Job Description

To be a core member of a multi-disciplinary Community Neuro Rehabilitation Team (CNRT) and contribute to the effective assessment and discharge planning of patients with stroke or other neurological conditions in both the area of Torbay and Teignbridge.



To undertake conversations to identify needs and risk and collate accurate and appropriate information to refer to the multi- disciplinary team or other Community Led and Voluntary/ Statutory services



Under distant supervision, you will provide support in Torbay and South Devon after discharge to from hospital. This can include, but is not limited to; case managing those on the discharge to assess (D2A) pathway, recognise a change in care needs, carer support, financial advice, community access, holistic social care assessments, in partnership with service users, families and carers, prepare care plans, commission services to ensure the most beneficial and cost-effective care packages are established, delivered, monitored and reviewed, and comply with all statutory requirements for Torbay and South Devon NHS Foundation Trust policies and guidelines



This post is an exciting opportunity to work across both Torbay and Southern Devon NHS Foundation Trust, and Devon County Council. To undertake holistic needs-led assessments in partnership with service users, patients and carers, prepare care plans, commission services and manage a caseload to ensure the most effective and beneficial care packages are established, delivered, monitored and reviewed, and comply with all statutory requirements. The post holder will need to ensure that their own contribution to service is delivered in a way that meets the diverse population of Southern Devon and adhere to policies on equality and diversity.



Why Work With Us



The Community Neuro Rehabilitation Team (CNRT) are part of the wider Stroke and Neuro Rehabilitation team. We have bases in both Newton Abbot Hospital and Paignton Health and Well Being centre and provide rehabilitation to patients following stroke or with neurological conditions. The team covers the Torbay and South Devon patches reaching from Dawlish to Dartmouth. We are supportive team who are passionate about delivering high quality care to our patients. We are a motivated and caring team with both our patients and colleagues at the heart of it.



Informed verbal and written consent should be obtained from service users and patients for all assessments care plans and interventions Communications may include dealing with those people who have difficulties relating to highly complex, contentious emotional, psychological as well as physical conditions associated with their presenting conditions. People may have difficulties in communicating or understanding, and may be dysphasic, depressed, deaf, blind, or unable to accept their diagnosis or situation Communication may involve skills in non-verbal communication, diffusing anger, motivating, negotiating, counselling, training, empathising and reassuring To communicate with members of the public, unpaid carers, family members, other professionals, colleagues & external partners over the phone, face to face and using IT solutions To exercise tact, empathy & sensitivity at all times and use negotiation skills To liaise and work closely with other members of the multi-disciplinary team. To communicate medical, social & sensitive information ensuring General Data Protection Regulations are adhered to To be able to collate appropriate information from a variety of sources relating to individuals, their needs and support network and to apply eligibility To analyse information to determine potential risk & priority and action required Assessment, care planning, and the subsequent commissioning of services are undertaken, including involvement with vulnerable adults,' in a timely way to ensure the right care is available in the most suitable environment. Identifying when a specialist assessment may be required Manage a caseload to ensure that individuals receive care to meet their assessed needs, within budget Where appropriate and having applied Care Act 2014 eligibility criteria, arrange services to meet the individual's assessed needs, within the framework of the social care contracting process In accordance with Torbay and South Devon NHS Foundation Trust policies, provide information and advice on alternative services which may be available To have clear responsibilities for the safeguarding of adults and children and for operating in a manner consistent with Human Rights legislation. To be compliant with and practice utilising social care legislation including Care Act 2014 and Mental Capacity Act 2005. To complete Mental Capacity Assessments and be involved in best interest meetings. To plan and prioritise own work and caseload supported through regular supervision and consultation To undertake home visits in the community as a lone worker unless a risk assessment stipulates that workers should not visit on their own Took work closely with the multi-disciplinary team (MDT), taking into account their assessments, for example of a patients cognitive and communication needs To protect the rights and advocate on behalf of vulnerable people in accordance with legislation To initiate investigations where the abuse of vulnerable adults may have occurred, and participate in Strategy meetings. Specialist roles may include Hospital Discharge, Learning Disability, Mental Health or Drugs and Alcohol To ask as a key worker for service users within the stroke and neuro rehab team (specifically the Community Neuro rehab team). To formulate/contribute to detailed support plans/summary of needs and contribute to setting goals and objectives based on assessments carried out Provide support to unpaid carers of stroke survivors, support them with changes to the individual's needs, if privately funded provide advice and signposting to services. Complete carers assessments and signpost to other support as required. To support the discharge pathway from acute hospital settings as well as discharge or transfer to/from short term placement or intermediate care (pathway 2 beds). To complete 6 monthly reviews of stroke patients in accordance with the Sentinel Stroke National Audit Programme (SSNAP) To adhere to Organisational policy and procedures To adhere to Department Standard Operating procedures To contribute to the development and implementation of systems, such as Evidence-based Practice, utilising research data, and the Single Assessment Process, PARIS, CareFirst, systm1 and electronic patient records * To contribute to service and professional development in social care through Forums and working groups. Including attendance at the Social Care Community of Practice for Stroke