The post holder will undertake the role of Registered Nurse to work as a core member of the Proactive Care Service MACCT alongside Community Matron within a multi-disciplinary borough-wide core team including; Social Workers, Physiotherapists, Mental Health Practitioners, Pharmacists, Navigators, and Administrators) providing holistic joint assessments, planning, and care co-ordination service to complex Adult (18 ) patients in Haringey who have been identified as at high risk of unplanned hospital admission/high-intensity users of services (GP / A&E) and at risk of their health deteriorating and care needs increasing. They will contribute to the delivery of the case management and coordination of care for identified moderate and high-risk patients; actively supporting them to work towards self-management of their condition. Act as a link for the MACC Team with GPs, other community-based nurses, LAS, Social Services, and other relevant professional areas and organisations as the post holder will work as part of the multidisciplinary team, working within and across professional and organisational boundaries. Liaising with GPs, other professionals, and statutory and voluntary agencies will complete holistic assessments and deliver individualised care to patients. To ensure the provision of a high standard of nursing care to patients and their families in the community To ensure that practice is always delivered in line with the NMC code Use the standardized initial assessment tool used by all MACCT professionals to gain a holistic overview of health and social care needs. Will contribute to the development of Proactive Care Service services for patients within Haringey, develop patient pathways and new ways of working across primary and secondary care (with a particular focus on anticipatory care/frailty and building working relationships with localities and intermediate care services). You will receive a thorough induction, regular operational and clinical supervision From MACCT Community Matron & Joint operational support from colleagues & Proactive Care Service Team Managers. Benefits include career development, flexible working, and well-being. To be the named nurse for clients of the proactive care service and coordinate care outside of the traditional nursing role when required. Ensure that all discharges from the caseload are discussed and agreed with the patient and Line Manager. To be involved in care/case management under the supervision of the Community Matrons, GP, and MACCT Managers, including clients with continuing care needs Whittington Health serves a richly diverse population and works hard to ensure that all our services are fair and equally accessible to everyone. Nowhere is this more obvious than in the way we look after our staff. We aim to employ a workforce which is as representative as possible of this population, so we are open to the value of differences in age, disability, gender, marital status, pregnancy and maternity, race, sexual orientation, and religion or belief. The Trust believes that as a public sector organisation we have an obligation to have recruitment, training, promotion and other formal employment policies and procedures that are sensitive to these differences. We think that by doing so, we are better able to treat our patients as well as being a better place to work. ACS Recruitment on Vimeo Nursing Recruitment on Vimeo Managing Resources To teach and supervise the clinical practice of team members and to appraise and to identify the training needs of all directly managed staff. In conjunction with the MACCT Team Managers and Community matron, to meet the training needs of staff. In conjunction with Community Matrons identify the health needs of the caseload to ensure the nursing team resources are deployed in a way that reflects those needs. To promote good communication, employment practices, and industrial relations within the nursing team. To chair and contribute to team (and other) meetings where appropriate. To ensure the successful implementation of appropriate organisational arrangements within the team, so that the overall aims and objectives of the service are achieved. To manage resources to ensure they relate to the overall objectives and responsibilities of the team. To comply with financial standing instructions. To be able to use the computer to: write written reports in Word, access/send emails on the Whittington Health system, and access the intranet/internet for relevant information according to Whittington Health policy. To be prepared to undertake training in using Protocol, the Whittington Health/SS joint single assessment process computer-held document. Record Keeping To ensure accurate, contemporaneous records are kept that ensure safety and continuity of patient care (including electronic records where appropriate). To ensure accurate statistical data is promptly submitted in line with Whittington Health Policies. Quality To participate in policy and standard setting, quality initiatives and clinical audit. To be fully aware of the clinical governance agenda. To ensure that the care given meets the standards and policies set by Whittington Health. To inform line management of constraints that will prevent these standards from being met. To respond promptly to any incident where service quality has fallen below an acceptable standard and report to the MACCT Team Manager. To attend regular clinical supervision and promote and support team attendance as per Whittington Health policy, as well as acting as a clinical supervisor. To appraise junior members of the team using the Knowledge and Skills Framework Whittington Health is an integrated care organisation and there may be occasions where staff is required to rotate between clinical environments to meet service needs. This could be on a long or short-term basis. Professional development and responsibilities Where the post holder has expertise, act as advisor/resource person to other staff. To participate in training as appropriate of student nurses, NVQ candidates, GP trainees, and other trainees. To participate in resource projects and health promotion programmes as requested. To undertake duties as delegated by the Research To participate in agreed research projects and/or innovations subject to discussion with the MACCT and following agreed policy and protocol. To contribute to the development of the nursing team and the community health services by participating in working parties, committees, and planning and discussion groups.