To undertake holistic needs assessment that explores individual patients and their carers/families physical, emotional spiritual, practical, welfare right and if appropriate the families pre and post bereavement need, using a variety of tools to support the process. To be able to develop, update and monitor the individualised care plans ensuring they are patient centred and support the identified patient needs, including ongoing referrals to other services as required. To be able to deliver both generalist basic and complex specialist nursing care interventions that are responsive to the individual patients requirements. To be able to communicate highly sensitive information, ensuring patients and their families/carers are adequately supported. To be able to demonstrate through electronic and paper documentation and verbal communication the care undertaken and the patient outcomes. To be responsible in leading on initial holistic assessment and reviews of care when required and discharge planning from service. To be able to communicate effectively to own team, extended team and outside agencies, ensuring continuity of care is maintained across the different care settings/home. To follow all agreed clinical procedures and statutory regulations related to Medicine Management. At identified shifts be responsible for dealing with any service enquiries, calls and referrals as required. To signpost and inform patients and their families/carers of the range of services available to them, external resources and day to day information relating to the service. Attend relevant MDT meetings as appropriate.