Job Description

Grade:

Band 7 equivalent Clinically Accountable To: Medical Director Responsible To: PCN Manager Location: Community Action Derby, 30-31 Charnwood Street, Derby, DE12GU Hours: 37.5 hours - 2 year fixed term Key Relationships Service Managers Clinical staff GPs within Team Up Other Admiral Nurse services Older peoples mental health services Families/carers affected by dementia1 Social care Primary care multidisciplinary teams Dementia UK Dementia Palliative care team Local voluntary organisations Social Prescribers Local Area coordinator Derby City Council Derbyshire community services Home visiting service Summary of Responsibilities: The Admiral Nurse will lead, deliver and coordinate relationship-centred dementia care within operational areas of Derby City South contract, in order to improve the experience of carers/families affected by dementia[1] with complex needs. In line with the Admiral Nurse Competency framework at an enhanced specialist level, the post holder will provide: Specialist bio-psychosocial assessment and support for people with dementia and families with complex needs Facilitation of education and training for staff in the delivery of evidence-based dementia care Clinical leadership with policy development and quality improvements in relation to dementia care Consultancy to other health and social care professionals regarding dementia Main Duties and Responsibilities: Clinical Work within the GP Led Complex needs team and Home Visiting Service to provide a holistic approach to anticipatory care utilising the multi-disciplinary/ multi-agency team where appropriate Deliver regular clinical 1:1 sessions for families affected by dementia who meetthe referralcriteriawithin designated areas/ practices Provide clinical leadership on the care of people with dementia and their carers/families with complex care needs from peri-diagnosis to post bereavement support, to support reduced reliance on GP appointments Provide specialist nursing assessment, using the Admiral Nurse Assessment Framework or appropriate tools for carers/families affected by dementia, including positive risk taking, managing distressed behaviours and risk minimisation strategies Provide a range of bio-psychosocial interventions to promote health and wellbeing for people with dementia and their carers/families Work collaboratively with other professionals to improve the identification and management of co morbidities and frailty for people with dementia and their carers/families Develop and support care plans for people with dementia and families including positive risk management Support people with dementia, carers/families and staff to understand and respond to changes in behaviour and relationships as a result of dementia Provide care coordination for a clinical caseload of families with complex needs as identified within triage assessment Ensure the safeguarding of vulnerable adults and that all legal requirements relating to Mental Capacity Act 2005, Mental Health Act 1983 (amended 2007), and Deprivation of Liberty Safeguards (2009)[2] are considered and adhered to in relation to patient care Act as an advocate for people with dementia and their carers/families to promote their rights and best interests Participate and lead on case conferences, continuing health care processes and best interest meetings where required Work collaboratively with health, social and voluntary sector services to achieve coordinated care Work in partnership with colleagues to promote the use of advance care planning for people with dementia and to support and inform families, around advance care planning, best interest decisions and end of life care Manage and advise on complex care transitions for people with dementia and their carers/families to reduce the frequency of crisis situations Regularly attend multi-disciplinary team meetings for long-term conditions to inform and receive information regarding patients who have a diagnosis of dementia Refer to secondary care if there is deterioration in condition/a review of medication including antipsychotics is required or any other concerns regarding a persons health that cannot be managed in primary care, in line with their dementia expertise Support and advise on carer assessments and reviews Ensure that care is delivered in accordance with relevant local and national guidelines and all relevant Derby City South policies and procedures Recognise the limits of own competency and professional boundaries and make appropriate and timely referrals to other services where required Ensure that clinical records are up to date and maintained and stored appropriately in line with local and national GDPR regulations Education and Leadership Facilitate and support the development and delivery of innovative dementia training and education to staff, to improve competence and confidence, in line with best practice and guidance Participate in and/or lead formal training events promoting best practice in dementia care and disseminating Admiral Nursing work Provide professional and clinical leadership and mentorship, acting as a clinical role model on the delivery of evidence-based practice in dementia care within Derby City south PCN Advise and support on the development and delivery of work streams as part of Derby City south, dementia strategy, where appropriate Work proactively with key local and national stakeholders to develop more integrated care pathways and holistic models of care, through dissemination of specialist skills and knowledge Contribute to the delivery of local policy, procedures and protocol for Derby City south PCN to improve identification, assessment, ongoing support for people with dementia and their family carers Work together with Derbyshire Community Services and Derby City Council to develop and improve upon current Delirium and Dementia Pathways Evaluation and Audit Support the audit and evaluation of quality improvements and initiatives aimed at improving the delivery of dementia care within Derby City South, where appropriate to role Collect and review quantitative and qualitative data, as agreed, to evaluate and audit the Admiral Nurse Service and make necessary improvements Undertake analysis and evaluation and make any recommendations to the Derby City South Dementia Strategy Group or similar Ensure service information and data recorded is relevant, accurate, complete and captured in a contemporaneous manner Support evaluation of workforce development in dementia to improve staff knowledge and skills across Derby City South Liaise with Dementia UK Insights and Evaluation team where appropriate, to ensure that the impact and effectiveness of Admiral Nurse interventions are well evaluated Be fully aware of and comply with the Data Protection Act (2018) and the GDPR in relation to protecting the confidentiality of patient and service-user information and enabling appropriate information-sharing Professional Ensure all nursing practice is carried out in accordance with the agreed policies and procedures of Derby City South and the NMC Code Improve understanding of the management of Long-Term Conditions in the community supported by GP Led team Attend and actively participate in practice development, clinical supervision, and continuing professional development supported by Dementia UK and underpinned by the Admiral Nurse Competency Framework. Develop own competence through use of the Admiral Nurse Competency Framework and portfolio development using resources provided by Dementia UK To maintain professional registration in line with NMC guidance, including re-validation Contribute to and lead the development of policies, procedures and protocols relevant to dementia and Admiral Nursing within Derby City South, including the Standard Operational Policy Ensure compliance with Derby City South clinical governance requirements, including all mandatory training Participate in clinical supervision/mentoring within Derby City South where appropriate Maintain up-to-date knowledge of research and evidence-based recommendations on supporting people with dementia and their carers/families within the primary care setting Agree a rotational working week to support families and GPs in the identified geographical areas Managerial Ensure the recording and investigation of all accidents, complaints, untoward incidents and losses in accordance with Derby City South policy Identify and record risks to the Admiral Nurse service, escalating appropriately Participate in recruitment of other healthcare professionals where appropriate Lead on Admiral Nurse steering groups with Dementia UK and Derby City South Lead, manage and develop the Admiral Nurse service, continuously seeking improvement opportunities in collaboration with the Admiral Nurse Steering Group Please note that this job description serves to provide an illustrative example of the duties and responsibilities the post holder will undertake during the course of their normal duties. It is not therefore an exhaustive list and the post holder may be required to undertake other responsibilities and duties that correspond with the band.