Palliative Care Support Team Leader

Job overview

We are offering an exciting opportunity to join the established Palliative Care Support Team, we are looking to recruit an enthusiastic and motivated nurse with a passion for palliative care to lead and manage the service. Have you undertaken recent study to support your knowledge and skills in this area? Are you experienced in undertaking projects, education, working autonomously and collaboratively within a multi -disciplinary team? Then we are looking for you.

We are a joint service with social services looking after patients in the last weeks of life. Our aim is to keep patients in their own homes if they wish to die at home with dignity and respect. The service is works closely with the District nurses and the Specialist Palliative Care Nurses.

Main duties of the job

The post-holder is responsible for the co-ordination of discharging patients who are at the end stage of life and who meet the continuing health care fast track criteria in conjunction with the multi-disciplinary team.

The post holder will be responsible for facilitating packages of care in conjunction with Community Nursing Teams, Social Service Teams and the Palliative care Support Team. To work with patients and their carers to ensure smooth transition between Primary, Secondary and Tertiary Care Services

Detailed job description and main responsibilities

• Developing and maintaining effective communication networks with other health care professionals, statutory and voluntary agencies and Social Services agencies
• Attending and participating in staff meetings, case conferences and other meetings as required
• Breaking bad news to patients/carers
• Ability to verbally explain complex issues in formal situations such as case conferences
• Ability to formally present and discuss to individual and groups, ideas and issues pertinent to the Palliative care support team
• Discussing and identifying appropriate professionals for assessment of patients and patient groups
• Using the knowledge and skills necessary to assess individuals and groups, identifying the multiple needs of the patient, family/carer with a holistic approach
• Working within the Community care setting as the Team leader of the Palliative care Support Team, participating in activities to address the health care needs of the caseload
• Teaching nursing procedures to relatives/carers so that End of Life Care of the patients be continuous over 24 hours, and give guidance in carrying out all treatments and care
• Ensuring the changing needs of individuals and groups are identified timely and adjustments to programmes of care made
• Promoting and maintaining optimum health by identifying, planning and undertaking specific health promotional activities with identified individuals and target groups
• To support the patient and the family in difficult decision making about stopping treatment and preferred priorities for care
• To lead and support the Palliative Care Support Workers in care delivery
• To participate in development and updating of policies and procedures in the development of the Palliative Care Support team as jointly agreed with social care partners
• To liaise with the wider Multi-disciplinary team and to develop robust methods of communication to be utilised by the Palliative care Support Team, including use of electronic systems eg Somerset Cancer Registry
• To undertake re-assessment of patients at key points in their disease trajectory and liaise directly with Social Service partners to ensure appropriate use of resources for patients
• To be able to work flexibly to ensure seamless discharge from hospital to home for patients on Rapid Discharge Home to Die Pathway
• To negotiate appropriate plan of care with all health care and social care delivery partners
• To communicate directly with patients GP and the locality based Multi-disciplinary team to ensure seamless plan of care