Job Description

Community Flow Key Worker

Salary: 25,467

Hours: 37.5 hours per week

Term: 18 months

Location: Mainly home based with travel across Exeter and Tiverton

Responsible to: Flow Projects Manager

Context

Encompass Southwest working with the Royal Devon University Healthcare Foundation deliver the Community Flow project in North Devon, which we are now starting in East Devon.

The project aims to provide better access to community support by establishing closer links between the RDUH hospital and community teams and the wider support in communities from volunteers, organisations and the VCSE sector across Exeter and Tiverton.

Key Workers manage a referral caseload including interaction with Flow colleagues and RDUH practitioners to link them in with services and support from statutory, VCSE and community resources to facilitate discharge and avoid readmission to hospital as well as to improve overall wellbeing outcomes.

Key Workers will work with a caseload of patient's living across Exeter and Tiverton and are the main point of contact, maintaining relationships with the RDUH teams within this area, including attending team meetings or offices to build effective working relationships to support service delivery and professional's understanding for referrals.

Support provided to patients is identified through an assessment of the need by a 'What Matters to Me' conversation, identifying patient goals and working alongside them to achieve these.

The Community Flow Key Worker will ensure that all referrals are managed in a timely and professional manner, placing the patient at the centre of the intervention. Support will be provided mainly over the telephone with home visits or visits to venues or RDUH offices as needed.

Our office is in Barnstaple and the role will initially require travel to the office for induction and training and ongoing for occasional meetings.

Why is Community Flow needed?

People most in need of support are least likely to receive it. They are expected to fit in with what services need rather than the other way around and many describe feeling that no-one cares. They feel 'bounced around' services, having to tell their story again and again, which can be distressing, particularly for people who have experienced trauma. People feel distanced from the professionals that support them as they get referred to various providers for more specialised support. What if people told their story once - they were listened to, understood and support was drawn in to 'flow' around them?

What is our 'Community Flow' approach?

Flow is a way of helping people get the full support they need to live the life they want. Rather than referring people to various practitioners for non-clinical. The Community Flow worker with the patient has a 'What Matters to Me' conversation to focus on the person's goals and strengths as well as their needs and a plan is developed together.

The Community Flow project has the following outcomes:

Outcome 1 - A comprehensive programme of support, accessible to all health & social care staff to refer patients into.

Outcome 2 - More resilient communities who have the support and structure to make best use of all the available assets in their community.

Key Working Relationships:

Flow Projects Manager

Community Flow Key Workers

Flow team

RDUH Discharge Co-ordinators

Community Health and Social Care teams

Community Developers

Primary Care Network Social Prescribers and Community Connectors

Community groups, VCSE organisations, other organisations/resources relevant to supporting Community Flow patients across the locations of Exeter and Tiverton.

Other working relationships

The post holder is required to deal effectively with staff of all levels throughout the Trust, the wider healthcare community, external organisations, volunteers, VCSE groups and the public. This will include verbal, written and electronic media.

Key Principal Duties and Responsibilities

Principal duties

To manage a Community Flow referral caseload:

o To ensure all patient data is processed and managed in line with approved RDUH and Encompass Information Governance processes.

o To connect patients to wider support where needed relevant to their goals identified from a 'what matters to me' conversation.

o To complete logs on EPIC, the NHS patient system.

o To record all cases, interventions and other required information on Advice Pro, Encompass case management system.

o Identify organisations/resources who can support patients and make timely referrals to them.

o Using and monitoring a small patient budget to support interventions.

Support to develop and establish the new Community Flow project in East Devon:

o Work closely with the Flow Projects Manager, Flow team, patients, NHS staff and others to develop and continually improve the service.

Monitor, evaluate and reporting:

o Collect feedback from referrer and patients.

o To assist with project reporting including writing case studies, evaluation including feedback to identify system/local gaps in provision.

o Attend Flow team meetings and others as needed.

Facilitate 'Team around the Person' meeting/interventions where appropriate:

Meetings are generally held virtually, and the Community Flow Key Worker will chair/facilitate these meetings and take meeting notes and action points for each person attending.

Person Specification

Required:

Able to work independently and as part of a team.

Good understanding of the not-for-profit sector as well as the statutory and public sectors in the East Devon area.

Experience of engaging with stakeholders from the statutory, voluntary, public sectors and community groups/resources in building effective relationships and working together in support of patients referred to the project.

Ability to be pro-active and self-starting in the development of new projects and partnerships.

Understanding of Health and Social Care environment

Experience of working with and supporting people with multiple needs.

Enthusiastic, flexible and solution focussed when adapting work to meet competing

deadlines and priorities with minimal supervision.

Excellent interpersonal skills with the ability to communicate well with others.

Excellent written, verbal communication and presentation skills, including the ability to write supporting material such as case studies for inclusion in project reports.

Competent to a high standard in using various software, including MS Office, Outlook, internet browser, case management systems.

Self-motivator and having an innovative approach.

The post holder must demonstrate a positive commitment to uphold the diversity and equality policies of Encompass Southwest and to fully understand and adhere to patient confidentiality.

Ability to travel, full driving licence and access to a vehicle. Initial induction and training will be at our Barnstaple office and ongoing occasional meetings at this location

Communication and Relationship Skills

The post holder will need to be able to effectively communicate with a range of patients, staff, external organisations, stakeholders and agencies. Communication will be with NHS teams, volunteers, health and social care workers, and a range of organisations who could support patients.

Analytical and Judgement Skills

The post holder will record referral and patient information and contribute to producing project reports.

Planning and Organisational Skills

Plans meetings and manages a caseload.

Physical Skills

Utilisation of advanced keyboard skills for operation of a wide range of computer software which is used for reporting purposes.

Responsibility for Patient and Client Care

The post holder is required to put the patient, as the first priority, at the centre of all activities.

Responsibility for Policy and Service Development

Responsible to the Flow Projects Manager for development of services and to support with service policies when required.

Responsibility for Information Resources

Create posters, leaflets, newsletters and reports when needed.

Decision Making

Working autonomously; managing a caseload and interpreting policies.

Physical Effort

There is a frequent requirement for sitting or standing in a restricted position for a substantial proportion of the working time. There may be a requirement for light physical effort e.g. using projector/equipment in project meetings/presentations.

Mental Effort

Concentration required when facilitating meetings, producing reports, attending meetings, analysing statistics, training/ frequent interruptions to deal with service issues.

Working Conditions

Office or home working conditions mean the postholder may use a VDU more or less continuously on most days. May be required to frequently drive around Trust sites.

GENERAL

Diversity and rights

1. Promote equality, diversity and rights at all times.

2. Treat others with dignity and respect at all times.

3. To raise with management any concerns related to the promotion of the diversity and rights of service users or peers.

Confidentiality

1. To maintain confidentiality at all times.

2. To not disclose any information regarding service users or their children obtained during the course of employment.

3. Failure to adhere to this will be regarded as serious misconduct and may lead to disciplinary action.

4. To ensure safe storage of service user information.

5. The GDPR Data Protection Act may render an individual liable for prosecution in the event

of unauthorised disclosure of information.

Policies and procedures

1. To be familiar with and to comply with Encompass policies and procedures.

2. Failure to adhere to this will be regarded as serious misconduct and may lead to disciplinary action.

Safeguarding children

1. Some of the people we work with have children, and all staff have a responsibility and duty of care to ensure the safety and protection of children. It is the postholder's responsibility to report any safeguarding concerns to the designated Safeguarding Officer and follow procedure.

2. It is the responsibility of all staff to be aware of and to comply with Encompass's Safeguarding policy. All staff are expected to act in accordance with the practice and principles outlined in this policy. Safeguarding is everyone's business.

3. Failure to adhere to this will be regarded as serious misconduct and may lead to disciplinary action.

Risk Management and Health and Safety

1. Support the Strategic Lead in promoting a risk management culture within the working environment, ensuring participation and involvement when requested

2. Identify potential risks that may impact on the ability of Encompass to achieve its objectives and report concerns to the Strategic Lead.

3. Health and Safety is the responsibility of all staff and the post holder is required to take due care at work, report any accidents or untoward occurrences and comply with the Encompass Health and Safety Policy.

Training and Development

1. Attend mandatory training updates as required.

2. Undertake training as necessary in line with the development of the post and as agreed with the Strategic Lead as part of the appraisal process.

3. Take responsibility for identifying what leaning is needed.

4. To participate in supervision meetings and reviews to discuss how your role will help deliver the best possible care to service users.

5. To subscribe to reflective practice and participate in monthly group clinical supervisions and action learning sets.

Service User Involvement

1. Encompass is committed to empowering clients to have a voice in the service they receive. All staff are required to take a proactive approach in supporting this objective.

Data Quality

2. Ensure that all data and case notes entered into data capture systems are of a high standard.

Modernisation and Change

3. To be aware of internal and external targets to achieve in terms of improving and progressing the work of Encompass

Sustainability

4. The post holder will be required to embrace the concepts of sustainability within the workplace.

5. The post holder will be required to carry out duties in a way that ensures a high regard for energy efficiency, carbon reduction, waste management and the most appropriate use of resources.

This job description is an outline of the role and responsibilities. From time to time due to the

needs of the service, we may ask to flexibly undertake other duties.

Job Types: Full-time, Fixed term contract
Contract length: 18 months

Pay: 25,467.00 per year

Benefits:

Bereavement leave Casual dress Employee discount Free fitness classes Free or subsidised travel Gym membership Health & wellbeing programme On-site parking Work from home
Work Location: Hybrid remote in Exeter EX2 5DW