To work under the direction of the Team leader and to be responsible for the assessment and management of the health needs of an identified population and for the development, implementation and evaluation of programmes of care within a range of target groups including patients with long term conditions and complex nursing needs. To support, and wherever possible maintain patients in their own preferred place of care, enabling them to maximise their independence and optimise their quality of life. To be expected to deputise in the absence of the Case Managers. To liaise with all healthcare professionals and other agencies to ensure appropriate and effective service delivery.
To work within the agreed framework for Community Nursing Services. To assess, provide and review holistic nursing care, advice and information to patients and carers within the clinic setting in a safe and professional manner using evidence based knowledge. To undertake initial assessments on receipt of specific referrals to the caseload, acknowledging the needs of clients and their carers. To assess, plan and implement and evaluate a plan of care to meet the patients physical, social, emotional and environmental needs, encompassing a rehabilitative/ self-care approach where necessary and as per district nursing contract.
To provide skilled nursing care and ability to undertake clinical tasks including wound care, leg ulcer assessment and management. To be able to recognize, interpret and analyse clinical data related to the individual clients needs including client observations. To demonstrate, teach and supervise the nursing care that can be safely delegated to the patient/carer giving support as necessary. To promote clinical excellence and evidence based approach to care by complying with the agreed Trust policies and procedures and maintaining clinical competencies in line with competency framework.
Take an active role in health education of the individual and community promoting selfcare and providing both planned and opportunistic care based upon evidenced based information. Accurately record all patient contacts on Emis web and Trust documentation as per MCHFT policy ensuring patient and professional confidentiality is maintained at all times in accordance with NMC guidelines Manage and assess patients discharge potential and need from the caseload. Ensure that equipment and aids, necessary for effective care, meet the needs of individual patients and are adequately maintained. Demonstrate and explain safe use of equipment for patient and/or carer where required.
Participate in the delivery of care involving complex needs and supporting carers and relatives in distressing circumstances. Refer people to other practitioners when needs and risks are beyond ones own scope of practice or require longer term support Prioritise and manage own caseload & client group Assume the responsibility for the clinical case load in the absence of the Team Leader/Senior Lead delegating work appropriately within the competency framework To participate in the measurement and monitoring of quality standards as appropriate. If a qualified nurse prescriber to participate fully in the Non-medical Prescribing initiative ensuring assessment of prescribing need is evidence based and cost effective and adheres to MCHFT wound care prescribing formulary. To maintain accurate personal and professional records adhering to MCHFT and Nursing and Midwifery Council policy and guidelines.
To ensure the most efficient and cost effective utilisation of all resources (human, physical and financial). To report accidents/incidents of patients or self which occur whilst on duty and to complete on the Incident reporting system immediately. To participate in any investigations as necessary. To contribute to and co-operate in the co-ordination of off duty and holiday leave with colleagues, ensuring service cover is maintained.
To work effectively to support other team members in all aspects of the service. To maintain all aspects of MCHFT Integrated Governance Strategy and requirements including active participation in appraisal and clinical supervision in accordance with Trust policy. Act at all times in a manner which illustrates respect for privacy dignity andconfidentialit

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