Assess patient and carers needs through strength based assessment, Develop individual care plans in partnership with patients and carers. This will include information, advice, sign-posting and education. Regularly evaluate care plans to ensure they are up to date and appropriate, reporting clinical changes or areas of concern to the appropriate member of the team. Provide skilled nursing care interventions, support and advice to colleagues, patients and carers. Work to reduce unwarranted variation in clinical practice, providing evidence based interventions which effectively enable people. Discuss issues relating to care and support of individual patients with other disciplines and agencies, and refer to those who can better meet their needs. Collaborate with colleagues in the Integrated Community Teams and other aligned services to enable people within their communities, maximising their potential and promoting their independence. Administer and monitor medications consistent with policies and procedures. Contribute to the prioritisation of workload, taking responsibility for a delegated caseload of patients. Assist in providing consistently high standards of evidence based care that meets the patients requirements and satisfaction. Maintain accurate patient documentation on the electronic clinical recording system. Respond appropriately to feedback from patients and carers about the service, using the open approach of the organisation and within Duty of Candour expectations. When suitably experienced, to act as a Named Nurse, providing care oversight for a defined cohort of patients managed in the ICT Community Nursing caseloads. When suitably experienced, to act as a clinical triage nurse within the centralised Community Nursing referral centres, providing clinical review of patients and engaging with health and care professionals to enable effective patient flow and referral management. Please refer to the attached job description and person specification for main roles and responsibilities of the job