SMI and Frailty Practitioner - Community (CPN) - Band 6

Job overview

An exciting opportunity has arisen to join a new innovative team within the Serious Mental Illness (SMI) and frailty pathway in NE Essex for older adults over 70 years of age with frailty. We are looking for a compassionate, motivated and caring individual whom has experience in working with people with a functional illness with or without frailty. As part of the national agenda for transformation the service will focus upon admission avoidance to both general hospital and a mental health inpatient setting.

The service will be working collaboratively with other health care providers, third sector agencies, service users, carers, clinicians and other practitioners. Close working with the community teams in the local neighbourhood model will take place in line with the North East Essex Alliance.

A key part of this role will be providing comprehensive assessment, as well as having responsibility for a case load of individuals. The role will entail providing person centred and evidence based interventions working alongside a multi-disciplinary team. There will be a requirement of ensuring quality interventions and high standards of documentation. The successful candidate will be required to have knowledge and experience of physical health and how this can impact upon an individual’s mental health.

Main duties of the job

As part of the ongoing North East Essex Alliance transformation of services and in line with the NHS Long Term Plan, development of Essex Partnership University Trust (EPUT) services for dementia have been working over the past year in developing an integrated Dementia and Serious Mental Illness with Frailty Pathway. This exciting role is to join EPUT as a Band 6 senior community practitioner. .

Working to develop an integrated approach to assessment and intervention for patients with SMI and Frailty. This role will include supporting ESNEFT inpatient and frailty services to facilitate timely discharge, care planning and identifying appropriate community place based services.

Detailed job description and main responsibilities

The post holder carries responsibility for the assessment of care needs and the development, implementation and evaluation of programmes of care for patients with SMI with frailty. Patients will be referred by GP’s, Colchester Hospital, Community Nursing Services and Internal EPUT Teams. As the integrated/SMI with Frailty Pathway develops it is expected that the roles will in future be aligned to the North East 6 Neighbourhood Hubs.

The SMI with Frailty Practitioner will provide short-term intervention either within in the person’s place of residence or Colchester Hospital linking the needs led care plan to place based services including community services, social care and third sector organisations e.g Age Well East. They will be expected to work collaboratively with individuals and their carer’s/family delivering person centred care. Actively participate in the training and education of staff, families and carers as required. In addition, they will also be responsible for ensuring that an integrated service is provided and ensure that good inter-disciplinary working is maintained.

Key Responsibilities

1. The post holder will be expected to act as an ambassador for EPUT in all settings.

2. Undertake assessments with people presenting with risk due to symptoms of frailty and mental health needs. Assessments will occur in a range of settings based on presenting needs and circumstances. Complete frailty screenings using Rockwood and complete Comprehensive Geriatric Assessments using validated tools.

3. Following assessment you will take a lead role with the implementation and evaluation of person-centred care being mindful of nursing strategies including nutrition, polypharmacy, falls, adherence to treatment, exercise/physical health, and cognitive intervention.

4. Be able to undertake physical health investigations which may include basic observations, ECG, Blood taking linked to a competency framework

5. Advise a range of health and social care professionals on effective treatment, interventions and management of individuals with SMI and SMI with Frailty needs promoting Ageing Well and maintenance of independence.

6. Signpost individuals to other appropriate place based services whether they be statutory or non-statutory.

7. Ensure effective lines of communication are maintained and establish to promote effective working relationships.

8. Disseminate specialist knowledge across a range of professionals and services as required.

9. Actively and constructively contribute in Team Meetings, MDT meetings initiating and discussing new methods/models of working.

10. Participate in research or trails where necessary or required.

11.. Inform the Team Manager if they are concerned with regards to any breaches of professional conduct.

12.. Have a sound knowledge/understanding of the legislation as part of the role of the Registered Mental Health Nurse or Registered Nurse, including Mental Health Act 1983, Mental Capacity Act, 1

13. In association with Anglia Ruskin University, University of Essex ensure the learning environment for all nurses in training is appropriate and that teaching areas comply with all N.M.C. Regulations. This is also extended and applies to student doctors and student social workers

14. Participate and take professional responsibility/accountability and ensure that accurate, timely records are maintained in line with the Trust Policy.

15. Ensure that clinical practice is evidence-based wherever possible and participate in research and audit.

16. Use research findings when designing care and to develop and awareness of the significance of nursing practice.

17. Keep updated in all legislative government initiatives.

18. Following any serious incident ensure that required documentation is fully completed in line with Trust Policy and Procedures.

19. Have an awareness of the complaints Policy and Procedure of EPUT

20. Be responsible for updating own knowledge of contemporary psychiatry and a commitment to continuing own professional and personal development, in line with Trust Appraisal and Development Policy

21. Attend training as provided and be responsible for keeping yourself up-to-date at all times with mandatory training.

22. Undertake and be proactive in clinical and managerial supervision as required and identify the training needs of junior, unregistered staff and students.

23. Participate in the appraisal process every year; ensure all personal objectives are met in a timely manner

24. Promote a positive image, showing a professional and helpful approach and identify where relationships with the public could be improved, in line with the Trust customer care agenda

OPERATIONAL RESPONSIBILITIES

1. Work with Team Manager and Service Manager and clinical lead to ensure all required service targets and activity is achieved.

2. Act at all times in accordance with: Midwifery and Nursing Council Code of Professional Practice

3. In liaison with the Team Manager contribute to setting objectives for the service and devise ways of implementing and effective monitoring.

4. To review at regular intervals with the clinical lead, the overall nature of the workload, work methods, techniques, and evaluating clinical practice as a whole.

5. In the absence of the clinical lead ensure that referral, assessment and workload allocation happens in a timely, flexible and responsive manner, taking into account the wishes of the patients and their carer’s.

6. On a daily basis help manage all incoming referrals effectively, providing appropriate prioritisation of the work load within agreed time frame e.g. urgent or non-urgent depending on the nature of the presenting needs and risks.

7. Participate in multi-disciplinary and multi-agency decision making process, through team meetings, team building and team maintenance.

8. Undertake and be proactive in Clinical supervision in accordance with Trust Policy and Procedures.

STAFF SUPPORT

1. Act as role model at all times, able to demonstrate leadership skills.

2. Provide specialist advice, support, supervision and consultation, to staff within the Team, outside Teams and other agencies.

3. Provide support and supervise junior staff in identifying training needs and actively participate in staff development programmes.

4. Contribute towards Team education and development providing opportunities for exchange of ideas, experience, techniques and intervention.

5. Instruct and supervise staff in nursing techniques applicable to the setting as necessary, identifying training needs and actively participating in staff development programmes

6. Ensure all junior staff is fully conversant with the physical health needs of all of patients. An approach to care is required that encompasses physical health, mental health and social care.

7. Assist the clinical lead &Team Manager in the maintenance and development of team morale, by demonstrating support for colleagues and showing high level of enthusiasm and commitment.

8. Undertake effective risk assessment and support other staff to recognise and de-escalate difficult, challenging and aggressive behaviour, ensuring all patients on the caseload have up to date risk assessments and risk management plans.

9. Ensure that clients on the caseload with behavioural problems, e.g. violent or potentially violent behaviour are identified and that other staff are aware of the risks involved, and that other staff act with caution and care is taken when visiting, if necessary organising joint visits and remaining mindful of the lone worker policy.

10. Ensure the learning environment for all nurses in training is appropriate and that teaching areas comply with NMC regulations.