Detailed job description and main responsibilities

Job Purpose

The post holder will work as part of the Integrated Community Diabetes Services, providing specialist diabetes advice and clinical support.  Demonstrating a sound knowledge of the issues related to the identification, assessment, treatment and management of diabetes.

They will support the delivery of structured educational to people with diabetes.  Give specialist advice to GPs and other health professionals about Diabetes, especially with reference to adjustment of medication and supporting the management of patients with complex needs.  Working closely with General Practices and other Health Care Professionals, they will support the delivery of integrated diabetes services across the primary / secondary care interface.  As well as contributing to Clinical Governance within the service by participating in audit and research as part of the team, they will be expected to champion priorities within national diabetes strategies and NICE guidance/standards for diabetes. 

Main Duties and Responsibilities 

1. Receive direct patient’s referrals according to referral criteria set out in the service contract and participate in joint clinics as necessary.
2. To contribute to preventing avoidable hospital admissions, by providing a holistic assessment of the individual needs of patients. Plan, implement and evaluate care delivered and support self-management.
3. To organise and when necessary, coordinate the overall care to meet clients’ care needs, which may be complex involving other professionals and agencies in an integrated and co-ordinated way.
4. Engaging the wider multi-disciplinary team as needed.
5. Understanding of approaches to motivating behavioural change for patients and their carers and champion and support diabetes self-management.
6. To champion and support diabetes self-management wherever appropriate in conjunction with senior nurses in team, work as an autonomous specialist practitioner.
7. Understand the implications of cultural differences for service delivery.
8. Plan and prioritise own caseload.
9. Provide specialist, expert clinical knowledge and advice to other health care professionals involved in diabetes care.
10. Collect, evaluate, report, and maintain accurate patient records on the Diabetes Computer Software System – SystmOne
11. To work in partnership with other agencies to deliver strategic national and local health priorities
12. To escalate Risk appropriately
13. To ensure that patients are treated with care and compassion at all times.
14. To support the delivery of group education including DESMOND and other bespoke programmes including specific programmes for the South Asian community.
15. Identify learning needs and be involved in planning, delivery, and evaluation of educational programmes for other Health Care Professionals. E.g. GPs, Practice Nurses, Community Nurses, student nurses
16. To be involved in updating and assessing diabetes competencies for self and junior team members.

Leadership

To support the teams delivery and evaluation of services; identify areas for improvement and contribute to plan the future development.

Ensure safe use of equipment by self and other health care professionals. Be involved in maintain stock and ordering of supplies and equipment.

Liaise with community nurses, GP’s and hospital staff to ensure a comprehensive diabetes service is provided across primary/secondary care.

Actively participate with the Lead and other Diabetes Nurse Specialists in formulating, implementing and evaluation of policies and procedures relating to diabetes care.

Developing relationships with external organisations and across boundaries.

Ensure own competencies, mandatory and role specific training are up-to-date.

Provide a positive public relations image by dealing with queries direct from members of the public.

Communication

To promote and facilitate excellent working relationships and communication within the Integrated Community Diabetes Services and multi-disciplinary teams, and between the hospital and community settings.

To communicate highly sensitive, condition related, information to patients and their relatives. To demonstrate good interpersonal and communication skills and the ability to explore health beliefs, attitudes, and behaviours.

To understand data protection and patient confidentiality and the policies and procedures surrounding them and to accurately record personally generated clinical observations, and update patient/client records.

To create opportunities to promote and share good practice, locally and nationally, by undertaking presentations and publications.

To anticipate barriers to communication and use interpreters or tools as required. 

To produce accurate and complete records of communication consistent with legislation, policy and procedure.

To attend, lead and participate in relevant meetings and events including relevant research projects and conferences as required 

Build and develop relationships between all health professionals involved in the patient pathway.

Key working relationships  

 Senior nurse 
All team members 
Patients, carers, and families 
Other community specialist services 
 Community Health Care Professionals 
General Practitioners and practice staff 
Luton & Dunstable hospital diabetes team      
CCS  personnel 
Local Clinical Commissioning Group 
External Organisations 
Care / Nursing Homes 
Hospital

Research & Development Activity 

Contribute to research, surveillance, and clinical audit in order to improve effectiveness of patient care.

To promote the use of research in practice.  

To contribute to appropriate audit of services and service role from user and provider perspectives and respond to research findings

Clinical and Practice Governance

Observe and maintain strict confidentiality with regards to any patient/family/staff/records and information in line with the requirements of the Data Protection Act.

Any data that is taken/shared as part of a phone call or transported, faxed, or transferred electronically must be undertaken with regard to the Trust Information Governance and Information Security policies.   
The post holder must adhere to the Trust risk assessment and risk management processes

The post holder must adhere to infection control policies and procedures
It is a condition of your employment that you are currently registered with your professional body, and it is your responsibility to maintain your professional registration.

Undertake mandatory training and any other training relevant to the role as required by Cambridgeshire Community Services NHS Trust. 

The post holder must participate in clinical and safeguarding audits as required

Provide patients and their families /carers with information on standards they should expect from the team

Participate in Clinical & Safeguarding supervision on a regular basis 

The post holder is required to participate in relevant emergency preparedness process for their team.

Continuing Professional Development

The post holder will be expected to undertake ongoing personal, professional and management development in line with the responsibilities of the post.

Improving Working Lives

The post holder is expected to demonstrate a commitment to the Improving Working Lives initiative.