Community Sister/Charge Nurse

JOB SUMMARY The Neighbourhood Teams Charge Nurse / Community Sister will: – Adapt and provide a wide range of nursing care in home and community-based settings Be accountable for assessing, planning, implementing and evaluating care for patients and managing unpredictable situations flexibly and responsively ensuring this is of a high standard. Be responsible for delivering skilled nursing care to patients in the community setting e.g., recording and monitoring a patients clinical observations, wound care management, palliative care, IV cannulation, intravenous medications, urinary catheterisation, and obtaining bloods for diagnostic purposes etc. Have the flexibility and skill set, with appropriate training, to work across planned and crisis pathways supporting patients to remain well in their own homes, or long-term place of residence and / or prevent hospital admission Be responsible for the management of caseloads, coordinating care, whether anticipated or unscheduled, with individuals and their families, through acute illness, long term and multiple health challenges and at the end of life. Have ongoing management of people with multiple pathology and long-term conditions whose mobility is impaired.; Lead and managing a team to deliver care in the home and community.

Prescribe according to assessed need from within the nurse prescribing formulary. Participate with the training of learners. Work in an integrated and partnership way with primary, secondary, social care, the independent and voluntary sector and others to improve the health and care of individuals, families and communities, particularly the most vulnerable. KEY RESULT AREAS: 1.1 Clinical Care Demonstrate a broad range of specialist nursing clinical expertise that supports high quality person-centred care for the caseload population in a variety of community settings.

Use appropriate physical and clinical examination skills to undertake the assessment of individuals with complex health care needs or those presenting with more acute illnesses, using a range of evidence-based assessment tools and consultation models. Assess the health-related needs of families and other informal carers, developing therapeutic relationships and using creative problem solving that enables shared decision making for the development of care plans, anticipatory care and delivery of care packages. Supervise the delivery of person-centred care plans by the team ensuring regular evaluation of care and develop systems to support staff interventions and care quality. Support all staff to use tools to identify changes in health status and maximise the skills of the nursing and support team to support complex assessment where the patient is showing signs of deteriorating health or new symptoms.

Assess when additional expertise is necessary and make objective and appropriate referrals, whilst maintaining overall responsibility for management and co-ordination of care. Ensure clear lines of accountability with respect to delegation, supervision and mechanisms for the assurance of clinical and care governance including antimicrobial stewardship. Work collaboratively with others to identify individuals who would benefit from further ongoing support and management within Neighbourhood Teams or wider support services. Promote the mental health and well-being of people and carers in conjunction with mental health professionals and GPs, identifying needs and mental capacity, using recognised assessment and referral pathways and best interest decision making and providing appropriate emotional support.

Where appropriate, undertake the case management of people with complex needs, with the support of the multidisciplinary team, to improve anticipatory care, self-management, facilitate timely discharges and reduce avoidable hospital admissions to enable care to be delivered closer to, or at home. Assess and evaluate risk using a variety of tools across a broad spectrum of often unpredictable situations, including staff, and people within their home environments. Develop and implement risk management strategies that take account of peoples views and responsibilities, whilst promoting patient and staff safety and preventing avoidable harm to individuals, carers and staff. Work in partnership with individuals, formal and informal carers and other services to promote the concept of self-care and patient-led care where possible, providing appropriate education and support to maximise the individuals independence and understanding of their condition(s) in achieving their health outcomes.

Analyse and use appropriate approaches to support the individuals health and well-being and promote self-care in addressing their short- or long-term health conditions. Support the team to facilitate behaviour change interventions for individuals. Explore and apply the principles of effective collaboration within a multi-agency, multi-professional context facilitating integration of health and social care and services, ensuring person-centred care is co-ordinated and anticipated across the whole of the persons journey. Demonstrate advanced communication skills engaging and involving people and their carers that foster therapeutic relationships and enable confident management of complex interpersonal issues and conflicts between individuals, carers and members of the caring team.

Prescribe from the appropriate formulary relevant to the type of prescribing being undertaken, following assessment of patient need and according to legislative frameworks and local policy. Use opportunities to identify and build the principles of making every contact count into clinical practice and use opportunities to raise lifestyle issues. Demonstrate a see and treat approach to patient care. 1.2 Leadership and Operational Management Contribute to public health initiatives and surveillance, working from an assets-based approach that enables and supports people to maximise their health and well-being at home, increasing their self-efficacy and contributing to community developments.

Lead, support, clinically supervise, manage and appraise a mixed skill/discipline team to provide community nursing interventions in a range of settings to meet known and anticipatory needs, appraising those staff reporting directly whilst retaining accountability for the caseload and work of the team. Enable other team members to appraise, support and develop others in the team and develop strategies for addressing poor practice. Manage the staff nurse team within regulatory, professional, legal, ethical and policy frameworks ensuring staff feel valued and developed. Facilitate an analytical approach to the safe and effective distribution of workload through delegation, empowerment and education which recognises skills, regulatory parameters and the changing nature of district nursing whilst establishing and maintaining the continuity of caring relationships.

Lead, manage, monitor and analyse clinical caseloads, workload and team capacity to assure safe staffing levels in care delivery, using effective resource and budgetary management. Manage and co-ordinate programmes of care, for individuals with acute and long term conditions, ensuring their patient journey is seamless between mental and physical health care, hospital and community services and between primary and community care. Collaborate with other agencies to evaluate public health principles, priorities and practice and implement these policies in the context of the district nursing service and the needs of the local community. Participate in the collation of a community profile, nurturing networks that support the delivery of locally relevant resources for health improvement and analysing and adapting practice in response to this.

Articulate the role and unique contribution of the service in meeting health care needs of the population in the community and the evidence that supports this in local areas. Ensure all staff are able to recognise vulnerability of adults and understand their responsibilities and those of other organisations in terms of safeguarding legislation, policies and procedures. Use knowledge and awareness of social, political and economic policies and drivers to analyse how these may impact on district nursing services and the wider health care community. Where appropriate participate in organisational responses and use this knowledge when advocating for people or resources.

Record all client contacts and activities accurately and contemporaneously maintaining accurate records and statistical returns as required by the Trust via SystmOne and monitor SytmOne usage within your team. Participate in clinical supervision on a regular basis with a designated person. To be aware of and act in accordance with Trust Clinical Standards and Guidelines and the NMC Code of Conduct and Guidelines. Contribute to the development, collation, monitoring and evaluation of data relating to service improvement and development, quality assurance, quality improvement and governance, reporting incidents and developments related to district nursing ensuring that learning from these, where appropriate, is disseminated to a wider audience to improve patient care.

For full details of the role please see the supporting documents attached.