Senior Integrated Community Nurse

at  Croydon Health Services NHS Trust

This post holder will be responsible for improving, maintaining and monitoring the Community Nursing
Service, to ensure that patient care is delivered to the standards detailed in the Performance
Management Framework and Nursing Strategy. This will be achieved through leadership, the promotion
of advanced clinical skills and the performance management of the caseload holder /District Nurse within

To provide a comprehensive assessment of the physical, psychological and social care needs of patients
and their main care providers followed by the instigation of an appropriate care package that maximises
health and wellbeing and promotes independence.
To take overall responsibility for the ongoing co-ordination of complex care packages including for those
patients requiring facilitated discharge form hospital, or other places of care, hospital avoidance and ongoing care.
To provide advanced, effective evidence based nursing care and case management to patients with
moderate and highly complex care needs, in a variety of community settings ensuring patient safety,
patient experience and patient outcomes are optimised and patients are free from harm.
4
To provide professional leadership, and direction to the integrated community nursing teams within the
cluster, acting as a resource and role model at all times.
In the absence of the Cluster Matron be responsible for Cluster management and escalate issues that
cannot be resolved locally to the identified Cluster Matron allocated to provide professional support.
Lead and participate in transformation of community nursing services in order that it can manage the
increasing demands and move to a fully integrated service in line with the accountable provider alliance
(APA) model of care.
Be accountable for the development, monitoring and maintenance of the standards of nursing care
delivered, by closely monitoring the clinical performance and competencies of the caseload holders /district
nurses in the ICNT; in partnership with Practice Educators.
The senior integrated Community Nurse will be involved with the ICN Multi-Agency GP Huddles. This is
working closely with the GP networks within Croydon to ensure patients who are medium high risk are
identified quickly and are proactively case managed by one or more members of the MAWS team.
Activity ensure the effective and efficient use of resources available including taking responsibility for the
care and safe keeping of equipment issued for personal, team and/or patient use. Ensure delivery of a
service that is responsive, high quality, value for money and achieves key performance indicators and
patient outcomes.
Clinical
To use advanced clinical decision making skills, physical assessment skills and expert knowledge to
assess the physical and psychosocial needs of patients on the caseload in order to identify early
symptom exacerbation in order to instigate treatment promptly, and therefore reduce the chance of
hospitalisation.
To develop an individualised care plan with the patient, carers, relatives and health care professionals
based on a comprehensive assessment of medical, nursing and social care needs.
To order investigations as necessary and to instigate therapeutic treatments based on best available
evidence in order to improve health outcomes and to provide expert clinical care and health promotion
interventions.
To work in collaboration with GPs; consultants in elderly care, Nurse Consultants and other health and
social care colleagues to determine diagnosis; provide specialist assessment, to establish appropriate
care planning, treatment and outcomes.
To prescribe within Nurse prescribing and independent or supplementary formulary and initiate medicines
review with colleagues to improve patient outcomes. Advice patients and staff on the safe storage and
administration of medication, liaising with other professionals as appropriate (e.g. pharmacists).
To regularly monitor / review the patient’s care plan and condition to increase independence and to identify
changes in condition to reduce the need for inappropriate hospital admission and to facilitate discharge
from the caseload.
5
Provide information and support to patients, relatives and other carers that promote and optimise
positive health and to undertake health promotion and disease prevention activities such as flu
immunisation, advice on stopping smoking, dietary advice and foot health.
To be accountable for the delivery of safe effective care provided to patients admitted to the ICNT. This
will include the coordination prioritisation and delegation of care to the most appropriate, competent staff
member.
Managerial
To be accountable for the delivery of safe effective care provided to patients admitted to the ICNT. This
will include the coordination, prioritisation and delegation of care to the most appropriate member of the
team who is competent to undertake the delegated task.
To work collaboratively with the line manager, Practice Educators and other ICNT team leaders to meet
the organisations clinical governance agenda and to actively contribute in this process.
To work in partnership and collaboration with the Clinical Governance leads to ensure practice is evidence
based; guidelines and policies are developed, monitored and implemented across the service.
To ensure that statutory requirements and directives of the NMC are promoted and adhered to and staff
work with their scope of practice.
To promote a suitable learning environment for staff and students to enable individuals develop the
required competencies according to their role and needs of the service.
To develop, monitor and evaluate staff objectives, personal development plans in accordance with the
organisations KSF Performance Management Framework.
Organise appropriate ICNT management and performance meetings to disseminate information to the
team and to keep staff informed on their team’s performance and the Organisations transformation
agenda.
Report, investigate, review and monitor complaints and clinical incidents and undertake clinical audit in
conjunction with Cluster Matrons, governance and performance leads and work collaboratively to develop
strategies around prevention of future occurrences and shared learning.
Work with clinical, pathway and professional leads to develop and re-design care pathways with other
partners and to implement best practice and ensure maximum utilisation of available resources
Lead on recruitment and selection initiatives and the subsequent employment and induction of new staff
and contribute to the trust wide workforce development programme.
To monitor and review the needs of the community clusters and prioritise as appropriate using effective
management of resources.
To ensure that off duty rotas are planned appropriately so that the needs of the service can be met and to
manage any resource implication related to this and to inform the line manager.
To keep accurate and up to date records jointly produced with patients, in accordance with the integrated
organisations and NMC policies and guidelines
To undertake regular caseload analysis in order to target health needs, and reduce inequalities in service
provision.
To manage complaints promptly according to the Organisations Policy in collaboration with Cluster
Matrons and Head of Service.
Professional Development
Facilitate the learning placement for students on post-initial qualification/advanced learning programmes
identifying appropriate mentors.
Manage all aspects of performance, development and training of staff in line with Trust policies, ensuring
that systems are in place to ensure that all staff within remit have an annual appraisal and personal
development plan and attend annual mandatory refresher training.
To keep self up to date on clinical and professional developments in line with NMC revalidation process
and evidence based practice; to share knowledge with other team members where appropriate.
To actively contribute to and participate in research, screening programmes and audits where appropriate.
To utilise research findings and evidence based practice to inform clinical decision making.
Service and Practice Development
To support staff engagement by encouraging team members to be involved in shaping and influencing
service delivery and ensuring that the contributions and perspectives of all staff are heard, valued and
influence management decision making.
To facilitate the engagement of staff within the ICNT with the Listening into Action process in order to
improve the care provided to our patients.
By effective role modelling promote effective communications within and between teams.
Actively participate in team, cluster, directorate and other relevant meetings, working groups and
committees.
Ensure that directorate, professional practice and service developments are implemented efficiently and
effectively within the team.
.
Actively contribute to developing guidelines, polices and protocols relevant to the delivery of care within
the ICNT. This will include participating in relevant steering groups.
To inform the line manager of any changes in service need and assist where possible to address the
changing need.
.
To motivate and lead the ICNT in developing a professionally accountable and responsible approach to
work, by acting as an exemplar role model