Clinical Nurse Specialist | Mersey Care NHS Foundation Trust in Knowsley

The post holder will demonstrate at all times a comprehensive knowledge base and promote excellence in nursing practice in a dynamic healthcare environment working within the integrated community nursing service to lead on optimising care, admission avoidance and complex supported discharge pathways.

As an active part of a team, the post holder is expected to lead, manage and provide direct patient care, acting as an expert practitioner and a role model to the whole team. It is essential that they demonstrate excellent leadership and communication skills, ensuring that they use initiative and work autonomously.

The Clinical Nurse Specialist will be part of a multi-disciplinary team and actively support integration, transformation and future establishment of health and care pathways. Responsible for standards of safe, high quality care consistently delivering evidence based practice. To support the delivery of care which is patient focused, promotes self-care and ensures that the service adapts/develops in response to the needs of the local population.

Key Responsibilities:

• To lead the processes for delivering, monitoring, and improving the quality of care provided to patients. This includes risk management, complying with and contributing to CQC requirements, incidents, and clinical audit.
• Delivers effectively skilled holistic assessments and case management including care coordination, care planning and treatment for complex patients as part of the integrated community nursing service.
• Identify risks to service delivery and problem solve to ensure resources are allocated across the team/teams to appropriately prioritise care.
• Ensure clinical research is conducted in line with Merseycare NHS Foundation Trust protocols and in liaison with the research team, ensuring that the research has had ethical approval.
• Ensure that patients receive the information they need and are treated with dignity and respect for their privacy.
• Carry out risk assessments and adhere to safe systems of work. This includes understanding and adhering to the reporting procedures for clinical and nonclinical incidents/near misses.
• Reports clinical and non-clinical incidents and proactively manages risk to patients including vulnerable adults and staff.
• Supports, monitors and challenges caseload management processes to ensure quality, safe and effective care delivery.
• To promote an environment conducive to effective learning and to comply with statutory and mandatory responsibilities in line with current local and National monitoring requirements.
• Teach and educate patients, carers and other healthcare professionals to recognise subtle changes in condition that could lead to exacerbation or acute deterioration and take appropriate actions.
• Acts as a clinical expert and information resource, leading in training, education and orientation programmes for staff, students and others.
• Proactively develop, implement and monitor public health and health promotion activities in accordance with national and local priorities.
• Incorporates relevant evidenced based findings with practice and participates in Merseycare NHS Foundation Trust approved research programmes.
• Initiates and implements change using quality improvement methodology.
• Be responsible for the performance review of community nursing staff which includes annual appraisal and individual development plans.
• Monitor staff against objectives set, giving feedback regularly via the supervision process.
• Leads the development, implementation and audit of protocols, policies and integrated pathways using current evidenced based practice/research that facilitates change in practice and improves clinical outcomes, meeting the needs of patients and carers.
• Input activity onto the recognised Trust database in order to support service development and meet contractual requirements.
• Use advanced skills and expert knowledge to assess the physical and psycho-social needs of adults in the community instigating therapeutic care plans and treatments based on the best available evidence in order to improve health outcomes, support admission avoidance and promote complex supported discharges in the community.
• Work within a multi-disciplinary team to ensure effective care plans and treatments are in place for highly complex patients including end of life, palliative care and long term conditions.
• Communicate highly complex information about patient’s conditions to multidisciplinary team colleagues to ensure effective delivery of patient treatments.
• Negotiate and agree with the patient, carers and other professionals individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring onto other services or professionals as appropriate.
• Maintain communication pathways if the patient is admitted to any inpatient facility and provide baseline health data for the receiving team, to support integrated and consistent care and facilitate discharge.
• Ensures effective communication with other professional groups and outside agencies, acts as an information source and works in partnership in the interest of individuals.
• Keeps accurate, contemporaneous records and written reports, as required.
• To identify patients who have complex care needs using a range of different case finding tools including proactive case finding in liaison with the GP.
• To be aware of the cost of equipment/supplies used and to meet the needs of the patient and service in a cost effective way.
• When necessary assist as delegated by the Operational Lead in the recruitment of staff, appraisal process, risk assessment process, incidents and complaints, and the performance management process.
• Provides clinical leadership to all team members.

To promote the attainment and maintenance of optimum health of patients who have long term conditions and acute disease management through predictive and proactive case management. To formulate care plans that address the complex health, social and cultural needs of the patient through working in partnership with the patient, the GP, specialist nurses, integrated care teams and other stakeholder providers.

To promote patient centred care by integrating and co-ordinating the activities of the patient, relatives and carers, the individual practitioners and teams in the provision of an effective management strategy for managing an individual’s long term condition.

To ensure that appropriate information regarding the condition of the patient is known to the GP and other appropriate stakeholder providers, by the development and maintenance of effective systems of inter-agency, inter-disciplinary communications.

Support care pathways for smooth transition between primary, secondary and tertiary care for patients, particularly those who are newly diagnosed or whose symptoms are poorly controlled, by liaison with specialists within primary and secondary care.

Inform the development of policies and procedures relevant to the care of people with long term conditions and acute diseases by co-operating and assisting in research programmes relating to the client group.

Ensure services are delivered and sustained in line with NICE guidelines/local targets and understand principles of disease management by leading, motivating, educating and developing colleagues and others.

Promote admission avoidance and early supported discharge by effective communication with internal and external stakeholders.