Job description

Job responsibilities

Summary of Role

You will be responsible for coordinating, integrating and delivering support to

• elderly
• learning difficulty
• end of life
• frail patients

You will liaise with a broad range of medical social and third sector services to provide effective and synchronised care to these patients.

You will work with frail and vulnerable adults to improve their health and wellbeing by navigating them to appropriate services. You will assist them to access these services and any appropriate funding. The service will be targeted at specific patient groups identified by GP practices.

These patients will include but are not limited to adults with

• Complex long term health needs
• Depression
• Organic mental illness
• Learning difficulties

You will be required to perform minor clinical observations such as basic monitoring and recording of vital signs, blood pressure monitoring on behalf of the DDHF and GP practices. These skills will be carried out in the community. Appropriate training and support will be provided as required. 

You will be working at a variety of venues in the community, including patients homes and utilising premises in agreement with stakeholders and clients. You will work collaboratively with the general practice teams to meet the needs of patients, supporting the delivery of DDHF policies and procedures, and support leadership as required.

Primary Responsibilities

Service Delivery

• Build and develop a robust knowledge of health & social sector provision in the Durham Dales area
• Build and develop strong working relationships with health, social, and third sector providers in the Durham Dales area, including GP practices
• Work closely with professionals from a variety of health specialties.
• Prepare proactive care plans for vulnerable patients
• Build relationships with patients, patients families, and carers with home visits, telephone consultations and reviews within the community setting and at dedicated venues.
• Act as an advocate for patients and service users to the health and social care system
• Signpost patients towards appropriate services

Communication

• Attend practice level MDT meetings to discuss patients and coordinate with health care professionals
• Utilise and demonstrate sensitive communication styles, to ensure patients are
• fully informed
• Communicate with and support patients who are receiving bad news
• Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding,
• cultural background and preferred ways of communicating
• Anticipate barriers to communication and take action to improve communication
• Maintain effective communication within the practice environment and with external stakeholders

Delivering a quality service

• Produce accurate, contemporaneous and complete records of patient contact, consistent with legislation, policies and procedures
• Prioritise, organise and manage own workload in a manner that maintains and
• promotes quality
• Assess effectiveness of care delivery through self and peer review, benchmarking and
• formal evaluation
• Participate in the maintenance of quality governance systems and processes across the organisation and its activities
• Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required
• In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate
• Evaluate patients responses to health care provision and the effectiveness of care
• Support and participate in shared learning across the wider organisation.
• Assess the impact of policy implementation on care delivery
• Understand and apply legal issues that support the identification of vulnerable and
• abused adults, and be aware of statutory vulnerable patients health procedures and local guidance

Specific Tasks/ Responsibilities

• Team working
• Understand own role and scope, work within this scope of practice and identify how this may develop over time
• Work as an effective and responsible team member, supporting others and exploring
• the mechanisms to develop new ways of working
• Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence
• Create clear referral mechanisms to meet patient need
• Prioritise own workload and ensure effective time-management strategies are
• embedded Work effectively with others to clearly define values, direction and policies impacting upon care delivery
• Discuss, highlight and work with the team to create opportunities to improve patient care

Managing information

• Use technology and appropriate software as an aid to management in planning, implementation and monitoring of care, presenting and communicating information
• Ensuring that patent data is kept confidential at all times and is shared on a need to know basis only.
• Understand responsibility of self and others regarding the Freedom of Information Act
• Collate, analyse and present data and information to the team

Learning and development

• Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (eg courses and conferences)
• Assess own learning needs and undertake learning as appropriate.

Equality and inclusion

• Identify patterns of discrimination and take action to overcome this and promote diversity and equality of opportunity
• Enable others to promote equality and diversity in a non-discriminatory culture
• Support people who need assistance in exercising their rights
• Adhere to local chaperoning policies
• Act as a role model in the observance of equality and diversity good practice
• Accept the rights of individuals to choose their care providers, participate in care and refuse care

General Responsibilities

• Ensure strict confidentiality of correspondence, reports, meetings and verbal communications as appropriate.
• Adapt to and support any changes that are implemented to improve the service.
• At all times provide a caring service and to treat those with whom they come into contact in a courteous and respectful manner.
• Demonstrate commitment by the efficient completion of all tasks allocated.
• Carry out duties and responsibilities in compliance with health and safety policy and statutory regulations.
• Adhere to equal opportunities policy throughout the course of employment.

Person Specification

Qualifications

Essential

• GCSE Grade C or above in Maths and English, or equivalent qualification

Desirable

• Qualification in a health or social care allied profession
• Phlebotomy
• HCA qualification

Experience

Essential

• Experience of working with or caring for elderly people, friends or relations

Desirable

• Experience of working in primary care
• Experience of working in social care or health
• Experience of working with frail and vulnerable patients
• Experience of working as part of an MDT

Skills

Essential

• Communication skills, both written and verbal
• Empathy with the older persons needs and conditions
• Positive attitude to work, colleagues and patients
• Non-judgemental attitude to patients
• Tact and diplomacy
• Desire to help and put people first
• Ability to negotiate the best possible services for patients
• Advocacy skills
• Time management
• Team working
• Good record keeping
• Good IT keyboard skills

Desirable

• Knowledge of SystmOne
• Care planning knowledge

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Job description

Job responsibilities

Build a robust knowledge of health, social and third sector provision available within the Durham Dales and surrounding areas

Promote social prescribing, its role in self-management, and the wider determinants of health.

Act as an advocate for patients and service users of the health and social care system.

Build relationships with key staff in GP practices within the local Primary Care Network (PCN). Attend relevant meetings and integrate as part of the wider network team, providing information and feedback on social prescribing matters.

Work proactively to develop strong links with all local agencies to encourage referrals, to recognise their requirements and enable confident approach to making referrals.

Work in partnership with all local agencies to raise awareness of social prescribing and demonstrate how partnership working can reduce pressure on statutory services, improve health outcomes and enable a holistic approach to care.

Provide referral agencies with regular updates relating to social prescribing, and include training for their staff to promote effective access to information and encourage appropriate referrals.

Work proactively in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.

The Social Prescribing Link Worker will have the capability of performing minor clinical skills such as Basic Monitoring and Recording of Vital Signs, Blood Pressure Monitoring, ECGs on behalf of the DDHF and GP practices. These skills may be carried out in GP Practice, hub setting or the community.

To support patients on discharge from hospital admission.

Build relationships with patients, their families and carers and carry out regular telephone consultations and reviews within the GP practice or community setting.

Meet people on a one-to-one basis, undertaking home visits where appropriate within organisations policies and procedures. Give people time to tell their stories and focus on what matters to me.

Build trust with the person, providing non-judgmental support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a persons assets.

Anticipate barriers to communication.

Be a friendly source of information about wellbeing and prevention approaches.

Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring.

Communicate effectively with patients, families and carers recognising the need for alternative communication methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating.

Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.

Work with individuals to co-produce a simple personalised support plan; based on the persons priorities, interests, values and motivations, including what they can expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.

Where appropriate, physically introduce people to community groups, activities and statutory services, ensuring they are comfortable. Provide follow-up to ensure that they are happy, engaged, included and receiving good support.

Where people may be eligible for a personal health budget, assist them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate. Support community groups and VCSE organisations to receive referrals.

Forge strong links with local VCSE organisations, community and neighborhood to promote micro-commissioning or small grants if available.

Develop supportive relationships with local VCSE organisations, community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced.

Ensure that local community groups and VCSE organisations being referred to have basic procedures in place for ensuring that vulnerable individuals are safe and, where there are safeguarding concerns, work with all partners to deal appropriately with issues. Where such policies and procedures are not in place, support groups, to work towards this standard before referrals are made to them.

Check that community groups and VCSE organisations meet in insured premises and that health and safety requirements are in place. Where such policies and procedures are not in place, support groups, to work towards this standard before referrals are made to them.

Support local groups to act in accordance with information governance policies and procedures, ensuring compliance with the Data Protection Act.

Work collectively with all local partners to ensure community groups are strong and sustainable

Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision.

Support local partners and commissioners to develop new groups and services where needed, through small grants for community groups, micro-commissioning and development support.

Work with commissioners and local partners to identify unmet needs within the community and gaps in community provision.

Support local partners and commissioners to develop new groups and services where needed, through small grants for community groups, micro-commissioning and development support.

Encourage people who have been connected to community support through social prescribing

to volunteer and give their time freely to others, in order to build their skills and confidence, and strengthen community resilience.

Data capture

Produce accurate, contemporaneous and complete records of patient contact, consistent with legislation, policies and procedures.

Work sensitively and effectively with people, their families and carers to capture key information, enabling tracking of the impact of social prescribing on their health and wellbeing.

Build relationships with patients, their families and carers and carry out regular telephone consultations and reviews within the GP practice or community setting.

Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.

Support referral agencies to provide appropriate information about the person they are referring to. Use the case management system to track the persons progress. Provide appropriate feedback to referral agencies about the people they referred.

Work closely with GP practices within the PCN to ensure that social prescribing referral codes are inputted to the clinical system and that the persons use of the NHS can be tracked, adhering to data protection legislation and data sharing agreements with the clinical commissioning group (CCG).

Seek regular feedback about the quality of service and impact of social prescribing on referral agencies.

Understand and apply legal issues that support the identification of vulnerable and abused children and adults, and be aware of statutory child/vulnerable patients health procedures and local guidance.

Develop a team of volunteers to provide buddying support for people, starting new groups and finding creative community solutions to local Issues.

Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering.

Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing.

Person Specification

Knowledge

Essential

• Knowledge of the needs of vulnerable adults, safeguarding and the associated legal framework
• Knowledge of local health and social care provision
• Knowledge of funding systems in social care
• Knowledge and understanding of cancer support services

Desirable

• Knowledge of public health issues
• Familiarity with information systems used in clinical practice
• Basic knowledge of Anatomy and Physiology
• Understanding of health and social care terminology

Skills

Essential

• Ability to manage and prioritise a caseload
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Communication skills, both written and verbal
• Build relationships with patients, their families and carers
• Ability to provide personalised support to individuals, their families and carers
• Ability to listen and empathise with people in a non-judgmental way
• Able to complete tasks in a timely manner
• Able to maintain effective working relationships and promote collaborative working

Desirable

• Communication of difficult messages to patients and families
• Experience of using clinical systems such as SystmOne

Experience

Essential

• Experience of working in a similar role
• Experience of working with vulnerable people
• Experience of working in health and social care
• Experience of coordinating services and event planning
• Experience of community engagement

Desirable

• Experience of working in liaison capacity with social care
• Experience of seeing patients and carers in a practice based setting or in their own home
• Experience of working in the farming/agricultural community
• Experience of using clinical systems such as SystmOne

Qualifications

Essential

• GCSE Grade C or above in Maths and English or equivalent qualification

Desirable

• Qualification in a health or social care
• Formal safeguarding qualification

Other

Essential

• Full UK driving licence
• Meet DBS reference standards
• Highly motivated
• Willingness to work weekends and flexible hours when required to meet work demands
• Able to demonstrate good time management skills
• Undertake additional training relevant to the role

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Job description

Job responsibilities

• Assess patients presenting with acute illness or for review of chronic disease conditions
• Undertake home visits for acute illness or chronic disease management
• Diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with an undifferentiated diagnosis
• Clinically examine and assess patient needs from a physiological and psychological perspective, and plan clinical care accordingly
• Assess, diagnosis, plan, implement and evaluate interventions/treatments for patients with complex needs
• Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition (as appropriate)
• Diagnose and manage both acute and chronic conditions, integrating both drug- and nondrug-based treatment methods into a management plan
• Prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence-based practice and national and practice protocols and formularies
• Work with patients and their carers in order to support compliance with and adherence to prescribed treatments
• Provide information and advice on prescribed or over-the-counter medication on medication regimens, side-effects and interactions
• Prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care
• Support patients to adopt health promotion strategies that promote healthy lifestyles, and apply principles of self-care
• Assess, identify and refer patients presenting with mental health needs in accordance with the NSF for Mental Health
• Undertake minor surgery as appropriate to competence
• Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
• Communicate with and support patients who are receiving bad news
• Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating
• Maintain effective communication within DDHF and with external stakeholders
• Attend and contribute to team meetings
• Undertake mentorship for more junior staff, assessing competence against set standards

Person Specification

Qualifications

Essential

• Registered first level nurse
• Relevant nursing/health degree
• Mentor/teaching qualification
• Non-medical independent nurse prescriber
• Msc in Advanced Clinical Practitioner or equivalent OR must be willing to work towards

Knowledge & Skills

Essential

• Advanced clinical skills
• Management of patients with long-term conditions
• Management of patients with complex needs
• Clinical examination protocols and procedures
• Boundaries of own role and other roles in a nurse-led service
• NSF, NICE guidelines
• Local and national health policy and wider health economy
• Clinical governance issues in primary care
• Patient group directions (PGDs) and associated policy usage
• Clinical leadership skills
• Communication skills, both written and verbal
• Communication of difficult messages to patients and families
• Negotiation and conflict management skills
• Change management
• Teaching and mentorship
• clinical setting Resource management

Desirable

• Knowledge of public health issues
• Able to identify determinants on health in the area
• Knowledge of public health issues in the area

Experience

Essential

• Minimum 2 years post registration experience
• At least 2 years recent primary and community nursing experience
• Nurse-led management of minor illness, minor ailments and injuries
• Nurse-led triage including telephone triage
• Partake in clinical audit

Desirable

• Project management
• Working with community development initiatives
• Health-needs assessment
• Home visit assessment of patients
• Community nursing specialist qualification
• Leadership in quality initiatives such as clinical benchmarking
• Clinical supervision training and experience

Other

Essential

• Full UK driving Licence
• Willingness to travel throughout the Durham Dales area
• Prepared to work out of hours on a staff rota
• Self-directed practitioner
• Highly motivated
• Enthusiastic

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).