Detailed job description and main responsibilities

1. To work with patients under the care of the service, for provision of a specialist nursing assessment or a generic core Initial assessment and screening tools making excellent use of MDT working.
   2. To undertake specialist nursing and assessment and treatment and also the development of rehabilitation/care programmes for adults, many of whom have complex medical and social needs with the aim of improving independence, function and quality of life.
   3. To promote avoidance of hospital admission through early recognition and effective management of the deteriorating patient, close agency working and being involved in Rapid Response initiatives and local practices where necessary.
   4. To support the role of the Clinical Lead, deputising in their absence as appropriate.
   5. To deliver regular education and training to staff within the service on core clinical skills relevant to the patient group including, infection control, medication management and wound care.
   Communication and Working Relationship Skills
   Communicates complex and sensitive information with patients regarding their management, treatment goals, likely outcomes, and ongoing care plans, taking into consideration communication differences and difficulties which may include but not be limited to, sensory loss, communication and cognitive impairments, and mood disturbances, ensuring this is done in a way that respects their views, autonomy and culture.
   Liaises and communicates effectively with carers and relatives, verbally or in writing, regarding their diagnosis, management and rehabilitation.
   Acts as a role model and provides support to junior staff and other members of the MDT when communicating sensitive and sometimes distressing information to patients, relatives and carers.
   Takes a collaborative role in ensuring effective communication with the multidisciplinary team, as well as colleagues across wider community health and social care services, to ensure a unified approach to treatment options and the delivery of optimum patient care.
   Pro-actively establishes links and networks with other nurses within the Trust, regionally and nationally in order to share best practice.
   Is proactive in coordinating high quality and timely written and verbal onward referrals to appropriate community services.
   To maintain accurate and confidential patient health care records and to submit statistical returns for the purpose of auditing and monitoring Analytical and Judgemental Skills
   Exercises independent clinical judgement by analysing and interpreting clinical signs and considers the range of options available.
    Able to assimilate large volumes of complex clinical information in order to inform clinical decision making at pace
   Works with staff in ensuring that patient’s progress is monitored and evaluated effectively and treatment programs are adapted in line with evidence base as required.
   To lead in undertaking risk assessments relating to nursing interventions and especially in relation to patient safety in their own environment – for example, medications management.
   Acts as deputy lead in the absence of the clinical lead, practising at a specialist level, demonstrating the ability to make judgements and decisions regarding patient care pathways, drawing on specialist theoretical, research and practical knowledge.
   Planning and Organisational Skills
   Organises own time, to manage and prioritise own caseload and manage clinical risk of own interventions.
   Role models flexibility and the need to be able to offer support to other clinical areas as required in line with escalation policy and major incident policy.
    Identifies to the Team Lead and Band 7 ESD Nurse any areas of concern in service delivery and works with them using a QI approach to plan and deliver service improvements.
    Organises and delivers an on-going programme of education and training to the staff within the service including induction training, competency assessment and nursing skills training to ensure patients are cared for safely and effectively.
   In the absence of the Clinical Lead coordinates the staffing workforce to deliver a timely and effective service including providing cover for sickness absence.
   Responsibility for Patient/Client Care, Treatment and Therapy
   To assess, plan, implement and evaluate the care of patients, to meet their specific needs, using specialist clinical acumen
    To provide highly complex information to patients and their families/carers, to empower them to manage their condition effectively and to make long-term health care choices
    To manage patient treatments using protocols regarding medication regimes, as clinically indicated.
    Provides expertise as a specialist clinician with advisory and clinical input into quality and harm-free patient care for patients, carers and MDT staff and other healthcare professionals
   In line with current evidence and using specialist clinical reasoning skills and physical assessment techniques, is responsible for the assessment and treatment of patients with frailty, providing particular expertise in:
   o Frailty syndrome
   o Falls, and multifactorial risks for falls
   o Medications management
   o Nutrition
   o Pressure area care
   o Continence assessment and management
   o Manual handling
   o Mood and anxiety
   o Psychological wellbeing
   o Carer support
    Ensures effective communication regarding assessment findings throughout the treatment process, to assist in the overall management of the patient.
   Utilises highly skilled nursing skills to optimise patient independence and progress whilst ensuring the safety of patient, staff, relatives, and carers throughout the rehabilitation process and as the patient progresses.
   Supports the team to effectively manage nursing needs within the community setting.
   May provide support to the acute hospital MDT in order for the in-patient team to perform appropriate assessments, identify risk and develop mitigation/management plans, in order to facilitate safe and timely discharge from hospital.              
2. Supports junior and un-registered team members in the evaluation of individual treatment programs and analysing patient responses to treatment, adapting individual treatment goals, program, and/or specific activities throughout the intervention to accommodate variations in patient performance.
   Provides specialised teaching and/or instruction to relatives, carers and other professionals to promote an understanding of the aims of the treatment plan and to ensure a consistent approach to patient care.
   Proactively supports the management of patient flow throughout the Trust.