enabling them to function independently by increasing their choice to remain in their own home / community and reduce the need for, or prevent inappropriate hospital admission

To maintain responsibility and accountability for the provision of a high quality, cost effective complex care based on health assessment of patients referred to the caseload.

Accountable for planning and evaluating the work carried out by self and neighbourhood colleagues. Managing and prioritising a caseload of patients according to their health status, who are referred by various agencies including GP, hospital, case managers, social care, and independent sector promoting self-care, self-management and independent living.

Contribute to the work carried out by Neighbourhood colleagues from a MH perspective.

Establishing effective working relationships with patients, their families and carers including education and promoting individual rights, recognising and respecting their contributions to care planning, placing patient in the centre of their care.  Referral on to the appropriate support, ie medical, mental health, physical health, third sector, well-being or social prescribing.

Develop individual evidence based holistic care plans and self-management plans with the patient, carers, relatives, health and social care professionals. Recognising the differing phase of illness and planning for deterioration.

Attends core neighbourhood working meetings as part of an integrated team and works in a collaborative manner with the Neighbourhood Lead.

Facilitate, participate and optimises case conferences / multi-disciplinary team (MDT) meetings, which includes those required within  Enhanced Health for Care Homes for residents with non Dementia diagnosis.

Establishes and maintains excellent trusted and credible relationships with individuals and groups, exploring issues relating to care options and decisions to sustain effective working across the health social care and voluntary system.

To work within the Mental Capacity Act and safeguarding policy. Refer to social services as per adult protection policies and complete all appropriate documentation

Maintain and record accurate documentation and correspondence in line with professional and Trust guidance in the appropriate legal records and formats. 

Plan, implement, monitor and review therapeutic interventions with individuals / carers who have serious mental illness through holistic patient centred assessments.

Support the local implementation of national and local policy that impacts upon the health and well-being of patients such as the NHS England framework for community mental health services.

Act as a role model and expert to neighbourhood colleagues, endorsing best practice, policies, procedures and guidelines to ensure risk assessments are completed for the environment in which the team is working .

To support the workforce development for managing the changing demographic and population health.

Develops and maintains highly developed clinical skills and support the learning and educational needs of others within the neighbourhood.

To act as a clinical specialist and contribute to service development by working as a member of working / steering groups and in partnership working and service transformation.

Engages patients and carers in individual health promotion action.

Participation in population health / management / improvement activities within the community and use high level communication skills to communicate complex issues with patients and carers, in particular the skills needed for cognitive assessment and mental health status.

Maintains patient confidentiality and works within the confines of the Data Protection Act

Undertake medicine management review and prescribe medicine and appliances for patients.

To work with the management matrix to understand the fiscal and governance issues that are applicable to the organisation and the neighbourhood in order to develop personal leadership and management skills.

To provide supervision to other team members on a day to day basis.

Promote direct supervision to specified staff delegated by the Service Manager.

Receive and, where appropriate participate in staff development and performance appraisals.

To recruit to posts within their locality.

Support the development of the professional practice in the service, ensuring the provision of clinical supervision.

Promote the mission and values of the Trust