Job summary
East Coast Community Healthcare CIC (ECCH) is commissioned to provide Community healthcare services to our local communitiy, this role is central in ensuring optimum patient outcomes and developing effective relationships with staff from other organisations and local health care providers.
Does this sound like something you would like to be a part of? Do you have a Can do attitude? Are you ready to shape and make real our aspirations for innovative, integrated healthcare, which will improve the health and wellbeing of our communities? Then we need you.
We are seeking an Allied Health Professional or Registered Nurse (Adult) to lead and manage the reablement element of our Primary Care Home, in order to deliver high quality community health care to the population of Gorleston & Great Yarmouth. If you are a compassionate, innovative, motivated and forward thinking clinical leader, then this could be the job for you.
Previous experience of providing health care in the community, rapid response, case management and people management would be beneficial. We will support the right candidate to transfer existing knowledge and skills as a registered AHP/Nurse working in a different care environment. We will work in partnership with you to create a personal development plan to become a PCH Integrated Care Lead.
Main duties of the job
The role requires a high level of autonomy as the Integrated Care Lead for the PCH you will be coordinating complex packages of healthcare, overseeing the delivery of reablement care by the multidisciplinary team, supporting the PCH response for Admission Avoidance, providing line management to a number of clinical employees. You will be working in close collaboration with the Lead Nurse, Lead Therapist, Community Matrons and Locality Lead to provide clinical leadership within the PCH. Confidence is needed to provide the team with support and guidance regarding patient care, staff development and delegation. Close links are developing with the acute and community hospitals to ensure care is provided in the best place for the patient and as an Integrated Care Lead you will be at the forefront of integration and development of these changes. This will include oversight of the assessment of patients suitable for discharge from the acute hospital.
The PCH is commissioned to provide a 24/7 service. The core shift is currently 08:30 to 16:30 hours. Applicants may be required to participate in working other shifts as part of the role including weekend and bank holiday working on a rotational basis.
About us
ECCH is a well established health care provider and has been successfully delivering NHS care within the community since 2011. We provide a range of NHS, community health and social care services predominantly across the easterly region of the Norfolk/Suffolk borders.
We are aligned to NHS terms and conditions, and offer many employee benefits, to find out more about us visit our website - We are a social enterprise and staff owned organisation which means staff can opt to be shareholders and have a real say in how ECCH is run and evolves to deliver healthcare for the future.
At the heart of our ambition, we work in partnership with and for the community to become the provider and employer of choice for community healthcare.
We encourage you to apply as early as possible as this job may close earlier than the advertised closing date once enough applications have been received.
The Primary Care Home (PCH) is a multidisciplinary team working closely with GP's and other community partners to provide an excellent standard of person centered care to adults in their own homes, or residential care settings, supporting patients to self manage whenever possible. The service uses SystmOne as a clinical IT system to support mobile working.
Job description
Job responsibilities
We Listen, We Learn, We Lead
1. Contribute to, support and promote ECCHs strategicdirection, values and culture in relation to Reactive services.
2. Discuss all treatment options with sensitivity, knowledgeand expertise and to act as a patient advocate when appropriate, respectingpatient confidentiality with privacy and respect for diverse culturalbackgrounds and requirements.
3. Understand and support the achievement of ECCH businessplan objectives and performance targets for team and self, and initiate andparticipate in screening and needs assessment as required.
4. Identify the potential for service developments, risk anddeficits and inform line manager making recommendations based on specialistknowledge and experience.
5. Provide leadership and ensure effective management ofintegrated teams, including rehabilitation support workers and paramedic teamsthrough identified and those providing a Reactive response.
6. Plan and organise a range of complex integratedmultidisciplinary coordination in a wide range of settings to ensure bestpractice is delivered across the designated area of responsibility and thewider community.
7. Provide clinical leadership within the integrated carecoordination team including Primary, Social Care, and all other providerorganisations to ensure high standards of care to patients the avoidance ofunnecessary admission to secondary care.
8. Through effective leadership, planning and coordination;be a key enabler for establishing integrated care teams both practically andbehaviourally.
9. Work with the Primary Care Home leadership team (LocalityLeads) to design, implement and review pathways and guidelines to supporthealth care professionals in establishing patients to access evidence-basedtherapies.
10. Develop systems to monitor, evaluate and audit servicequality in order to meet nationally and locally set targets and report toLocality governance groups.
11. Effectively communicate at all levels of the organisationand wider stakeholder, including a variety of health professionals, users andcarers, to provide the best health outcomes.
12. Maintain high levels of performance for service area andensure that goals and objectives are monitored effectively to ensure qualityoutcomes are developed and maintained.
13. Provide leadership and manage stakeholder relationshipseffectively within service area and ensure teams and individuals are supportedwhen faced with opposition or when working under conditions or pressure.
14. Identify potential service developments, risks anddeficits and discuss with line manager, making recommendations based on expertknowledge to enhance the capacity and quality of community care.
15. Monitor and maintain standards/provide benchmarking datawithin service area to allow comparison with other healthcare providers.
16. Participate in teaching and clinical supervision withprimary care home team and other provider staff as required.
17. Critically evaluate research findings, nationalguidelines and implement changes in clinical practice as appropriate.
18. Signpost patients, families, and carers to tailorededucation programmes, advice and support that may precipitate symptoms of acuteexacerbation of underlying conditions or illness and include lifestyle changesthat would be advantageous to health.
19. Be responsible for participating and maintaining alearning environment and maximise opportunities for education and developmentin the clinical area to enhance individual development and performance in thedelivery of high standards of care.
My Accountability, My Responsibility
20. Take responsibility for own personal and professional development;maintain competence, knowledge and skills commensurate with role.
21. Using a standardised approach but with a high degree of professionalautonomy and accountability, work with Health, Social Care, Voluntary and otherhealth providers and agencies, to provide patients with complex needs a singleplan of care co-produced with the patient.
22. Responsible for ensuring effective patient/case tracking within the localhealth system; provide baseline health data for receiving teams to supportintegrated, coordinated care. To include facilitation of Community Leddischarge processes.
23. As Care Coordination Lead, ensure high visibility and be accessible topatients, families and carers and be seen as being in charge of their care.
24. Use assessment tools/skills that will ensure an appropriate level ofnursing or therapeutic intervention so that patients who present with highlycomplex needs are timely referred to the appropriate specialist.
25. Be wholly accountable for practice taking every reasonable opportunity tosustain and improve knowledge and professional competence and, ensure that allaspects of professional behaviour as required within professional code arefollowed at all times.
26. Maintain legible, accurate and contemporaneous patient records inaccordance with ECCH Policy; the Nursing and Midwifery Council and Health andCare Professionals Council standards for record keeping.
27. Assist with the investigations of complaints, participate in the riskmanagement process, critical incident reporting, evaluation, dissemination andchange in practice.
28. Be responsible for understanding, following and implementing ECCH policiesand procedures, and influencing working practices to support this accordingly.
29. Contribute to the clinical governance agenda through participation inclinical risk assessment and management, clinical audit.
30. Create an environment conducive to effective working, respecting andsupporting staff to deliver high quality clinical services.
31. Ensure a high standard of record keeping is achieved in line with ECCH andprofessional standards.
32. Take responsibility to ensure compliancy with Health and Safety Policy,Fire and Environmental Waste Regulations.
Respect Our Resources: People, Time and Money
33. Take responsibility for the cost-effective management and safe use ofexpensive and highly complex equipment, provide recommendations for effectiveuse of resources and contribute to the effective delivery of cost improvementplanning.
34. Analyse, interpret, compare and contrast complex information, servicerequirements and options ensuring the effective approaches to service deliveryand team working within service area.
35. Evaluate the impact of Health Coaching programmes designed for patientsand carers, to ensure that they provide the necessary knowledge and skills togain independence, safely manage changing circumstances and plan forunavoidable progression of conditions.
Work Together, Achieve Together
36. Using generalist clinical skills to evaluate the delivery of care,identifying subtle changing health care needs. Being able to discuss treatmentoptions with other generalists and specialists.
37. Co-ordinate care across the whole patient pathway in ECCH for servicearea. This includes ensuring a robust relationship and ongoing effectiveinterface with ECCH specialist services, primary and secondary care asrequired.
38. Working with partners in Primary and Social care to support a model ofcare which identifies and case manages those patients needing complex chronicdisease management or palliative care supporting the needs of the localcommunity.
39. Negotiate and agree with the patient carers and other healthcareprofessionals, individual roles and responsibilities with actions to be takenand outcomes to be achieved, referring on to other services or professionals asappropriate.
40. Work in partnership with the patients to empower them to make informedchoices about their healthcare and support choices about end of life care.
41. With peers, and under the supervision of the Locality Lead, establishlocal networks in partnership with other health and socialprofessionals/agencies and national links with other generalists in order todevelop protocols according to national and local guidelines for the safe andeffective provision of a community nursing services.
42. In partnership with Primary Care colleagues provide seamless care pathwayfor patients who occupy the Beds with Care.
43. Work with partners in nursing and residential care to improve the healthoutcomes of the residents and so prevent unnecessary hospital admissions orextended in- patient care episodes.
44. Provide professional expertise and clinical leadership within servicearea, acting as a resource to other professionals internally and outside ECCH,concerning clinical caseloads to ensure continuous service provision, highlevels of communication and effective inter-professional working.
45. Work with ECCH Colleagues, and other partner agencies and stakeholdersincluding the acute trust to contribute to the development and delivery of newinnovative models of service delivery, ensuring a leading edge approach toservice development in-line with evidence based practice.
46. All roles within East Coast Community Healthcare CIC (ECCH) require staffto demonstrate our Values and Signature Behaviours in the care and service theyprovide to patients, service users, stakeholders and colleagues. All members ofstaff should consider these as an essential part of their job role.
47. Our Values outline the core behaviours that we can all achieve and aresummarised as an acronym within the word CARE. These stand for: Compassion, Action, Respect and Everyone.
48. Underpinning our Values are our Signature Behaviours which highlight bytaking the right actions we continue to build a strong culture. Our four Signature Behaviours are: Compassion- We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility |Respect - Respect Our Resources: People, Time and Money | Everyone - WorkTogether, Achieve Together.
Person Specification
Personal Attributes
Essential
49. Ability to embrace our Culture, Values and Signature Behaviours:
50. (Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together)
51. Willingness and ability to work across different sites and travel to alternative sites and across the community as required
52. Flexible team orientated approach to work
53. Passion and enthusiasm to deliver person centred care
54. Self-motivated and solution focused
55. Commitment to lifelong learning
Skills and Knowledge
Essential
56. Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software with proven ability to problem solve
57. Evidenced high standards of leadership and people management skills
58. Evidenced experience of negotiating and influencing skills
59. Excellent interpersonal skills, including communication with different stakeholders
60. Ability to travel throughout the locality in accordance with role requirements
61. Advanced communication skills
Qualifications
Essential
62. BSc in Nursing Practice or equivalent, or Allied Health Professional degree level qualification
63. Professional registration with Nursing and Midwifery Council (NMC) or Health Care Professions Council (HCPC)
64. Leadership/ management qualification or willing to undertake
Desirable
65. Masters level study or working towards a masters level qualification in a relevant field
66. Health Coaching Programme
Experience
Essential
67. Evidenced and relevant experience of working in a community clinical role at a management/supervisory level.
68. Evidence of partnership working with other care agencies
69. Social care Services/voluntary sector/primary care
70. Evidence of managing team(s) and individuals to a high standard of performance. Including absence, appraisal, performance and conduct (disciplinary) processes
Desirable
71. Experience of team leadership
72. Experience of Coordinating multidisciplinary integrated care for patients
73. Experience of complaint investigation
74. Project management experience.
75. Experience of facilitating clinical supervision
76. Experience of audit