Hours: 15 hours per week. Your normal working hours will be Monday, Tuesday and Wednesday at the Tutbury Health Centre; 5 hours per day during core working hours. Responsible to: The IM&T Manager Accountable to: Practice Manager and Partners General description of the post: The Enhanced Health in Care Homes model moves us away from reactive care to a proactive model of care, this role is pivotal in making this happen. To act as the central point of access for all care homes to support the delivery of the Enhanced Health in Care Homes element of the Primary Care Network (PCN) Direct Enhanced Service.
Duties: To develop and refresh as required a personalised care and support plan for every resident a standard template will be developed. Within 7 working days of admission to the home and within 7 working days of readmission following a hospital episode. This is to be done in conjunction with the patient, family and or carer and MDT members. Work with the Practices to ensure that all relevant information is held within the patients medical record when transferring to a new practice.
List of up to date medication, ESCAs, summary print out is requested from their previous practice if required Draw on any existing assessments that have been made. Use a directory of services (this will be complied for you but it is expected that in time you will forge links with other external provision to help enhance the care and support available to care homes) to navigate the right care to the right home as and when this is required. This active engagement with external providers will include the voluntary sector and Social Prescribing link workers. To be the central point of contact for all care homes and ensure that each care home has access to a weekly check in home round facility and prioritise residents for review according to identified need based on MDT clinical judgement and care home advice.
To identify and or engage in locally organised shared learning opportunities as appropriate and as capacity allows. Actively encourage an excellent working relationship with the care home and support them to self-manage by disseminating educational material, advice and guidance as prepared by MDT members when and where appropriate. To ensure that action points arising from MDT meetings are followed up To support the patients discharge from hospital and transfers of care between settings giving due regard to NICE Guideline 27 Relates to referrals only Assist with the collection of data required for the PCN EHCH DES Implement and co-ordinate advanced care plans on annual bases and when notified of a new patient. Work with the home (and MDT) in coordinating their flu immunisation campaign.
Where someone is identified as likely to die in next few days or hours, to ensure everyone who needs to be aware is. Liaise with dispensary and GPs to ensure anticipatory drugs, DNAR etc all arranged. Liaise with St Giles as appropriate. The patients care plan is reviewed and treatment escalation plan in place.
Family have been informed and DNAR etc discussed. If a treatment plan surrounding their death is in place it is followed where possible, through collaboration with the home and other in the MDT where necessary. Following a death, ensure that the relevant parties have been informed. Bereavement support is available for the families (and care workers) Ensure ADASTRA form is uploaded in a timely manner.
Aware of when SMRs need doing, add them to the MDT meetings to ensure all relevant parties review medications of the patient. If a falls prevention plan is in place, ensure it is reviewed as required, at least annually. Ensure it is on the agenda for the MDT meetings. Identify who needs a review, of what, when.
Make sure that the relevant parties are aware, follow it up to make sure it has been actioned. Co-ordinate hospital discharges i.e. onward referrals, (where a patient has had a fall, referral to falls team) medication changes, DNARs etc Confidentiality: All patient information that you come into contact with must be dealt with in the strictest of confidence. Any breach in confidence can lead to instant dismissal: - In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters.
They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. They may also have access to information relating to the Practice as a business organisation. All such information from any source is to be regarded as strictly confidential Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Practice policies and procedures relating to confidentiality and the protection of personal and sensitive data. Health & Safety: The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy, to include: Using personal security systems within the workplace according to Practice guidelines Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks Making effective use of training to update knowledge and skill Safeguarding: All employees are required to act in such a way that at all times safeguards the health and wellbeing of children and vulnerable adults.
Familiarisation with and adherence to Safeguarding policies is an essential requirement of all employees as is participation in related mandatory/statutory training. For further information regarding these policies please look at the T: Drive folder under Safeguarding, or the Staffordshire Safeguarding Childrens Boards website. We operate a No Smoking Policy

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