Job summary To work within the integrated 'Acute care at Home' integrating rapid response with our Virtual Ward service supporting the provision of enhanced care in the community, reducing avoidable attendance and admission to secondary care, and supporting early discharge.
This will be achieved by utilising expert clinical assessment and diagnostic skills in the management of patients who require an urgent assessment.
To be a key member of multi-disciplinary team and identify optimal pathways for patients, utilising community capacity, skills, and experience, to ensure care is provided at the right time and in the right setting.
This service will be transitioning to HCRG Care Group from the 1st April 2025.
The successful candidate may transfer over (under Transfer of Undertakings (Protection of Employment) Regulations 2006) on the terms and conditions they are employed on.
Great Western Hospitals NHS Foundation Trust is committed to ensuring a smooth transition for everyone involved.
Main duties of the job 1.
The post holder will be able to combine high level assessment to establish differential diagnosis and clinical decisions to initiate medical and/or nursing/therapy treatments, appropriately refer and lead the co-ordination of care from an integrated team perspective, working with partner agencies and key stake holders.
2.
To be a key driver for change to assist integrated care pathways/systems across GWH services and system partners.
3.
To provide clinical and professional leadership within the acute care @home service supporting the wider community including Primary Care, Social Care, and all other provider organisations to deliver high standards of care to patients.
Where appropriate this will be the avoidance of unnecessary admission to secondary care.
To be an integral member of the multidisciplinary team working with a shared vision in partnership with each other.
4.
Draw on clinical knowledge to be a resource for the wider multidisciplinary team (MDT) and give clinical advice.
5.
To work in alignment with Primary care around established practice populations and to facilitate the establishment of a shared vision between Primary care and the Community teams.
About us Our STAR values are at the heart of everything we do.
You can expect to see them in the way we act andthe way we treat each other.
Our values make us who we are.
We will expect your values and behaviours toreflect the STAR Values of the organisation:Service We will put our patients first.Teamwork We will work together.Ambition We will aspire to provide the best service.Respect We will act with integrity Job description Job responsibilities 1.
Working with partners in Primary and Social care further develop a virtual ward model/Urgent communityresponse which identifies, and case manages those patients needing complex chronic diseasemanagement or palliative care supporting the needs of the local Maintain accountability for practice following the Nursing and Midwifery Council Code of ProfessionalConduct/Health and Care professions Council Standards of conduct Performance and ethics and compliancewith Great Western Hospitals NHS Foundation Trust Policies and Maintain legible, accurate and up to date records that are dated and signed in accordance with Trust Policiesand the Nursing and Midwifery Council / Health and Care Professions Council standards onrecord Work autonomously with patients, their families and carers managing referrals according to need Negotiate and agree with the patient, carers and other care professionals, individual roles, and responsibilitieswith actions to be taken and outcomes to be achieved, referring on to other services orprofessionals as Establish local networks in partnership with other health and social professionals/agencies and national linkswith other generalists to develop protocols according to national and local guidelines for the safeand effective provision of a community nursing To work with partners in nursing and residential care to ensure optimum health outcomes for Critically analyse complex clinical data and information to inform diagnosis and, where appropriate, order investigationsand/or instigate therapeutic treatments to inform clinical decision making and improvehealth outcomes.
Person Specification Qualifications Essential Registered nurse Non -Medical Prescribing qualification (V300) or equivalent validated and accredited by NMC Qualified to master's level or working towards the following Modules: Physical assessment and Clinical reasoning (PACR or equivalent) Evidence of relevant up to date CPD Desirable Post graduate community qualification community specialist practitioner Further qualifications relevant to community nursing.
Awareness of recent Government initiatives that may affect future clinical practice To be knowledgeable of the clinical governance agenda and have an awareness of commissioning Experience Essential Experience at senior level working in relevant field.
Confident to undertake home visiting to assess and treat patients Demonstrate clinical examination and assessment skills history taking, physical assessment.
Desirable Profiling community needs and targeting identified health needs of population Evidence of innovative and flexible approach to care and the organisation of care Teaching experience Knowledge Essential To be able to communicate with people from a wide range of backgrounds.
To be able to work flexibly and sensitively.
Wide range of interpersonal and communication skills Undertake specific nursing tasks requiring precision and/or intense concentration.
Undertaking complex nursing skills Ability to sensitively inform service users on highly complex and distressing issues.
Able to support and facilitate staff in dealing with these situations Ability to build effective working relationships with clinicians and Managers at all levels Desirable Further training in dealing with difficult situations Specific speciality area Teaching experience Report writing