Main Tasks Foster and implement a multi-disciplinary team approach in all aspects of clinical and non-clinical performance To act as an autonomous practitioner and be responsible for leading and managing the team on a day-to-day basis Work within the NMC code of conduct Manage a caseload of patients with varying long-term conditions, providing patients and families with information on secondary prevention, education, advice and encouragement. Maintain and record accurate documentation for all patients. Work in partnership with complex care teams, primary care and relevant 3rd sector organisations to develop care plans and pathways Demonstrate the ability to keep up to date with developments in nursing practice, maintaining professional knowledge and attending essential in-service training programmes. Ensure that all nursing practice is based on current evidence, best practice, and where available, validated research. To manage a clinical caseload, dealing with patients needs in a Nursing and Care Home setting Provide advanced nursing care and case management to patients with multiple complex longterm conditions Develop mechanisms for supporting staff in the development of their scope of practice. Encourage a learning environment, which facilitates appropriate education and training. Support staff through clinical supervision, reflecting on own role as an accountable practitioner. Escalate concerns through appropriate channels. Clinical Duties will include Provide high quality, comprehensive, holistic and timely assessments and treatments for patients and their families referred to the service using an assessment process to achieve patient focused care at all stages of their care including palliative stage. To include the prescribing and administration of appropriate medication within local and national guidelines. Negotiate goals for lifestyle modification. Be proactive in health promotion, provide patients and carers with information and advice about their condition ensuring the best level of understanding and always promote self-care and management. Utilise counselling skills to support patients, carers, and staff, whilst remaining aware of limitations and other specialist resources available. Maintain clear, concise, and up-to-date clinical records, in line with NMC Record keeping guidance Maintain and develop relevant expertise and knowledge related to the intricacies of caring for patients with complex health needs Advise patients and healthcare professionals on adjustment of medication Ensure open channels of communication with both internal and external agencies, to achieve a coordinated service to patients and their families. Demonstrate a high level of interpersonal skills, self-awareness, and empathy in all communications. To provide education, training and support to the nursing and care home team and ensure the highest standards of care are provided for patients. Assist the qualified staff in the delivery of planned packages of care working to evidence based care plans Proactively manage the delivery of unscheduled, unpredictable episodes of care with appropriate use of initiative in particular regarding crisis management and end of life care Undertake delegated care without direct supervision where appropriate. This may require the use of observational/ analytical skills to monitor the health and wellbeing of clients. Observe a personal duty of care when using equipment ensuring own safety and that of others. To lead clinically and professionally, making autonomous decisions daily. Professional Duties Act as a role model for quality nursing care always, promoting the need for effective evidencebased interventions and compassionate care. Act as patient advocate at all points of the care pathway. Work within the NMC Code of Conduct always. Adhere to national, local, and professional standards, guidance and directives relevant to their sphere of practice. Work collaboratively with the commissioners and other providers to ensure a consistent approach to service development. Promote the service through communications and media internally Frequent contact with staff at all levels including senior clinicians through the delivery of training Verbal and written communication on data and reports Formal presentations to teams and groups Develop and foster effective support networks locally, regionally, and nationally and attend appropriate meetings relevant to role. To maintain links with all relevant agencies. Undertake on-going service review which will shape the service in response to user involvement, professional opinion and audit / survey data along with local and national guidelines/evidence. Submit data as required per contract and commissioning arrangements and on request ,in a timely manner. Ensure electronic record is updated in real time and that data is validated and assured Adhere to CHFT policies and protocols. Audit work to aid service performance and development Establish and maintain effective communication pathways including the use of IT systems with relevant health and social agencies and professionals. Communicate relevant and factual information to patients and carers using sensitivity and tact. Report any changes to a patients condition to the appropriate member of the team at the earliest opportunity Ensures effective communication is maintained for those patients with communication difficulties. Managerial Duties To act as Deputy Team Leader for the Quest team, undertaking staff supervision and performance reviews. To be responsible for managing all aspects of leave within the team. To manage sickness, disciplinary and performance issues in line with the Trust policy To investigate clinical incidents and complaints related to the service as required To establish clear referral patterns, communicating and co-operating with the acute Trust, GPs, district nurses and any other relevant health care professionals. To maintain an accurate and effective record system To lead the team in achieving the service objectives. To actively participate in the professional development programme of the Quest team. To assist the Team in the monitoring of professional, clinical and departmental standards and assist implementation of change as appropriate. To comply with the national, professional, Trust and service policies and procedures and to be involved in the reviewing and updating process as appropriate. To participate in the staff recruitment process Maintain confidentiality of all patient identifiable information in line with relevant Trust policies. Initiate discussions with the Matron about any circumstances that could prevent the post holder or other staff fulfilling the requirements of the job description. To act as a mentor and role model for other staff To assist on service development and audit in the team. Within the framework of clinical governance, work continuously to improve quality and safeguard standards of care, maintaining a patient focused service, promoting and implementing evidence-based practice with measurable standards of care and outcomes. Be involved in audit projects to measure standards of care. To identify and highlight any gaps in the evidence/service provision for patients in nursing and care homes. Maintain a flexible approach and develop the role according to needs. Develop relevant educational resources for patients, carers and staff Financial Duties To monitor the delegated budget. To provide expert clinical advice into the tender process to support contract negotiations with external companies to ensure excellent value for money and service delivery. To monitor and control the use of resources through effective systems of stock control. Managing Self Participate in regular supervision. Attend all mandatory training. Participate annually identifying, developing and agreeing your own development plan with your line manager using the Trust Appraisal. Comply with all Trust policies, procedures and protocols. Carry out duties with due regard to the Trusts Equal Opportunity Policy. Seek advice and support from Line Manager whenever necessary. Maintain professional conduct always including appearance. Ensure maintenance of Professional Registration.