The post holder actively supports the District Nursing team by undertaking responsibility for a delegated caseload. Undertakes the assessment, planning and evaluation of patients care needs. Liaises with the District Nurse to ensure information sharing in relation to patient care / changes to care plan and the continuity of care and reviewing of complex care packages. Mentoring, Teaching and Assessing. Liaises with all health care professionals and other agencies to ensure effective service delivery. Duties and Responsibilities: To promote the health and well-being within the family unit and community as a whole. Perform comprehensive assessment of patient nursing needs as the named nurse. Plan, assess and evaluate programmes of care according to changing health needs under the direction of the District Nurse. To support the team leader in the co-ordination of complex and continuing care packages. Maintain accurate records in accordance with NMC. Attend a multi-disciplinary case conference as the named nurse if appropriate. To communicate and collaborate with other members of the PHCT, voluntary and statutory organisations to support individual patient care. To establish and maintain effective communication with patients, relatives and carers in complex and potentially challenging situations. To competently perform clinical skills related to the post. To be professionally responsible for a delegated caseload under the supervision of the District Nurse. To assess health needs at individual, practice and community level. To undertake chronic disease management reviews using appropriate template. To work without direct supervision.