Senior Staff Nurse

at  The Christie NHS FT

DUTIES AND RESPONSIBILITIES Clinical Prioritise patients referred to the service who are in their last days of life. To provide a robust, timely and comprehensive assessment of patients care needs in preparation for their discharge/transfer of care. This should be a holistic assessment including their carers needs/commitments and the active part they can play in supporting the patient once home. To be responsible for a delegated patient caseload and provide proactive case management to ensure a quality patient experience on discharge from the Trust.
To develop an individual discharge care plan for patients in collaboration with health, social services, community services, the patient, carer and family in order to facilitate a safe/co-ordinated transfer of their care management to the community services. To re-evaluate patients and carers needs throughout the discharge process and adjust plans accordingly To act as an advocate and support for patients/carers/relatives to improve their experience of discharge or transfer from the Trust into the community or alternative healthcare setting. To empower patients and their representatives to engage fully in the above processes To organise capacity assessments, best interest meetings and case conferences in relation to patients included in my case load. Include the patient, family members, carers, and hospital and community personnel as appropriate.
To directly order or facilitate the ordering of any community equipment that may be required to ensure a safe transfer of care takes place. With patients consent, forward written information to community personnel in line with Trust guidelines and the Data Protection Act Liaise closely with Trust and community colleagues when arranging patients safe discharge or transfer. This may include Consultants, General Practitioners, Social Workers, Specialist Nurses, District Nurses, CCGs, Commissioners and staff at other healthcare settings. To increase awareness within the Trust multi-disciplinary team of the role of colleagues in the community services and inform them of any relevant community care legislation affecting the care planning of the patient on discharge Maintain accurate and comprehensive documentation and patient records, either written or IT based, in line with both Trust policy and NMC guidelines To provide specialist support and advice pertaining to discharge planning at the daily ward board rounds, ward multi-disciplinary meetings and Trust staff members.
Participate in the protection of vulnerable adults, reporting any serious untoward incidents to the Trust Safeguarding Lead and participate in any meetings/actions relating to my case managed patients. Communication To use advanced communication skills to provide emotional and psychological support when working with patients and carers in sensitive situations, when breaking bad news, discussing end of life issues or dealing with difficult/challenging situations. Ensure good communication with patients, their carers, nursing and medical colleagues, other healthcare and social care professionals and community services To supply written information to patient, their family, relatives, and carers in regard to the community services that will be involved in their ongoing care following their discharge. Maintain own advanced communication skills through attending formalised teaching sessions or courses To report and record incidents/accidents that occur during the discharge/transfer process in accordance with Trust procedure Additional Services Community Oxygen Provision The team advises Trust registered staff regarding the Department of Health process to follow when ordering home oxygen for patients.
Liaise with the Oxygen Provision and Installation service, the patients General Practitioner and Regional Respiratory Teams as agreed with the Trust and Northwest Regional Oxygen Lead and complete any necessary documentation. Provide advice and training of Trust staff on request and via the Trust website. To facilitate the use and recall of hospital equipment loaned out to facilitate a timely discharge. National Standard Framework for NHS Funded Nursing Care and NHS Continuing Healthcare (CHC) To carry out all the Trust screening of identified inpatients in compliance with the NSF for NHS Funded Nursing Care and NHS Continuing Healthcare Lead on the application for Fast Track CHC funding that can be used to facilitate the rapid discharge of a patient who is entering the last days of life.
Complete a CHC checklist to identify if a patient is eligible for a full process application to be made for funding via CHC funding. Involve/inform the service user, family members, and carers of the process that is to be carried out, outline their involvement/entitlements, and gain their consent for data sharing with other professionals. If a full process application is identified act as the Trust Co-ordinator of the required case conference. Collate all the required documentation and arrange the attendance of all the relevant staff members, patient, and carers at the case conference.
A regional CHC member will chair the meeting and present the patients case at the next Commissioners meeting where a decision re-funding will be made If NHS funded Continuing Health Care is to be applied for act as the Co-ordinator for the process. Management To be responsible for organising and planning own caseload to meet service and patient priorities, including the re-adjustment of plans as situations change/arise. To provide statistical information on clinical activity required by the hospital and external bodies, including the Department of Health and NHS Continuing Healthcare teams. Represent the Discharge Team Leader, in their absence, at any designated meetings or in relation to any discharge or service enquiries, should they occur.
Participate in planning the development of the service to meet the increasing demands and complexity of cases. To provide management support for junior staff and act as a mentor to designated staff. To organise daily work schedule ensuring appropriate and effective deployment of staff for appropriate patient needs. Be aware of Health & Safety issues and ensure relevant risk assessments are undertaken.
Ensure all trust policies and procedures are adhered to and new ones implemented as necessary. Regularly liaise and report to the Discharge Team Manager on team affairs and developments. Assist in team recruitment process when required. Take a progressive approach to the management of short and long-term sickness/absence in collaboration with Discharge Team Manager.
Education and Training To act as part of a highly specialised resource team for staff within the hospital and for community teams. Lead and advise in the training and education of all staff in all aspects of Discharge Planning. To take responsibility for maintaining own essential training and professional development. Demonstrates the agreed set of values and be accountable for own behaviou

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