JOB DESCRIPTION. ellenor. Head of Adult Community Services Director of Patient Care

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1 JOB DESCRIPTION ellenor Clinical Nurse Specialist Responsible to: Accountable to: Head of Adult Community Services Director of Patient Care General ellenor is a specialist palliative care provider for adults and children in the North of West Kent and the London Borough of Bexley. The organisation has inpatient and day therapy facilities at Northfleet, a comprehensive Hospice at Home service and a range of outpatient and community services, all supported and delivered through a multi-disciplinary team approach. The Hospice at Home team provides specialist palliative care at home with regular contact by Specialist Nurses and Doctors to assess and address the patient and family s needs and problems. This is achieved with the support of GPs and other local health and social care services, and is available 24 hours a day, 365 days a year. Our team also includes nurses, health care assistants and volunteers who assist and relieve the family, providing respite, companionship and practical nursing care where appropriate. Job Summary Working as part of an integrated multidisciplinary team, the purpose of this role is to facilitate optimum quality of life for patients and families with advanced progressive life limiting disease. This will be achieved in collaboration with patients through the provision of specialist palliative care nursing interventions based on comprehensive holistic assessment, care planning and education and support to both patients and families, and for other health and social care professionals. The role supports primary care key workers in the delivery of high quality palliative and end of life care, through partnership working and giving information and advice, training and education. The post holder will supervise the work of colleagues in the extended Hospice at Home team as appropriate. Key Responsibilities 1. Clinical Practice To take responsibility for a defined group of patients in the community, ensuring the highest possible standards of individualised care and prioritising need in line with available resources. Ensures that the patient s dignity is promoted and respected and that equality and diversity are a top priority in the care of patients and families. CNS Dec 15 1

2 Undertakes a comprehensive specialist palliative care nursing assessment in an outpatient, home or care home setting, agreeing a plan of care for patients and families based on clear goals intended to bring about effective, measurable patient / family outcomes. Works proactively to meet the needs of patients providing an urgent response when needed to support patients and their families at the end of life. Delivers, monitors and reviews the care of patients and families reporting any variances of concern to senior colleagues in the team, taking appropriate advice in complex cases. Ensures patients / families preferred place of care is clearly discussed and identified and advanced care plans are in place wherever possible. Makes proactive patient referrals to appropriate alternative internal or external services. Actively plans and discharges patients / families when identified goals have been met or when disease progression is stable in line with the organisation s policies and protocols. Provides advice and guidance related to symptom management, and psychological, social and spiritual needs, referring onto the appropriate professional or service accordingly. Works pro-actively to ensure that everything is in place to support patients with complex/ end of life care needs, including medicines, DNACPR and advance care plans/ directives. Also ensures this has been communicated to all those involved in the care. Provides clear explanations and education as appropriate to ensure that patients and families have the information they require in a timely fashion. Undertakes bereavement follow-up in line with the agreed pathway and bereavement risk assessment. Actively promotes the rehabilitative and therapeutic approach to specialist palliative care. Participates in the full range of services and time-specified therapeutic patient / carer programmes as appropriate, and co-ordinates this with other elements of clinical work. Participates in a seven day per week operational service including out of hours provision Works proactively to ensure patients, families and professionals have appropriate links to colleagues in the absence of the post holder, ensuring continuity of advice and intervention through effective team working Regularly attends Hospice at Home multidisciplinary team meetings, proactively discussing and planning care for patients and families. In the best interests of patients and families, proactively collaborates with a wide range of community and hospital based health and social care services including voluntary support groups. Regularly attends and provides services to GP practices, supporting and advising on up to date, evidence based palliative care practice, facilitating the establishment and review of Gold Standards Framework, disease registers, proactive advanced care planning and clear understanding of patients and families preferred place of care. Promotes the work of the organisation in all settings, encouraging collaborative working and the referral of appropriate patients with all diagnoses. CNS Dec 15 2

3 Utilises the electronic patient administration system and makes full use of the information and technology resources to ensure high quality patient care, maximise patient benefit and make best use of resources. Ensures accurate and contemporaneous records, inputting patient data as required by the organisation. 2.. Education, Training and Professional Development Maintains own expert clinical knowledge and skills, and achieves the educational standards set out in line with the skills, knowledge and competency level required for the role. Participates in the induction, training and support of new staff and colleagues. At the request of the Lead Nurse, plays a supportive role to health and social care students undertaking training within the organisation. As directed, actively participates in the delivery of training sessions including internal and external courses, education and awareness raising events for professionals Participates fully in clinical supervision sessions in line with organisational policy 3. Quality, audit and research Participates in regular clinical audit to aid ongoing service improvement and development. Keeps abreast of research and audit activity to ensure that his / her practice is appropriately updated in line with latest guidance, research findings and local policies and procedures. Assesses, reports and manages risks in line with the Nursing and Midwifery Council s Code and the organisation s policies. Identifies and reports verbal complaints in line with the organisation s policy. Contributes to the Clinical Governance framework of the organisation, participating in a Sub Group as required, and keeps up to date with governance activity and latest policies and procedures. Supports the work of the User Governance Sub Group to ensure that patient and carer views actively inform service improvements. Together with colleagues, actively seeks and identifies areas where changes to routines and practices will result in quality improvements. Participates in research and audit aimed at enhancing patient or family care. Actively works to ratified clinical policies and procedures. Abides by all organisational policies and guidance in relation to confidentiality and information governance. 5. General Organises and prioritises any competing demands of the role, completing duties as required within working hours. Adapts and develops in line with changing needs of the role Acts as an ambassador for ellenor in order to raise the profile of the organisation at a local, regional and national level as required CNS Dec 15 3

4 Works flexibly across sites and departments from time to time as may be requested by their managers. Undertakes other duties commensurate with the seniority of the post as maybe requested by their managers. At ellenor we are committed to creating and managing a safe working environment for all our staff, visitors, volunteers and patients. All ellenor employees are expected to know, understand and deliver their Safety Responsibilities. All ellenor employees may be set at least one Safety Objective by their manager or supervisor which must be delivered if they are to meet their objectives. The post holder will work within the NMC Code of Conduct and Scope of Professional Practice at all times. All organisational policies and procedures will be followed. This job description is not exhaustive and may be reviewed r and changed by discussion with the post holder to meet the needs of the service. Signed and agreed with the current post holder. Name (please PRINT) Signature Date And Line Manager CNS Dec 15 4

5 PERSON SPECIFICATION Clinical Nurse Specialist ESSENTIAL DESIRABLE QUALIFICATIONS First Level Registered Nurse with demonstrable experience in Palliative Care (min 2 years) Degree in palliative care or related subject Post-registration diploma qualification in either specialist palliative, community care or end of life care Teaching / mentorship module Advanced Communication Skills certificate / training KNOWLEDGE, SKILLS AND ATTRUBUTES Evidence of commitment to ongoing professional development Good understanding of the role that specialist palliative care has to play in end of life care Good knowledge of end of life care tools and improvements they bring to patient care Knowledge of symptom management, and ability to make initial assessment of patients psychological, social and spiritual needs, referring as necessary to the most appropriate services Ability to deliver training programmes / packages with confidence and clarity Advanced assessment skills Ability to communicate effectively at advanced level with patients and families with specialist palliative care needs CNS Dec 15 5 Ability to work effectively with a diverse range of colleagues / individuals involved in palliative care

6 services Ability to undertake clinical audit and recommend change to practice if appropriate EXPERIENCE Ability to maximize use of IT in the workplace Experience working in either community, specialist palliative care, or general palliative care services Experienced in working within own developing level of competence Experience in delivering training for others Experience of productive multi and inter-disciplinary working Personal Attributes Resilient and able to meet the complex demands of the post. Flexible approach with ability to adapt to changing or conflicting priorities Ability to work effectively with indirect supervision and with unpredictable work patterns, managing time, work commitments and priorities within the working hours allocated. Identifies any limitations to own ability within the role and actively plans how to address these Conscientious, reliable, punctual and acts with integrity at all times. OTHER REQUIREMENTS Car owner / driver with full licence Flexible approach to working hours, times and days of week CNS Dec 15 6

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