This is a permanent community nursing and care coordinator role.
To make assessments within Health (SAP/CPA) and Social Care (Care Management) frameworks.
To set up, implement and review appropriate care plans and to support and advise relatives and care givers.
To promote the needs of service users with mental health needs and to offer and provide training and education whenever possible.
In conjunction with the crisis pathway services, provide a safe and effective urgent community assessment and treatment response service.
Undertake comprehensive assessments, including risk assessment, effectively and efficiently.
Formulate and agree crisis safety care plans and support and advise relatives and caregivers.
Be rotational and flexible, working according to the needs of the NMHT service and the Neighbourhood.
Develop and maintain a high standard of practice based on assessment through the use of psycho education, the Recovery Model and supportive clinical management.
Liaise and establish good working relationships with referring agents, colleagues in Primary Care services, Social Services, Community Mental Health Teams, Assertive Outreach, In-Patient services, Criminal Justice, Voluntary Sector and other agencies as appropriate, and work with the multi‑disciplinary team in developing plans that offer supportive crisis care in the least restrictive way.
Act as a role model in the practice area, encouraging staff in teaching and supervision to sustain a supportive learning environment.
Be responsible for the maintenance and accurate recording of patient information in the documentation systems and to ensure the effective dissemination of service user information throughout the multidisciplinary team.
Our mission is to make a positive difference to people's lives by improving the quality of life for all we serve. Our values are: We Care, We Respect, We are Inclusive – so we are looking for people who live and breathe these qualities when supporting service users and carers, and in their relationships with colleagues in the Trust and our partner organisations.
Patient Care
- To proactively involve people in their care, and to include them in decision‑making processes.
- To take responsibility to act using sound professional judgement and effective problem solving when decisions have to be made in highly complex and challenging situations.
Clinical
- To evaluate effectiveness whilst working within the framework of Risk Assessment.
- To report all relevant information to the referring agent and keep them informed of the service users progress.
- To assess, plan, set goals with the service user, carers and families; implement and evaluate care using psycho‑social interventions and skills to meet individual needs.
- To actively support the person in crisis in self‑management of their symptoms through the formation of their care plans.
- To act as care co‑ordinator for service users.
- To respond to emergency referrals within a timely fashion and to agreed protocols and targets.
- To develop and implement appropriate Health Promotion strategies including the Recovery College appropriate to the client group.
- To refer for carers' assessments and provide information and support to carers as appropriate.
- To be responsible for accurate record keeping in line with Trust and NMC policy and procedures.
- To maintain high standards of professional practice and competence in keeping with the NMC code of conduct and scope of professional practice.
- To report to the Deputies or Operational Lead any incident or Serious Untoward Incidents that may take place and provide accurate records relating to the incidents.
- To contribute to establishing and maintaining liaison with the members of the primary/secondary health care team, voluntary agencies in the professional disciplines necessary to provide a comprehensive service to clients and their families.
- To provide service users, relatives and carers with details of the Complaints procedure and PALS.
- To support in the making of complaints and forwarding of compliments.
- To complete assessment and discharge documents in a timely fashion.
- To communicate effectively with service users, persons in crisis and their families.
Duty Coordination
- To participate in duty co‑ordination, organising the work of the whole team as required and directed by the Operational Lead or Senior Mental Health Practitioners and in accordance with team protocols.
- To respond to emergency referrals within agreed local protocols and timeframes.
- To ensure that a safe and effective home treatment team service is delivered to both the ongoing clients on the teams' caseload and any referred cases.
- To utilise the quality improvement approach to think systemically about complex problems, develop potential change ideas and test these in practice using the Trust's QI framework.
- To engage in and make time for quality improvement.
- To develop the appropriate level of skills in quality improvement.
Administration
- To plan and prioritise own workload.
- To document all care interactions on the relevant clinical system as per local arrangements.
- To administer and/or monitor medication as prescribed in keeping with policies and NMC requirements.
- To keep self up‑to‑date through training and CPD.
Human Resources
- To work within the relevant ELFT policies.
- Be aware of any conflict or distress experienced by team members.
- To assist in providing a clinical learning environment for students.
- To act as an assessor/mentor to student nurses on placement.
- To participate in the education of new workers and trainees through the provision of fieldwork experience, tutorials, seminars and case presentations, evaluations and reports.
- To participate in clinical and managerial supervision.
Performance and Quality
- To strive for excellence and the provision of the highest quality, evidence‑based care and clinical outcomes throughout the service, striving for accreditations where relevant with national standards.
- To ensure compliance with the Trust's Equality and Diversity Policy, supporting the delivery of the Trust's Race Equality Scheme and the Trust's duty to positively promote race equality, ensuring services are responsive to the needs of people with protected characteristics.
- To act as an effective role model working in a courteous, patient‑focused manner and maintaining patient confidentiality at all times.
- To actively participate in maintaining own personal and professional growth, undergo and actively participate in own and others' performance appraisals and identify own educational and training needs.
- To ensure your own mandatory and statutory training is always in date.
- To support the development and embed quality improvements within the team and actively embrace quality improvement projects in the team, creating a culture for learning and development.
Financial and Physical Resources
- To support the achievement of financial balance in the team, making the best use of your financial resources to achieve positive clinical outcomes for service users and carers.
- Arranging for the replacement or repair of equipment and furniture as required.
Therapeutic Interventions
- To have knowledge of and practice a range of therapeutic interventions available to reduce distress for individuals experiencing an acute mental health crisis.
Ability to work autonomously and within MDT setting.