Job Description

Contribute to, support and promote ECCHs, strategic direction, values and culture in relation to proactive and reactive services. Discuss all treatment options with sensitivity, knowledge and expertise and to act as a patient advocate when appropriate and respecting patient confidentiality with privacy and respect for diverse cultural backgrounds and requirements. Offer a supportive service to patients and their carers from diagnosis through all stages of the disease process, in conjunction with other healthcare professional using a range of communication skills to manage care and information empathetically. Understand and support the achievement of ECCH business plan objectives and performance targets, and initiate and participate in screening and needs assessment as required.



Supervise other health and social care professionals in the delivery of proactive health promotion activated, e.g. chronic disease management with individuals and groups. Identify the potential for service developments, risk and deficits and inform line manager making recommendation based on specialist knowledge. Provide leadership and management of locality nursing teams with identified lines of responsibility.



Plan and organise a range of complex activities in a wide range of settings to ensure best practice is delivered across your designated area of responsibility and the wider community. To provide clinical leadership within the Primary Care Home Team/s and the wider integrated Community Care teams including Primary, Social Care, and all other provider organisations to provide high standards of care to patients and where appropriate avoiding unnecessary admission to secondary care. To be a key driver for establishing integrated care teams both practically and behaviourally. Assist with the implementation of pathways and guidelines to support health care professionals in establishing patient on evidence-based therapies.



Develop systems to monitor, evaluate and audit service quality in order to meet nationally and locally set targets and develop reporting mechanisms. Effectively communicate at all levels of the organisation, with a variety of health professionals, users and carers, to provide the best health outcomes. Maintain a high level of performance and be goal and outcome focussed when faced with opposition or when working under conditions or pressure. Identify potential service developments, risks and deficits and discuss with line manager, making recommendations based on expert knowledge to enhance the capacity and quality of community care.



Monitor and maintain standards / provide benchmarking data to allow comparison with other healthcare providers Participate in teaching and clinical supervision with nursing teams and other provider staff as required Critically evaluate research findings, national guidelines and implement changes in clinical practice as appropriate Participate in clinical supervision with nursing teams as required. Provide patients, families and carers with tailored education programmes, advice and support, that may precipitate symptoms of acute exacerbation of underlying conditions or illness and include lifestyle changes that would be advantageous to health. Be responsible for participating and maintaining a learning environment and maximise opportunities for education and development in the clinical area to enhance individual development and performance in the delivery of high standards of care. My Accountability, My Responsibility Take responsibility for your own personal and professional development; maintain competence, knowledge and skills commensurate with role.



Using a standardised approach but with a high degree of professional autonomy and accountability, work across Health, Social Care, Voluntary and other health providers and agencies, to identify a defined group of patients with complex needs to provide a single plan of care co-produced with the patient. Using advanced clinical practice skills assess the physical and psychosocial needs of a defined client group. Critically analyse complex clinical data and information to inform diagnosis and, where appropriate, order investigations and/or instigate therapeutic treatments to inform clinical decision making and improve health outcomes. Maintain Key Worker responsibility for the patient when admitted to any inpatient facility and provide baseline health data for the receiving team, to support integrated and consistent care and facilitate Community Led discharge.



Be highly visible and accessible to patients, families and carers and be seen as being in charge of their care. Provide individualised care plan for patients with Long Term Conditions, so that their condition remains as stable as possible and, where appropriate, hospital admission is prevented and early discharge facilitated. Analyse complex patient situations establishing a therapeutic relationship in which they are able to utilize counselling skills to assist the individual to adjust to their illness and care. Use assessment tools/skills that will ensure an appropriate level of nursing or therapeutic intervention so that patients who present with highly complex needs are timely referred to the appropriate specialist.



Be wholly accountable for practice taking every reasonable opportunity to sustain and improve knowledge and professional competence and, ensure that all aspects of professional behaviour as required within Nursing and Midwifery Council Code are followed at all times. Maintain legible, accurate and contemporaneous patient records in accordance with ECCH Policy and the Nursing and Midwifery Council standards for record keeping. Assist with the investigations of complaints, participate in the risk management process, critical incident reporting, evaluation, dissemination and change in practice. Be responsible for understanding, following and implementing ECCH policies and procedures, and influencing working practices to support this accordingly.



Contribute to the clinical governance agenda through participation in clinical risk assessment and management, clinical audit. Create an environment conducive to effective working, respecting and supporting staff to deliver high quality clinical services. Ensure a high standard of record keeping is achieved in line with ECCH and professional standards. Take responsibility to ensure compliancy with Health and Safety Policy, Fire and Environmental Waste Regulations.

Respect Our Resources:

People, Time and Money Take responsibility for the cost effective management and use expensive and highly complex equipment, provide recommendations for effective use of resources and contribute to the effective delivery of cost improvement planning. Analyse, interpret compare and contrast complex information, service requirements and options ensuring the effective approaches to service delivery and team working. Contribute to the ongoing review of the wound care formulary and guidelines. Evaluate the impact of training programmes, for patient and carers, to ensure that they provide the necessary knowledge and skills to gain independence, safely manage changing circumstances and plan for unavoidable progression of conditions.



Work Together, Achieve Together Using advanced generalist clinical skills to evaluate the delivery of care, identifying subtle changing health care needs. Being able to completely discuss treatment options with other generalists and specialists. To be an integral member of the primary care network team, working with a shared vision and developing caseloads in partnership with each other to deliver both proactive and reactive care. Demonstrate responsibility and accountability for the clinical caseload and co-ordinate care across the whole patient pathway within ECCH.



This included ensuring a robust relationship and constant interface with OOHT and secondary care as required. Working with partners in Primary and Social care to develop a model of care which identifies and case manages those patients needing complex chronic disease management or palliative care supporting the needs of the local community. Negotiate and agree with the patient carers and other healthcare professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate. Work in partnership with the patients to empower them to make informed choices about their healthcare and support choices about end of life care.



Establish local networks in partnership with other health and social professionals/agencies and national links with other generalists in order to develop protocols according to national and local guidelines for the safe and effective provision of a community nursing services. Work with partners in nursing and residential care to provide proactive care to improve the health outcomes of the residents and so prevent unnecessary hospital admissions or extended in- patient care episodes. Provide professional expertise and clinical leadership, acting as a resource to other professionals within and outside your own organisation, regarding clinical issues to ensure continuous service provision and inter-professional working. Work with ECCH Colleagues, and other partner agencies and stakeholders including the acute trust to contribute to the development and delivery of new innovative models of service delivery, ensuring a leading edge approach to service development in-line with evidence based practice.



All roles within East Coast Community Healthcare CIC (ECCH) require staff to demonstrate our Values and Signature Behaviours in the care and service they provide to patients, service users, stakeholders and colleagues. All members of staff should consider these as an essential part of their job role. Please see attached job description for full duties.