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FORMAL CONSULTATION RELATING TO THE MANAGEMENT STRUCTURE INCLUDING NEIGHBOURHOOD TEAM, OUT OF HOURS AND MDT CO-ORDINATORS

Older People’s and Adult Community Directorate

Consultation Start: 3rd October 2018

Consultation Finish: 2nd November 2018

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Contents

1. Purpose

1.1 This formal consultation paper outlines:1.1.1 the changes proposed to the management structure across neighbourhood

teams, out of hours (OOH) and Multi-disciplinary team (MDT) co-ordinators

1.2 The proposal is to:1.2.1 create an integrated area management structure across the north and south

localities. This structure will incorporate the OOH’s nursing service and continue with the integrated model of nursing, therapy and mental health management posts.

1.2.2 Replace the existing MDT co-ordinator role with a new patient flow co-ordinator role, interfacing more closely with primary care and acute hospitals.

1.3 The proposed nursing, therapy and mental health management posts would be supported by:

1.3.1 A business support role to assist with the operational functions within neighbourhood teams.

1.3.2 A neighbourhour team duty practitioner role integrated within the neighbourhood team nursing structure to lead the delivery of county wide community nursing services after hours.

1.4 The aim of this proposed structure is to support delivery of efficient, effective, joined up community services, improve patient satisfaction and experience with our services and strengthen closer working with system partners.

1.5 The purpose of this document is to advise staff and their representatives of the proposed changes and to provide an opportunity for them to consider and present their views on the proposals.

1.6 This consultation affects the following staff groups:1.6.1 All substantive Band 8a Managers within the current structure, Band 7

neighbourhood team managers and Out of Hours Managers1.6.2 All substantive Band 5 MDT Co-ordinators working within neighbourhood

teams.1.6.3 All staff currently in seconded roles of NT Manager, Area Manager and OOH

Manager posts.

All staff that are presently in substantive posts and are directly affected by the proposal will be consulted with to allow them time to consider and present their views on the proposals. The process for those affected is explained in this paper.

2. Background

2.1 Neighbourhood teams have been evolving since their creation over three years ago. However, with the current demand for services and financial

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challenges across the Cambridgeshire and Peterborough health system a full review is now required.

2.2 A key driver of the proposed management model is to increase efficiency and reduce expenditure, and is therefore a part of the Trust Cost Improvement Programme (CIP). The OPAC directorate is required to achieve a £3m saving this year and has considered multiple options for this, of which the proposed neighbourhood team structure is one.

2.3 Feedback obtained from the affected staff in individual and team meetings over the past twelve months indicates that while the integrated model of care works, structures across the model could be improved to support career progression, development of clinical staff, enhance governance and clinical leadership within the integrated model.

2.4 The North and South Alliance vision is that: Health and care services for people living with long-term conditions, mental health problems or advancing age are sustainable, designed with the people and communities who use them around their needs and support them to be resilient, independent and enabled.

2.5 At present there is momentum across the system to further develop neighbourhood infrastructure, using the model at “Home is best” and “place-based care”. The directorate is therefore committed to enhance and strengthen integrated management and leadership across the neighbourhood teams.

3. Current Service Outline

Table 1 – Current Establishment List

Post Title Band NT/Team WTEEstablishment Headcount

WTE in PostSubstantive/secondment

Current Base

MH Lead 8a North Locality 1.00 1 1 substantive North Cambs Hospital.

MH Lead 8a South Locality 1.00 1 1 substantive Brookfields Hospital

Area Manager

8a Cambridgeshire 1.00 1 1 secondment

Signet Court

Area Manager

8a Huntingdonshire 1.00 1 1 substantive Hinching-brooke Hospital

Area Manager

8a East Cambs and Fenland

1.00 1 1 secondment

Area Manager

8a Greater Peterborough

1.00 0 1 vacancy

NT Manager

7 Cambridge East 1.00 1 1 substantive Sawston Medical Practice

NT Manager

7 Cambridge City South

1.00 1 1 secondment

Brookfields Hospital

NT 7 Cambridge 1.00 1 1 substantive Histon

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Manager North Villages Police Station

NT Manager

7 Cambridge City North

1.00 1 1 secondment

Signet Court Cambridge

NT Manager

7 Isle of Ely 1.00 1 1 secondment

POW Hospital

NT Manager

7 Wisbech 1.00 1 1 substantive North Cambs Hospital

NT Manager

7 Peterborough Borderline

1.00 1 1 secondment

Botolph Medical Practice

NT Manager

7 Peterborough Borderline Central

1.00 1 1 substantive Botolph Medical Practice

NT Manager

7 Peterborough City 1

1.00 1 1 substantive City Care Centre

NT Manager


1.00 0 1 vacancy City Care Centre

NT Manager

7 Fenland 1.00 1 1 secondment

Alan Conway Court

NT Manager

7 Huntington Central

1.00 1 1 substantive Redshank House

NT Manager

7 St Neots 1.00 1 1 substantive Knowledge Centre, Wyboston

NT Manager

7 St Ives 1.00 1 1 substantive Kings Hall

OOH Manager

7 Cambridge 0.53 1 0.53 substantive

Hinchingbrooke

OOH Manager

7 Hunts 0.53 1 0.53 substantive

Hinchingbrooke

OOH Manager

7 North 0.8 1 0.8 secondment

Alan Conway Court

Post Title Band NT/Team WTEEstablishment Headcount

WTE in PostSubstantive/secondment

Current Base

MDT co-ordinator

5 Cambridge East 1.00 1 1.00 substantive

Sawston Medical Practice

MDT co-ordinator

5 Cambridge City South

1.00 1 1.00 substantive

Brookfields Hospital

MDT co-ordinator

5 Cambridge North Villages

1.00 1 1.00substantive

Histon Police Station

MDT co-ordinator

5 Cambridge City North


Signet Court Cambridge

MDT co-ordinator

5 Isle of Ely 2.00 2 2.00substantive

POW Hospital

MDT co-ordinator

5 Wisbech 1.00 1 1.00substantive

North Cambs Hospital

MDT co- 5 Peterborough 1.00 1 1.00 Botolph

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ordinator Borderline substantive Medical Practice

MDT co-ordinator

5 Peterborough Borderline Central


Botolph Medical Practice

MDT co-ordinator



City Care Centre

MDT co-ordinator



City Care Centre

MDT co-ordinator

5 Fenland 1.00 1 1.00substantive

Alan Conway Cour

MDT co-ordinator

5 Huntington Central


Redshank House

MDT co-ordinator

5 St Neots 1.00 1 1.00substantive

Knowledge Centre, Wyboston

MDT co-ordinator

5 St Ives 1.00 0 1.00substantive

Kings Hall

4.Proposed Service ChangesThe proposed management structure is to enhance the integrated model recognising the need for professional specific leadership.

The proposed structure integrates the delivery of OOH services within the neighbourhood team framework. Previously OOH’s sat outside of the NT’s. However it has been recognised that to enhance continuity and co-ordination of planned care and to provide greater service resilience across the whole of the Cambridgehire and Peterborough locality during the out of hours period, this service would be better supported within the integrated neighbourhood team model.

4.1 Area Nursing Manager This post will be responsible for the operational management and leadership of nursing staff within the neighbourhood team of a defined geographical locality. The post holder will maintain excellent working relationships with their locality’s primary care teams, and acute trusts as well as other key stakeholders.

4.2 Area Therapy ManagerThis post will be responsible for the operational management and leadership of therapy services across the defined geographical locality. The post holder will maintain excellent working relationships with their locality’s primary care teams, and acute trusts as well as other key stakeholders including social care.

4.3 Area Mental Health ManagerThis post will be responsible for the operational management and leadership of Mental Health services across the defined geographical locality. The post holder will maintain excellent working relationships with their locality’s primary care teams, and acute trusts as well as other key stakeholders.

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4.4 Neighbourhood Team Duty Practitioner This post will be responsible for the co-ordination and delivery of community nursing services outside the core hours of neighbourhood teams across the wider Cambridgeshire and Peterborough geography.

4.5 Locality Business Support Co-ordinatorThe post will provide full business and operational support to neighbourhood teams, working closely with the Area Managers in their defined locality. This role aims to support Area Managers with the day to day service requirements. The neighbourhood teams will continue to be supported for administrative duties by the present admin hub and spoke model.

4.6 Patient Flow Co-ordinator

This post will focus on co-ordination and tracking of complex patients on neighbourhood team caseloads across the system to ensure patient flow in to, through and out of the system. The role will involve close working with all system partners to ensure all patients flow through the system in a timely and safe manner.

Table 2 – Proposed New Establishment ListPost Title Current

WTEBand Future

WTEProposed Base Impact

Area Nursing Manager

0 8a 6 Botolph Medical PracticeThe City Care CentreDoddington HospitalHinchingbrooke,Sawston Medical Centre,Signet Court **

Area Therapy Manager

0 8a 2 The City Care Centre/ Doddington HospitalHinchingbrooke / Brookfields **

Area Mental Health Manager

0 8a 2 Doddington HospitalBrookfields Hosp

NT Duty Practitioner 0 7 1.72 Redshank House

Locality Business Support Co-ordinator

0 5 4 The City Care Centre/Botolph Medical PracticeDoddington HospitalHinchingbrooke / Signet Court

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Post Title Current WTE

Band Future WTE

Proposed Base Covering

Patient Flow Co-ordinator

0 TBC* 1 The City Care Centre

City 1 & 2 Peterborough


0 TBC* 1 Botolph Medical Practice

P’br Borderline & Borderline Central


0 TBC* 1 Alan Conway Court or North Cambs Hospital **

Wisbech & Doddington


0 TBC* 1 Histon Police Station or Signet Court **

Cambridge City North and North Villages


0 TBC* 1 Brookfields Hospital or Sawston Medical Practice **

Cambridge South City and East


0 TBC* 1 POW Hospital or Kings Hall **

St Ives & Ely


0 TBC* 1 Redshank House or Knowledge Centre, Wyboston **

Hunts & St Neots

*subject to agenda for change job matching

** to be agreed with post holder

Employees who are required to change their base as a result of organisational change may be eligible for reimbursement in line with section 10 of the Trust’s Protection of Pay and Terms & Conditions of Service Policy.

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5. Key Reasons for Proposed Change

5.1 Neighbourhood Team Management StructureThe proposed structure seeks to strengthen leadership and management within the integrated neighbourhood team model.

It is anticipated that by having Area Managers responsible for staff across a number of neighbourhood teams, the workforce within these teams will work collectively to ensure equity of activity, sharing of resources and shared learning which will enhance staff morale, well being and resilience.

It is also anticipated that the introduction of professional specific senior managers for therapy, nursing and mental health will be positive for neighbourhood team staff as the new roles will be clinically credible and therefore able to fully understand the operational and professional issues relevant to each discipline.

Other anticipated outcomes from the proposed new management structure include: Retaining the neighbourhood team model of working but enhancing clinical

staff working more closely aligned to their local GP practices Delivery of care in the same geographical areas but in more efficient way Strengthened integration of nursing, therapy and mental health services

through an integrated area leadership and management model Increased support and resilience from neighbourhood team staff. Increase support and better integration for OOH’s nursing staff.

5.2 Multi-disciplinary Co-ordinationThe directorate needs to ensure delivery of neighbourhood team services is closely aligned with the current primary care agenda and supports the GP Five Year Forward View strategy, as well as the developing framework of GP Federations and current direction of travel of the North and South Alliance.

To support timely and safe patient flow through the system, the new patient flow co-ordinator role seeks to strengthen neighbourhood team pathways and processes, with better interfacing with primary care, acute trusts and other stakeholders that support the system.

6. Impact on StaffingThe main impact of these changes is:

A change of work base for some affected staff Line management and team changes for some affected staff Affected staff will be asked to give preferences in terms of the role they would

like to be considered for. All affected staff will have 1:1 meetings to discuss and consider vacant posts

across the Trust.

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Please note that there are a significant number of Advanced Clinical Nurse Practitioner (ACNP) vacancies across all localities which individuals may consider when reviewing suitable vacant posts.

Following competitive recruitment to the new posts, affected staff that are not successful in obtaining a new role within the new management structure will be considered for redeployment.

Please see section 10 for full details regarding the process for change.

7. Impact on ServiceNo significant negative impact on the delivery of core neighbourhood team services is anticipated as a result of the proposed changes. A Quality Impact Assessment regarding the proposal has been undertaken and approved by the CPFT Executive Team.

8. Impact on Service Users and Carers In order to meet existing and future demand given the current operational, capacity and financial challenges, CPFT is keen to engage with stakeholders to develop and enhance the neighbourhood team model to ensure we are fit for the future. Service users, external stakeholders and partners will therefore be kept updated regarding the development of the management structure as it supports the evolving neighbourhood team model.

With enhanced leadership and management in neighbourhood teams, there will be an improvement in care delivery, a reduction in serious incidents and standardisation in the quality of care across the county.

Developing our clinical staff to be more effective clinicians Improved clinical outcomes for patients More efficient processes and better utilisation of existing resources Ongoing evaluation of service delivery Improved clinical productivity

Therefore the impact on service users and carers will be a positive outcome.

9. Job Descriptions and Person SpecificationsNew job descriptions and person specifications for the following posts can be found in appendix 1:

Area Nursing Manager Area Therapy Manager Area Mental Health Manager NT Duty Practitioner Locality Business Support Co-ordinator Patient Flow Co-ordinator

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A job description and person specification for the following existing post is also available in appendix 1:

Advanced Clinical Nurse Practitioner

10. Process for ChangeThe process for appointing posts in the new structure will be conducted according to the Trust’s Organisational Change Policy. This will be as follows:

10.1 Employees directly affected by the consultation are: All substantive Band 8a Managers within the current structure. All substantive Band 7 neighbourhood team managers and Out of Hours

managers All substantive Band 5 MDT Co-ordinators

As part of this process all staff who are directly affected by this consultation will be given the opportunity to complete an expression of interest form with preference details and a supporting statement of which post they would prefer in the new structure and their preference on base. Wherever possible we will slot staff in to their first preference. However, where there are more staff stating a preference than there are posts we may have to conduct interviews under restricted competition in order to make decisions on who goes where. In this case interviews will be conducted by a Locality or Deputy Locality Manager and a HR representative. Assessment for posts will be based on the person specifications as per a normal recruitment and selection process – any mitigating circumstances will also be taken in to account, these should be included in your supporting statement. Staff that are currently on maternity or sick leave will be contacted by their current line manager who will ensure they are communicated with on a regular basis. 10.1 Employees indirectly affected by the consultation are:

All staff currently in seconded roles of NT Manager, Area Manager and OOH Manager

All staff who are in a seconded role of NT Manager, Area Manager or OOH Manager will be affected by this proposal in that their secondment will come to an end.

These staff are not at risk and will return to their substantive post.

These staff will therefore not be asked to submit preferences but will be able to apply for any remaining vacancies once the process for those affected staff is concluded. We anticipate this will be done in a timely manner. This will be done in line with the Trust’s Recruitment Policy. These staff will also have the opportunity to feed back and ask questions regarding the new structure.

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On completion of the consultation, each staff member in a seconded role will receive an individual letter advising them what the outcome means for them, confirming the end date of their secondment and confirming the date they will return to their substantive role within their previous team.

Staff that are currently on maternity or sick leave will be contacted by their current line manager who will ensure they are communicated with on a regular basis.

10.2 Slotting in Wherever possible we will slot staff in to their first preference. This will apply where the substantive duties of the post holder are wholly or substantially the same in the new structure as they were in the old, and where no other staff in the same role are displaced. In these cases the member of staff should slot in automatically without competition, and without detriment to their terms and conditions.

Staff will only be slotted in to posts at the same band and can not be slotted into higher graded posts. 10.3 Redeployment

If you are a staff member who has not been appointed to a role via the ‘slotting in’ or interview process then you would remain ‘at risk’. Any displaced member of staff who becomes at risk will be supported to secure redeployment as per the Trust policy on redeployment. If you find yourself in this situation then you would be asked by your manager to complete a Redeployment Record Form which will ensure that your skills can be matched on the redeployment register. The Trust’s vacancies will be checked for potential matches with the redeployment register. Recruiting managers will ensure that preference is given to redeployment candidates where a potential skills match exists for any of their vacancies. You would be encouraged to be as flexible as possible in looking for alternative roles and to express an interest in any vacancy where your skills potentially match. You would also be entitled to 'preferential consideration' when applying for any Trust vacancy, which is not a promotional vacancy. Preferential consideration means that you would be considered before any other employees or outside applicants (except other employees under notice of redundancy). You would need to meet the essential criteria of the post or that you could undertake the post with a short period of training (usually no more than 3 months). You would need to make clear in your application that you are at risk and that your current post is redundant and you are therefore entitled to 'preferential consideration'. You would have a trial period (normally 4 weeks) in your new role. For further details of the redeployment procedure, please refer to the Redeployment Procedure. 10.4 Posts Unfilled

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Posts that have not been filled by slotting in or restricted competition will be advertised externally, subject to redeployment. Please refer to the Trust’s Redeployment Procedure.

10.5 Redundancy

All possible actions will be taken to avoid compulsory redundancy – It is hoped that a redundancy situation would not arise for any existing member of staff as a result of the new management structure however, redundancies cannot be ruled out.

Every effort will be made to slot staff into suitable alternative posts via slotting in, restricted competition, internal advertising, and preferential consideration. Information about vacancies will be made available throughout the consultation process.

If you find yourself in a redundancy situation, then the following principles would apply:

Notice of redundancy would be issued in line with your contract of employment and Agenda for Change or statutory requirements. This would identify a date at which employment with the Trust would cease. The Trust would continue to seek suitable alternative employment during this notice period;

If during the trial period, either you or your manager deems the employment unsuitable (unless you are deemed to have made an unreasonable refusal of the employment) you would not have forfeited your rights to a redundancy payment based on your substantive post. Further suitable alternative employment may be sought during the remainder of the notice period.

If a post is found at any point during your notice period, you would still be entitled to a trial period in the post. In this case the notice would be frozen during the trial period. If the trial period is successful, notice will cease and you would be confirmed in post. If the trial period is unsuccessful your notice would recommence at the point the trial period started and the search for a suitable alternative post would continue.

Please note that if you are a female staff member and your post is made redundant whilst you are on maternity leave then you must be offered a suitable alternative post which is equivalent to your original post. . You would not need to apply for it. This is because maternity leave is a protected period during which a woman is entitled to special consideration; this is to make good any disadvantage she may otherwise experience.

If your employment is terminated for reason of redundancy then you would be eligible for redundancy payments in accordance with Agenda for Change (or your terms and conditions of employment if other than Agenda for Change).

To be eligible for a redundancy payment, you must have two years or more continuous service after the age of 18. The amount of redundancy payment

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you would be entitled to is contained in Section 16 of Agenda for Change Terms and Conditions Handbook.

If you are put at risk of redundancy then the Trust would provide you with reasonable time off to look for work and with assistance in finding alternative employment. Please also refer to the Trust’s Organisational Change Policy and Procedure (including redundancy) for further details around redundancy.

11. Staff Support

The Trust will provide support and guidance to employees affected by these changes. Sources of support include your current line manager in the first instance, Trade Union/Staff Side Representatives, Occupational Health service, Insight Counselling Services, telephone 0800 027 7844 and Human Resources Team.

Any affected employees will be given the opportunity to access external resources and assistance in finding alternative employment within the Trust. If any affected member of staff wishes specific support regarding interviews or the application process, please contact Becky Sistig, HR Business Partner for OPAC and this can be arranged.

This process will be conducted according to the Trust’s policies which are available on the intranet, these are:• Organisational Change Policy and Procedure (including Redundancy); • Redeployment Procedure;• Protection of Pay and Terms & Conditions of Service Policy.

Staff that are currently on secondment, maternity or sick leave will be contacted by their current line manager who will ensure they are communicated with on a regular basis throughout this process and will be sent the consultation paper and any updates.

11. Consultation Process

Consultation Timetable

Date and Time Venue Action

31/08/2018 Hinchingbrooke Hospital

Informal meeting to discuss consultation – with staff-side. Elaine Young, Sonya Gardiner, Kuljit Mann, Becky Sistig met with Shona Greig.

Proposed NT management structure and draft JDs for Nursing and Therapy manager jobs shared with staff side

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following meeting.

01/05/2018 – 30/09/2018

Various Ongoing 1:1 meetings with NT staff

18/09/2018 Oak tree Centre, Huntington

Workshop with internal and external staff regarding partnership working with NTs

19/09/2018 Hills Room

Hinchingbrooke Hospital

Workshop with MDT staff on enhancing GP and acute hospital engagement

03/10/2018 Hemingford Abbots Village Hall

Launch meeting with NT Managers, Area Managers and OOH Managers

03/10/2018 Hemingford Abbots Village Hall

Launch meeting with MDT Co-ordinators

03/10/2018 Commencement of formal consultation

08/10/18 – 19/10/18

Individual meetings available. Contact Sue Roberts to book.

02/11/2018 Formal consultation ends.

Closing date for comments or representations to [email protected]

14/11/2018 Response to formal consultation reviewed.

Preference forms issued to affected staff

Way forward paper signed off at DMT

21/11/2018 Deadline for preference forms to be returned to [email protected]

From 26/11/2018 Interviews commence

From 14/02/2019 Implementation of proposed new structure

11.1 During the consultation period you will have the opportunity to individual consultation meetings with a member of the NT management team to discuss the personal implications of this proposal on an individual basis.

These consultation meetings will be available for 10 working days between Monday 8th October and Friday 19th October.

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mailto:[email protected]


Staff may be accompanied to these meetings by their Staff Side representative or a Trust work colleague. To make an appointment please contact Sue Roberts, Executive Assistant on 07800 715 756 or [email protected] .

11.2 A copy of this consultation paper will be provided to staff affected by the proposal and to Shona Greig, Staff Side Convener. (Shona’s contact details are Block 14, Ida Darwin, Cambridge, CB21 5EE. [email protected]. Telephone: 01223 884241)

11.2 If you wish to make any comments or representations regarding this proposal please forward these to [email protected]

Closing dates for comments or representations is 2nd November 2018.

Comments and representations will be considered and responded to in accordance timescales detailed in the table above.

11.4 For HR Support or queries on the process please contact:

Becky SistigHR Business PartnerBlock 14, Ida Darwin, Fulbourn, Cambridge, CB1 5EETel: 01223 884446Email: [email protected]

11.5 You may find it useful to obtain support during this difficult process from Insight (a 24 hour free advice and counselling service) useful and other teams within the Trust in Appendix 5.

12. ReferencesThe following policies may be useful during this consultation:

Organisational Change Policy Protection of Pay & Terms & Conditions Policy Redeployment Policy

All can be found on the CPFT Intranet at: http://nww.intranet.cpft.nhs.uk/sites/Corporate/PeopleBusinessDevelopment/HR/PoliciesandProcedures/Pages/Home.aspx

You can find the Employment Rights Act 1996 here - https://www.legislation.gov.uk/ukpga/1996/18/contents.

13. Appendices

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https://www.legislation.gov.uk/ukpga/1996/18/contents

http://nww.intranet.cpft.nhs.uk/sites/Corporate/PeopleBusinessDevelopment/HR/PoliciesandProcedures/Pages/Home.aspx

http://nww.intranet.cpft.nhs.uk/sites/Corporate/PeopleBusinessDevelopment/HR/PoliciesandProcedures/Pages/Home.aspx





Appendix 1 Job Descriptions & Person Specifications

Area Nursing Manager Area Therapy Manager Area Mental Health Manager NT Duty Practitioner Locality Business Support Co-ordinator Patient Flow Co-ordinator Advanced Clinical Nurse Practitioner

Appendix 2 Staff support leaflet

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Job Description

Job Title: Area Nursing Manager

Band: Band 8a

Responsible to: Deputy Locality Manager

Department: Neighbourhood Teams

Directorate: Older People’s and Adults Community Directorate

Our ValuesBehaviour How we will demonstrate this

behaviour Professionalism We will maintain the highest

standards and develop ourselves and others

By demonstrating compassion and showing care, honesty and flexibility

Respect We will create positive relationships

By being kind, open and collaborative

Innovation We are forward thinking, research focused and effective

By using evidence to shape the way we work

Dignity We will treat you as an individual By taking the time to hear, listen and understand

Empowerment We will support you By enabling you to make effective, informed decisions and to build your resilience and independence

Job PurposeThis post is a key management role within the integrated area management team within a defined north or south locality.

* The Area Nursing Manager will work collectively with the Area Therapy Manager and the Area Mental Health Manager/ OPMH Clinical Manager to ensure the neighbourhood teams or relevant clinical teams within their locality deliver high quality community services for clients.

* The post holder will be expected to provide clear leadership and take management responsibility for the effective delivery of the relevant nursing staff within the neighbourhood teams.

* The post holder will be also responsible for the day-to-day operational functioning of

the nursing staff in their neighbourhood teams and be accountable for their performance. With respect to this, the manager will receive regular constructive supervision from his/her direct line manager.

* The post holder will work closely with their nursing leadership team to deliver a quality led integrated service.

* The post holder will also work to develop and maintain excellent working relationships with their locality’s’ GPs and primary care teams ensuring regular meetings are held and attending engagement events.

Role of the DepartmentNeighbourhood teams aim to provide multi-disciplinary, seamless care closer to patients’ homes, reducing avoidable admission to hospital and facilitating hospital discharges.

Staffed by community nursing, therapy and mental health clinicians, neighbourhood teams provide integrated care for populations of 30,000- 50,000, based around GP registered lists.

The teams proactively care for those with long-term conditions, the dying, care home residents, and mental health service users’ conditions where care can be provided at home.

Main Tasks, Duties and Responsibilities1. Have overall management responsibility for their respective service including being

accountable for all aspects of performance for their services within the directorate’s Service Line Reporting (SLR) framework

2. Undertake the day-to-day team management for nursing teams providing support and lead on service development in collaboration with team members. This will involve a coordinated service delivery where policy and practice are regularly reviewed and evaluated, in-order to ensure evidence based effective practice

3. Ensure that the arrangements defined within the team’s Operational Policy for accepting, prioritising, dealing with referrals, and planning clients’ discharge are met

4. Ensure that teams are able to provide a responsive and effective service in line with the current service specification for Neighbourhood Teams

5. Represent the activities of the integrated area management team to external bodies, including senior management and commissioning authorities. This will involve attendance at meetings and the submission of reports as and when required

6. Deputise for the Deputy Locality Manager as required7. Undertake planned management supervision aiming to ensure an equitable workload

across their services8. Contribute to the business planning cycle for their locality and services9. Lead on Clinical Governance planning and development for their service and

participate in the wider directorate Clinical Governance structure 10.Ensure that there is an established system for all staff working within the team to

receive formal clinical and managerial supervision. Close liaison with the Head of Nursing on these issues will be necessary;

11.Be responsible for staff recruitment and selection with a view to complementing the service’s skill mix

12.Ensure that training needs for all team members are identified in line with the service provided

13.Monitor and manage all staff sickness, absences and annual leave entitlement

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14.Ensure that all new staff receive an induction programme appropriate to the post in accordance with agreed policy

15.Implement risk assessment procedures related to the working environment, tasks and client management

16.ensure that staff are aware of their rights and responsibilities under the Health & Safety at Work Act

17.Monitor and respond to all reported accidents or incidents following agreed local procedures

18.Manage staff performance and initiate disciplinary procedures as required19.ensure that all local risk assessment and management procedures are implemented20.Be responsible for ensuring CQC compliance for their locality and services

Equipment & Systems1. Ensure that their service develops appropriate advance technological skills and

knowledge base2. Ensure the accurate and timely collection and utilisation of team-generated

information3. Analyse and provide key performance management data to aid service development

and meet team and service targets4. Ensure that staff have access to appropriate mobile technology’s, and relevant

clinical systems (System 1 (S1) / Rio) to enable the completion of data, care plans and other key record information

5. Ensure that staff are capturing relevant and appropriate information for their services onto the relevant clinical system (System One / Rio)

6. Ensure that data is used to inform staff performance and that data capture is used to drive quality initiatives to further develop services

Decisions & Judgements1. Actively promote strong and effective leadership within a care quality structure that is

built on the principles of integration, open engagement and learning2. Ensure delivery of nursing services is in line with the trust’s Nursing Strategy3. Provide a management style that acknowledges staff contribution and enhances

motivation, opportunity and development at all levels4. Create a culture in which creativity and innovative ideas can flourish and provide a

shared vision and inspiration to enable staff to deliver support effectively5. Ensure their own leadership style facilitates effective communication, collaboration

and motivation of staff and partnership working to achieve the effective function of the Neighbourhood Team model

6. Develop partnerships within the health and social care system to promote integrated care based on the principles of population health

7. Develop and maintain strong working relationships with primary care to develop seamless care to the patient group across organisations

8. Ensure that effective performance management structures are in place and that all staff have structured supervision and an annual appraisal with personal development plan

9. Ensure staff are compliant with their statutory and mandatory training and are provided with learning and development opportunities appropriate to their needs, within financial constraints

10.Ensure staffing levels and skill mix fully and effectively meet the needs of the

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services and are within best practice guidelines ensure staff are treated fairly, equally and consistently and within the operational policies and procedures applied in the organisation

11.Ensure services are cost effective and delivered within budget

12.Ensure services meet care quality and performance management standards and are compliant with all regulatory requirements and standards

Research & Audit1. Ensure that services are continually monitored, reviewed and adapted to meet

changing service user need and identified commissioning requirements2. Promote new ways of working embracing technology where possible to improve

care, and ensure productivity3. Ensure the delivery of clinical and care quality standards and objectives4. Be responsible for implementing service changes when required, ensuring effective

implementation with measurable outcomes and agreed timescales5. Ensure that systems are in place to monitor stakeholders views of services and

ensure that service users, carers, relevant community organisations and other key stakeholders are involved in and influence key decisions on service development and continuous improvement

6. Participate in the evaluation of the services provided within services and actively promote service development including undertaking relevant audit and research.

7. Facilitate the development of clinical guidelines, protocols and patient related policies in partnership with clinicians and other managers within the organisation to promote safe and effective patient care.

8. Facilitate evidence based practice, assist in disseminating research findings to support changes in care

9. Take part in research projects as appropriate and support and facilitate other staff who are undertaking research/audit projects

10. In conjunction with team leads, lead in the development of annual audit plans for the locality team

11.Be responsible for the management of all risks across their locality and services, ensuring that lessons are learnt and agreed actions are embedded into daily operational practices of nursing teams

Communication & Relationships1. Ensure effective communication across all neighbourhood team services and with

internal and external partners and other stakeholders2. Be responsible for ensuring a full and timely response to all complaints and ensure

that lessons from these complaints are disseminated within the service.3. Undertake investigations, write investigation reports and feed back to service, service

users and carers as appropriate4. Develop and sustain relationship management with key stakeholders and partner

agencies, such as GPs, commissioners, local authorities, Acute Trusts, service user and carer groups, voluntary sector organisations

5. Promote the Trust’s services and positively enhance the Trust’s corporate image internally and with external agencies

Managerial & Financial Requirements

23

1. Provide line management to services and delegate line management of others within their team structure

2. Ensure all staff are aware of their role and responsibilities

3. Ensure all staff (including students, temporary, part time staff and junior members of the multidisciplinary clinical teams) acquire appropriate skills, experience and knowledge and are supported and supervised to deliver competent and timely patient care

4. Initiate and participate in education and development programmes and clinical supervision for all staff

5. Actively manage staff appraisal/performance, PDP and recruitment processes and all other key HR policies and procedures in line with the Trust guidance

6. Develop and monitor orientation and induction programmes specific and relevant to their clinical area for all new staff

7. Support workforce planning and talent management within their service area.

8. Be responsible for all staff undertaking annual mandatory and CPD training

9. Maintain their own professional development and meet their requirement to take part in their own appraisal and KSF process with a relevant line manager or clinical supervisor

10.Work with team leaders to ensure that policies are adhered to in respect of the recruitment and selection and retention of staff ensuring the equal opportunities policy and practice is adhered to

11.Clearly communicate team and service objectives and providing feedback to staff

12. Implement agreed processes to enable meaningful carer and service user involvement in the planning and delivering of services

13.Robustly manage delegated staffing, equipment and all other budgets within authorisation limits

14.Ensure efficiencies are realised in accordance with organisational objectives15.Monitor expenditure against agreed budgets and ensure information on the service’s

activities is recorded, for contracting and quality monitoring purposes16.Act as an authorised signatory/budget holder and monitor spend within their

delegated services17.Manage the effective use of allocated resources as delegated by the Deputy Locality

Manager18.Manage the budget monitoring and setting process for their services19.Develop and ensure the delivery of the Cost Improvement Plans (CIP) for the

financial year in line with the directorate annual Cost Improvement Plan.

Clinical1. Ensure all staff appropriately manage and support clients with complex health needs,

utilising their own knowledge and advanced skills to assess, plan, implement and initiate changes where required within eligibility criterion

2. have occasional direct contact with clients during the support, development and assessment of staff within their services

3. Act as a resource for Neighbourhood Teams and others involved in provision of clinical services through the provision of expert clinical advice

24

4. Promote holistic assessment and care in all areas to make one contact count5. Ensure clinical practice is delivered in line with evidence base and accordance with

National Standards

Training & Development To participate in regular supervision (clinical or management) in accordance with

good practice guidelines and Trust policy. To participate in the Trust’s annual Appraisal process. To attend all relevant mandatory training as and when required to do so.

Quality & Patient Safety Protection of Children & Vulnerable Adults – To promote and safeguard the welfare

of children, young people and vulnerable adults. Implementation of NICE guidance and other statutory / best practice guidelines. (if

appropriate) Infection Control - To be responsible for the prevention and control of infection. Incident reporting - To report any incidents of harm or near miss in line with the

Trust’s incident reporting policy ensuring appropriate actions are taken to reduce the risk of reoccurrence.

To contribute to the identification, management and reduction of risk in the area of responsibility.

To ensure day to day practice reflects the highest standards of governance, clinical effectiveness, safety and patient experience.

To ensure monitoring of quality and compliance with standards is demonstrable within the service on an ongoing basis.

To be aware of the responsibility of all employees to maintain a safe and healthy environment for patients/ clients, visitors and staff.

General To maintain up to date knowledge of legislation, national and local policies and

issues in relation to both the specific client group and mental health. To comply with the Professional Codes of Conduct and to be aware of changes in

these. To maintain up to date knowledge of all relevant legislation and local policies and procedures implementing this.

To ensure that all duties are carried out to the highest standard and in accordance with currently quality initiatives within the work area.

To comply with all relevant Trust policies, procedures and guidelines, including those relating to Equal Opportunities, Health and Safety and Confidentiality of Information and to be aware of any changes in these.

To comply at all times with the Trust’s Information Governance related policies. Staffs are required to respect the confidentiality of information about staff, patients and Trust business and in particular the confidentiality and security of personal identifiable information in line with the Data Protection Act. All staff are responsible for ensuring that any data created by them is timely, comprehensive, accurate, and fit for the purposes for which it is intended.

Equality & DiversityThe Trust is committed to equality and diversity and works hard to make sure all staff and service users have access to an environment that is open and a free from discrimination.

25

As a Trust we value the diversity of our staff and service users, and therefore recognise and appreciate that everyone associated with the Trust is different and so should be treated in ways that are consistent with their needs and preferences.

Therefore all staff are required to be aware of the Trust’s Equality and Diversity Policy and the commitments and responsibilities the Trust has to: Eliminate unlawful discrimination, harassment and victimisation and other conduct

prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic

and those who do not. Foster good relations between people who share a protected characteristic and

those who do not.We firmly believe that it makes good business sense to have a workforce representative of the communities we serve and so encourage applications from all sections of the community.

To be noted: This is not an exhaustive list of duties and responsibilities, and the post holder may be

required to undertake other duties, which fall within the grade of the job, in discussion with the manager.

This job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.

This post is subject to the Rehabilitation of Offenders Act 1974 (Exemption Order 1975) and as such it will be necessary for a submission for disclosure to be made to the Criminal Records Bureau to check for previous criminal convictions. The Trust is committed to the fair treatment of its staff, potential staff or users in line with its Equal Opportunities Policy and policy statement on the recruitment of ex-offenders.

26

Person SpecificationJob Title: Area Nursing Manager

Band: Band 8a




Criteria Essential Desirable

Education / Qualifications

Registered Nurse Extensive experience within

community/integrated services

Educated to degree level or equivalent professional experience within NHS or social care or private sector

Post graduate qualification or equivalent experience

Leadership Qualification or commitment to complete

Leadership Management qualification

Experience in organisational development and change management

Prince or Agile Project management

Lean methodologies

Experience Demonstrate experience in a care setting

Successful management and delivery of a service

Project management experience

Knowledge & Skills

Service improvement skills Excellent communication

skills both verbal and written Well-developed interpersonal

skills and the ability to foster good working relationships with all levels of people

Ability to work autonomously Ability to motive others and

use influencing and negotiating skills

Ability to use management information and demonstrate understanding of

PRINCE 2 qualified

performance information Analytical and judgmental

skills Ability to deal with

implications of not meeting deadlines and imparting unwelcome news to staff, senior management and other stakeholders

Ability to identify and facilitate areas for collaborative working

Excellent IT skills Ability to prioritise and

respond flexibly to frequent changing demands

Demonstrate experience of how to effect cultural and

Behavioural change Demonstrates understanding

of safeguarding issues Appreciates the significance

of safeguarding for all individual children and young people/ vulnerable adults whatever their life circumstances

Can demonstrate an ability to contribute towards a safe environment

Is up-to date with legislation and current events

Can demonstrate how s/he has promoted “best practice”

Has a balanced understanding of self and others

Has a realistic knowledge of personal strengths and areas for development

Can demonstrate flexibility of approach

Aware of the range of emotions in self and others

Demonstrates empathy for the concerns of others

Listens to and understands directly and indirectly expressed feelings

Encourages others to express themselves openly

Manages strong emotions

28

and responds constructively to the source of problems

Shows respect for others’ feelings,, views and circumstances

In highly stressful situations keeps own feelings in check, takes constructive action and calms others down

Has a range of mechanisms for dealing with stress, can recognise when to use them and does so

Listens to personal comments without becoming defensive

Accepts responsibility and accountability for own work and can define the responsibilities of others

Recognises the limits ow own authority within the role

Seeks and uses professional support appropriately

Understands the principle

Personal Qualities Positive approach to older people

Recognise people’s right to privacy and dignity, treating every person with respect

Willingness to embrace integrated model and new ways of working.

Willingness to be flexible in approach and attitude

Other Ability to travel across the County sometimes at short notice

Participate in the on call managers rota

The Trust is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults and expects all staff and volunteers to share this commitment. The Trust believes in treating everyone with dignity and respect and encourages applications from all sectors of the community. We guarantee an interview to candidates with disabilities who meet the minimum essential criteria.

29

Job Description

Job Title: Area Therapy Manager

Band: Band 8a














Job Purpose This post is a key management role within the integrated area management team

within a defined north or south locality.

The Area Therapy Manager will work collectively with the Area Nursing Manager and the Area Mental Health Manager/OPMH Clinical Manager to ensure the neighbourhood teams or relevant clinical teams within their locality deliver high quality community services for clients.

The post holder will be expected to provide clear leadership and take management responsibility for the effective delivery of the relevant therapy staff within the neighbourhood teams.

The post holder will be also responsible for the day-to-day operational functioning of the therapy staff in their neighbourhood teams and be accountable for their performance. With respect to this, the manager will receive regular constructive supervision from his/her direct line manager.

The post holder will be professionally accountable to the Allied Health Professional

30

Lead and work closely with them and the other Area managers to deliver a quality led integrated service.

The post holder will also work to develop and maintain excellent working relationships with their locality’s’ GPs and primary care teams ensuring regular meetings are held and attending engagement events.






2. Undertake the day-to-day team management for therapy teams providing support and lead on service development in collaboration with team members. This will involve a coordinated service delivery where policy and practice are regularly reviewed and evaluated, in-order to ensure evidence based effective practice

3. Ensure that the arrangements defined within the team’s Operational Policy for accepting, prioritising, dealing with referrals, and planning clients’ discharge are met

4. Ensure that teams are able to provide a responsive and effective service in line with the current service specification for Neighbourhood Teams

5. Represent the activities of the integrated area management team to external bodies, including senior management and commissioning authorities. This will involve attendance at meetings and the submission of reports as and when required




receive formal clinical and managerial supervision. Close liaison with the AHP Lead for the directorate on these issues will be necessary

11.Be responsible for staff recruitment and selection with a view to complementing the service’s skill mix

12.Ensure that training needs for all team members are identified in line with the service provided

13.Monitor and manage all staff sickness, absences and annual leave entitlement;14.Ensure that all new staff receive an induction programme appropriate to the post in

accordance with agreed policy15. Implement risk assessment procedures related to the working environment, tasks

31

and client management16.Ensure that staff are aware of their rights and responsibilities under the Health &

Safety at Work Act17.Monitor and respond to all reported accidents or incidents following agreed local

procedures18.Manage staff performance and initiate disciplinary procedures as required

19.Ensure that all local risk assessment and management procedures are implemented



information3. analyse and provide key performance management data to aid service development


clinical systems (System One) / Rio) to enable the completion of data, care plans and other key record information



Decisions & Judgements1. Actively promote strong and effective leadership within a care quality structure

that is built on the principles of integration, open engagement and learning2. To play an active part in the Trust AHP Leadership group and ensure the delivery

of therapy services is in line with the trust’s AHP Strategy3. To support AHP Lead in delivery of the Section 75 requirements for Occupational

Therapy and maintain good partnership working with Cambridgeshire County Council. Attend the OT performance meetings with CCC

4. Provide a management style that acknowledges staff contribution and enhances motivation, opportunity and development at all levels

5. Create a culture in which creativity and innovative ideas can flourish and provide a shared vision and inspiration to enable staff to deliver support effectively

6. Ensure their own leadership style facilitates effective communication, collaboration and motivation of staff and partnership working to achieve the effective function of the Neighbourhood Team model




10.Ensure staff are compliant with their statutory and mandatory training and are provided with learning and development opportunities appropriate to their needs, within financial constraints


32

services and are within best practice guidelines ensure staff are treated fairly, equally and consistently and within the operational policies and procedures applied in the organisation

12.Ensure services are cost effective and delivered within budget

13.Ensure services meet care quality and performance management standards and are compliant with all regulatory requirements and standards

14.Research & Audit1. Ensure that services are continually monitored, reviewed and adapted to meet


care, and ensure productivity3. Ensure the delivery of clinical and care quality standards and objectives4. Be responsible for implementing service changes when required, ensuring

effective implementation with measurable outcomes and agreed timescales5. Ensure that systems are in place to monitor stakeholders views of services and


6. Participate in the evaluation of the services provided within services and actively promote service development including undertaking relevant audit and research

7. Facilitate the development of clinical guidelines, protocols and patient related policies in partnership with clinicians and other managers within the organisation to promote safe and effective patient care




11.To work with Learning and Development team to ensure appropriate provision of, and governance, of student education and return to practice


internal and external partners and other stakeholders2. Be responsible for ensuring a full and timely response to all complaints and ensure

that lessons from these complaints are disseminated within the service.3. Undertake investigations, write investigation reports and feed back to service, service

users and carers as appropriate4. Develop and sustain relationship management with key stakeholders and partner



Managerial & Financial Requirements

33

1. Provide line management to services and delegate line management of others within their team structure

2. Ensure all staff are aware of their role and responsibilities3. Ensure all staff (including students, temporary, part time staff and junior members of

the multidisciplinary clinical teams) acquire appropriate skills, experience and knowledge and are supported and supervised to deliver competent and timely patient care




7. Support workforce planning and talent management within their service area.8. Be responsible for all staff undertaking annual mandatory and CPD training9. Maintain their own professional development and meet their requirement to take part

in their own appraisal and KSF process with a relevant line manager or clinical supervisor


11.clearly communicate team and service objectives and providing feedback to staff12. Implement agreed processes to enable meaningful carer and service user

involvement in the planning and delivering of services13.Robustly manage delegated staffing, equipment and all other budgets within

authorisation limits14.Ensure efficiencies are realised in accordance with organisational objectives15.Monitor expenditure against agreed budgets and ensure information on the service’s

activities is recorded, for contracting and quality monitoring purposes16.Act as an authorised signatory/budget holder and monitor spend within their

delegated services17.Manage the effective use of allocated resources as delegated by the Deputy Locality

Manager18.Manage the budget monitoring and setting process for their services19.Develop and ensure the delivery of the Cost Improvement Plans (CIP) for the


Clinical1. Ensure all staff appropriately manage and support clients with complex health needs,

utilising their own knowledge and advanced skills to assess, plan, implement and initiate changes where required within eligibility criterion

2. The post holder will demonstrate highly specialist knowledge and skills in therapies (OT or PT) and have undertaken appropriate post registration training.

3. have occasional direct contact with clients during the support, development and assessment of staff within their services

4. As a professional lead, to be highly proficient in managing complex referral patterns and processes, matching referrals and resources effectively and managing waiting lists as required

5. Act as a resource for Neighbourhood Teams and others involved in provision of clinical services through the provision of expert clinical advice

34

6. Promote holistic assessment and care in all areas to make one contact count7. Ensure clinical practice is delivered in line with evidence base and accordance with

relevant National Standards

Training & Development1. To participate in regular supervision (clinical or management) in accordance with

good practice guidelines and Trust policy.2. To participate in the Trust’s annual Appraisal process. 3. To attend all relevant mandatory training as and when required to do so.

Quality & Patient Safety1. Protection of Children & Vulnerable Adults – To promote and safeguard the welfare

of children, young people and vulnerable adults.2. Implementation of NICE guidance and other statutory / best practice guidelines. (if

appropriate)3. Infection Control - To be responsible for the prevention and control of infection.4. Incident reporting - To report any incidents of harm or near miss in line with the


5. To contribute to the identification, management and reduction of risk in the area of responsibility.

6. To ensure day to day practice reflects the highest standards of governance, clinical effectiveness, safety and patient experience.

7. To ensure monitoring of quality and compliance with standards is demonstrable within the service on an ongoing basis.

8. To be aware of the responsibility of all employees to maintain a safe and healthy environment for patients/ clients, visitors and staff.

General1. To maintain up to date knowledge of legislation, national and local policies and

issues in relation to both the specific client group and mental health. 2. To comply with the Professional Codes of Conduct and to be aware of changes in


3. To ensure that all duties are carried out to the highest standard and in accordance with currently quality initiatives within the work area.

4. To comply with all relevant Trust policies, procedures and guidelines, including those relating to Equal Opportunities, Health and Safety and Confidentiality of Information and to be aware of any changes in these.

5. To comply at all times with the Trust’s Information Governance related policies. Staffs are required to respect the confidentiality of information about staff, patients and Trust business and in particular the confidentiality and security of personal identifiable information in line with the Data Protection Act. All staff are responsible for ensuring that any data created by them is timely, comprehensive, accurate, and fit for the purposes for which it is intended.


35










36

Person SpecificationJob Title: Area Therapy Manager

Band: Band 8a






Registered Allied Health Professional (Occupational Therapist or Physiotherapist)

Extensive experience within community/integrated services







Lean methodologies




Knowledge & Skills






Ability to use management information and demonstrate

PRINCE 2 qualified

understanding of performance information

Analytical and judgmental skills

Ability to deal with implications of not meeting deadlines and imparting unwelcome news to staff, senior management and other stakeholders

















Encourages others to

38

express themselves openly Manages strong emotions


Shows respect for others’ feelings, views and circumstances







Understands the principle of confidentiality








39

Job Description

Job Title: Area Mental Health Manager – Stepped Care, Neighbourhood Teams and Memory Teams

Band: Band 8a














Job Purpose This post is a key management role within the integrated area management team

within a defined north or south locality.

The Area Mental Health Manager will work collectively with the Area Nursing Manager and the Area Therapy Manager to ensure the neighbourhood teams or relevant clinical teams within their locality deliver high quality community services for clients.

The post holder will be expected to provide clear leadership and take management responsibility for the effective delivery of the relevant therapy staff within the neighbourhood teams.

The post holder will be also responsible for the day-to-day operational functioning of the Mental Health staff in their teams and be accountable for their

41

performance. With respect to this, the manager will receive regular constructive supervision from his/her direct line manager.

The post holder will be professionally accountable to the Mental Health Head of Nursing Lead and work closely with them and the other Area Managers to deliver a quality led integrated service.

The post holder will also work to develop and maintain excellent working relationships with their locality’s’ GPs and primary care teams ensuring regular meetings are held and attending engagement events.






2. Undertake the day-to-day team management for Mental Health teams providing support and lead on service development in collaboration with team members. This will involve a coordinated service delivery where policy and practice are regularly reviewed and evaluated, in-order to ensure evidence based effective practice;

3. Ensure that the arrangements defined within the team’s Operational Policy for accepting, prioritising, dealing with referrals, and planning clients’ discharge are met;

4. Ensure that teams are able to provide a responsive and effective service in line with the current service specification for the teams

5. Represent the activities of the integrated area management team to external bodies, including senior management and commissioning authorities. This will involve attendance at meetings and the submission of reports as and when required.




receive formal clinical and managerial supervision. Close liaison with the AHP, Nurse & Psychology Leads for the directorate on these issues will be necessary;

11.Be responsible for staff recruitment and selection with a view to complementing the service’s skill mix;

12.Ensure that training needs for all team members are identified in line with the service provided;

42

13.Monitor and manage all staff sickness, absences and annual leave entitlement;14.Ensure that all new staff receive an induction programme appropriate to the post in

accordance with agreed policy; 15. Implement risk assessment procedures related to the working environment, tasks

and client management; 16.Ensure that staff are aware of their rights and responsibilities under the Health &

Safety at Work Act;17.Monitor and respond to all reported accidents or incidents following agreed local

procedures;18.Manage staff performance and initiate disciplinary procedures as required; 19.ensure that all local risk assessment and management procedures are implemented,20.Be responsible for ensuring CQC compliance for their locality and services

Leadership1. Actively promote strong and effective leadership within a care quality structure

that is built on the principles of integration, open engagement and learning2. To play an active part in the Trust Mental Health Leadership group and ensure

the delivery of services is in line with the trust’s Mental Health Strategy.3. Provide a management style that acknowledges staff contribution and enhances

motivation, opportunity and development at all levels4. Create a culture in which creativity and innovative ideas can flourish and provide

a shared vision and inspiration to enable staff to deliver support effectively.5. Ensure their own leadership style facilitates effective communication,

collaboration and motivation of staff and partnership working to achieve the effective function of the teams

6. Develop partnerships within the health and social care system to promote integrated care based on the principles of population health.

7. Develop and maintain strong working relationships with primary care to develop seamless care to the patient group across organisations.



10.Ensure staffing levels and skill mix fully and effectively meet the needs of the services and are within best practice guidelines ensure staff are treated fairly, equally and consistently and within the operational policies and procedures applied in the organization

11.Ensure services are cost effective and delivered within budget12.Ensure services meet care quality and performance management standards and

are compliant with all regulatory requirements and standards

Clinical1. Ensure all staff appropriately manage and support clients with complex health

needs, utilising their own knowledge and advanced skills to assess, plan, implement and initiate changes where required within eligibility criterion

2. The post holder will demonstrate highly specialist knowledge and skills (OT or mental health nursing) and have undertaken appropriate post registration training.

3. have occasional direct contact with clients during the support, development and

43

assessment of staff within their services

4. As a professional lead, to be highly proficient in managing complex referral patterns and processes, matching referrals and resources effectively and managing waiting lists as required.

5. Act as a resource for Specialist Services and Neighbourhood Teams and others involved in provision of clinical services through the provision of expert clinical advice

6. Promote holistic assessment and care in all areas to make one contact count

7. Ensure clinical practice is delivered in line with evidence base and accordance with relevant National Standards



information3. Analyse and provide key performance management data to aid service development


clinical systems (System One) / Rio) to enable the completion of data, care plans and other key record information



Decisions & Judgements1. Actively promote strong and effective leadership within a care quality structure

that is built on the principles of integration, open engagement and learning2. Ensure delivery of nursing services is in line with the trust’s Nursing Strategy3. Provide a management style that acknowledges staff contribution and enhances

motivation, opportunity and development at all levels4. Create a culture in which creativity and innovative ideas can flourish and provide

a shared vision and inspiration to enable staff to deliver support effectively5. Ensure their own leadership style facilitates effective communication,

collaboration and motivation of staff and partnership working to achieve the effective function of the Neighbourhood Team model






44

services and are within best practice guidelines ensure staff are treated fairly, equally and consistently and within the operational policies and procedures applied in the organization

11.Ensure services are cost effective and delivered within budget12.Ensure services meet care quality and performance management standards and

are compliant with all regulatory requirements and standards

Research & Audit1. Ensure that services are continually monitored, reviewed and adapted to meet


care, and ensure productivity3. Ensure the delivery of clinical and care quality standards and objectives4. Be responsible for implementing service changes when required, ensuring effective

implementation with measurable outcomes and agreed timescales5. Ensure that systems are in place to monitor stakeholders views of services and


6. Participate in the evaluation of the services provided within services and actively promote service development including undertaking relevant audit and research.

7. Facilitate the development of clinical guidelines, protocols and patient related policies in partnership with clinicians and other managers within the organisation to promote safe and effective patient care.




11.Be responsible for the management of all risks across their locality and services, ensuring that lessons are learnt and agreed actions are embedded into daily operational practices of nursing teams


internal and external partners and other stakeholders2. Be responsible for ensuring a full and timely response to all complaints and

ensure that lessons from these complaints are disseminated within the service.3. Undertake investigations, write investigation reports and feed back to service,

service users and carers as appropriate4. Develop and sustain relationship management with key stakeholders and partner



Managerial & Financial Requirements1. Provide line management to services and delegate line management of others

45

within their team structure2. Ensure all staff are aware of their role and responsibilities3. Ensure all staff (including students, temporary, part time staff and junior members

of the multidisciplinary clinical teams) acquire appropriate skills, experience and knowledge and are supported and supervised to deliver competent and timely patient care




7. Support workforce planning and talent management within their service area.8. Be responsible for all staff undertaking annual mandatory and CPD training9. Maintain their own professional development and meet their requirement to take

part in their own appraisal and KSF process with a relevant line manager or clinical supervisor


11.Clearly communicate team and service objectives and providing feedback to staff12. Implement agreed processes to enable meaningful carer and service user

involvement in the planning and delivering of services13.Robustly manage delegated staffing, equipment and all other budgets within

authorisation limits14.Ensure efficiencies are realised in accordance with organisational objectives15.Monitor expenditure against agreed budgets and ensure information on the

service’s activities is recorded, for contracting and quality monitoring purposes16.Act as an authorised signatory/budget holder and monitor spend within their

delegated services17.Manage the effective use of allocated resources as delegated by the Deputy

Locality Manager18.Manage the budget monitoring and setting process for their services19.Develop and ensure the delivery of the Cost Improvement Plans (CIP) for the








46












As a Trust we value the diversity of our staff and service users, and therefore recognise and appreciate that everyone associated with the Trust is different and so should be treated in ways that are consistent with their needs and preferences. Therefore all staff are required to be aware of the Trust’s Equality and Diversity Policy and the commitments and responsibilities the Trust has to: Eliminate unlawful discrimination, harassment and victimisation and other conduct



those who do not.

We firmly believe that it makes good business sense to have a workforce representative of the communities we serve and so encourage applications from all sections of the community.



47



48

Person SpecificationJob Title: Area Mental Health Manager

Band: Band 8a






Registered Professional (Occupational Therapist or Registered Mental Health Nurse)

Extensive experience within community/integrated services







Lean methodologies




Knowledge & Skills






Ability to use management

PRINCE 2 qualified

information and demonstrate understanding of performance information

Analytical and judgmental skills

Ability to deal with implications of not meeting deadlines and imparting unwelcome news to staff, senior management and other stakeholders

















Encourages others to

50

express themselves openly Manages strong emotions


Shows respect for others’ feelings,, views and circumstances







Understands the principle








51

Job Description

Job Title: Neighbourhood Team Duty Practitioner

Band: 7 - Subject to Agenda for Change Job matching

Responsible to: Nursing Area Manager


Directorate: Older People’s and Adult Community Directorate











Job PurposeThe post holder will be responsible for co-ordination and delivery of community nursing provisions outside the core hours of neighbourhood teams (NT) across the whole of the Cambridgeshire and Peterborough geography. The role will also support the out of hours nursing teams in localities to assist with the triage of referrals into the service, as well as be the point of escalation for clinical teams requiring clinical advice.

Out of hours community nursing services are delivered seven days a week continuing the provision of community nursing service after the hours of day time neighbourhood team nursing services. The post holder will be expected to work from 4pm to midnight shifts to ensure the smooth transition and handover of nursing services from the NT to out of hours staff.


52


The teams proactively care for those with long-term conditions, the dying, care home residents, and mental health service users’ conditions where their care can be provided at home.

Main Tasks, Duties and Responsibilities1. To ensure that community nursing care delivered out of hours is triaged and

delivered on a case by case basis dependent on individual patient need2. To co-ordinate the delivery of nursing resources out of hours across Cambridgeshire

and Peterborough3. To demonstrate excellent clinical and leadership skills in order to review, allocate,

deploy and coordinate nursing resources out of hours in an efficient and safe manner4. To work autonomously taking overall clinical responsibility for care, quality and

clinical activity out of hours by providing professional nursing leadership and guidance, clinical advice and clinical supervision to out of hours nursing staff

5. To provide high quality clinical nursing care using advanced assessment and diagnostic reasoning skills along with expert knowledge and critical understanding

6. To work closely with other members of neighbourhood teams including Advanced Clinical Nurse Practitioners (ACNPs) and district nurses, and other external provider services, health and social care partners and GPs to ensure that patients are enabled to live at home with dignity and maximal independence

7. To actively participate in regular clinical supervision sessions for NT and out of hours nursing teams

8. To provide training to support the development of less experienced community nursing staff

9. To deploy staff in urgent situations to achieve safe staffing levels within available resources.

10.The booking of bank staff to cover depleted shifts as well as having oversight of Health roster and management of safe staffing.

11.To ensure a high standard of nursing care based on assessment of care needs and the development, implementation and evaluation of the care plan.


knowledge base

2. Ensure the accurate and timely collection and utilisation of team-generated information

3. Analyse and provide key performance management data to aid service development and meet team and service targets

4. Ensure that staff have access to appropriate mobile technology’s, and relevant clinical systems (System 1 (S1) / Rio) to enable the completion of data, care plans and other key record information


6. Ensure that data is used to inform staff performance and that data capture is used to

53

drive quality initiatives to further develop services

Research & Audit1. Be responsible for undertaking audits pertinent to the service and embedding

findings in practice.2. To participate in clinical audit and evaluation of clinical effectiveness in line with

the organisations commitment to clinical governance 3. To contribute to research design, implementation and data collection

Communication & Relationships1. To liaise with Area Managers (within working hours) and on call managers (OOH’s) about clinical situations.

2. To liaise with patients and family members, representing the service and offering professional advice where appropriate.

3. To actively participate in ensuring safe handover of patients between shifts.

4. To ensure effective communication between all members of the clinical teams in matters which require central co-ordination.

4. Act as a resource and role model for all other staff.

Managerial & Financial Requirements1. To undertake the role of an investigating manager for complaints and serious

incident investigations. To provide a response within the time frame allocated and develop actions plans in conjunction with the responsible team.

2. To monitor stock levels and request new equipment as appropriate.

Physical, mental, emotional & environmental demands of the job1. The ability to cover a large geographical area. 2. Required to work without supervision and under pressure.3. Unsocial hours of working to cover 7day service.4. The ability to undertake physical moving and handling.






54

















those who do not.


To be noted:

55

This is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties, which fall within the grade of the job, in discussion with the manager.



56

Person Specification

Job Title: Neighbourhood Team Duty Practitioner

Band: 7 – Subject to Agenda for Change Job Matching

Responsible to: Area Nursing Manager




RN Degree/diploma adult qualification

Recognised Community Nursing qualification

Mentorship qualification

Evidence of Continued Professional Development

Previous management experience

Non-medical prescriber

Experience Experience of working in the community services

Experience of working with older people

Extensive post qualification experience

Experience of complex care planning and MDT working

Triage experience for unplanned care

Experience of working with people with long term conditions.

Clinical supervision experience.

Health coaching

Knowledge & Skills

Effective communication and IT skills

Motivating team members

Demonstrate the understanding of services within CPFT and across the wider health system

Able to advocate for patients and colleagues

Able to demonstrate

commitment to high quality care and service provision

Demonstrate competency in a range of clinical skills including advanced clinical assessment.

Ability to calmly manage complex and stressful situations prioritising own work and work of others.

Good listening skills and empathetic



Willingness to embrace the integrated model and ways of working.

Other To be forward thinking and positive in approach to changes that takes place to meet the needs of the service.


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Job Description

Job Title: Locality Business Support Co-ordinator

Band: 5














Job PurposeThe post is a fundamental role within the neighbourhood team structure. The role has the main responsibilities of providing full business support to neighbourhood teams within a locality.

The post holder will work closely with Nursing, Therapy and OPMH Mental Health Area Managers to support with business delivery for the Neighbourhood teams.

The post holder will also have delegated authority and responsibility to act independently and to handle and deliver local decisions and actions with regards to the business functions of neighbourhood teams within a defined locality.



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Main Tasks, Duties and Responsibilities1. Support with health roster management for NTs2. Support with recruitment for teams in NTs3. Support with sickness management processes for NT staff4. The co-ordination and management of regular local governance, operational and

performance meetings 5. Support with the co-ordination and completion of clinical audits6. Project support to deliver clinical and service improvement projects such as

winter flu programmes, ambulant care clinics7. Support with preparation of reports on NT performance and the analysis of

performance information8. The monitoring and management of mandatory training compliance for NT staff9. Co-ordination of inductions and new starters in to NTs10.Support with business continuity plans11.Responsibility for dealing with telephone complaints/ enquiries and other

communications with a high degree of tact, diplomacy and confidentiality in line with CPFT procedures and policies.

12.Participate in the contribution to the production of service development proposals for the defined service areas and contribute towards the Directorate and Trust planning processes, including service re-design.

13.Participate in the production of policies and procedures which facilitate the operational and quality effectiveness of service areas

14.Ensure effective communication systems for all NT staff are in place enabling local and corporate information to be shared with all staff within the defined locality and for views to be fed upwards.

15.Orders stock and stationery; authorised signatory for travel arrangements, meeting expenses


knowledge base 2. Ensure the accurate and timely collection and utilisation of team-generated

information 3. Analyse and provide key performance management data to aid service

development and meet team and service targets 4. Ensure that staff have access to appropriate mobile technology’s, and relevant

clinical systems (System 1 (S1) / Rio) to enable the completion of data, care plans and other key record information




good practice guidelines and Trust policy.

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2. To participate in the Trust’s annual Appraisal process. 3. To attend all relevant mandatory training as and when required to do so.

Quality & Patient Safety1. Protection of Children & Vulnerable Adults – To promote and safeguard the

welfare of children, young people and vulnerable adults.2. Implementation of NICE guidance and other statutory / best practice guidelines.

(if appropriate)3. Infection Control - To be responsible for the prevention and control of infection.4. Incident reporting - To report any incidents of harm or near miss in line with the












Equality & DiversityThe Trust is committed to equality and diversity and works hard to make sure all staff and service users have access to an environment that is open and a free from discrimination. As a Trust we value the diversity of our staff and service users, and therefore recognise and appreciate that everyone associated with the Trust is different and so should be treated in ways that are consistent with their needs and preferences.



and those who do not.

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Foster good relations between people who share a protected characteristic and those who do not.






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Person SpecificationJob Title: Locality Business Support Co-ordinator

Band: 5





English and Maths to GCSE level or equivalent

Educated to degree level or ability to demonstrate ability at this level

Relevant clinical qualification

Experience Experience in a similar role working for Senior Management/Team Leader level.

Experience supporting an operational service with business functions

Knowledge of administrative procedures, range of computerised software, own directorate specialised terminology and managerial knowledge

Experience of initiating and seeing through to completion tasks or work streams within health care

Experience of working effectively with colleagues across partner organisations

Experience of S1 and databases

Experience of working with patients with varying and/or complex needs and their families

Experience of working with GP practices or health teams

Experience of either working within or the commissioning of services

Customer care course/ experience

Experience of working in services for older people and people with complex needs

Experience of health systems including SystmOne and EMIS


Knowledge & Ability to work with a high Understanding of NHS

Skills degree of autonomy and flexibility

Self-motivated and able to work on own initiative with the ability and confidence to make decisions.

Confident nature with a proactive and constructive approach to problem solving

Well-developed organisational and planning skills

Ability to prioritise and respond flexibly to frequent changing demands

Exceptional communication skills, with the ability to convey sensitive information

Ability to assimilate and manage appropriately complex information

Proven team working skills Experience liaising with a

range of staff from different professions and organisations

Ability to resolve conflict and remain calm under pressure.

Ability to foster good working relationships, to facilitate collaborative working

Well-developed inter-personal skills

Negotiation skills (persuading people to do things)

Proven ability to create reports and maintain project information systems

Demonstrable numerical skills

Excellent IT skills (including Word, Excel, PowerPoint, knowledge of databases)

Advanced knowledge of Word Processing, Spreadsheets and Presentation packages

Data preparation and manipulation skills (Excel)

Experience of taking minutes and drawing up action points and project managing the

Information Systems Knowledge of health

commissioning

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completion of these. Demonstrates understanding

of safeguarding issues Accepts responsibility and

accountability for own work and can define the responsibilities of others

Recognises the limits of own authority within the role


Understands the principles of confidentiality




Personal Qualities Positive approach to people with complex health needs

Positive approach to working within teams

Positive approach to working with multi-agency partners




Other Ability to travel independently in the community


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Job Description

Job Title: Patient Flow Co-ordinator

Band: TBC - Subject to Agenda for Change Job Matching





behaviour

Professionalism We will maintain the highest standards and develop ourselves and others








Job PurposeThe Patient Flow Co-ordinator is a fundamental role within the neighbourhood team structure. It is responsible for the co-ordination and tracking of complex patients on neighbourhood team caseloads across health and social care teams such as acute hospitals, GP surgeries, social services, voluntary organisations and other CPFT services.

This role will co-ordinate clinical meetings, and liaise with teams, services, wards and GP practices to facilitate the provision of safe, timely, joined up care and services delivered by neighbourhood teams. Patient flow co-ordinators are key in supporting neighbourhood teams to prevent hospital admissions and ensure safe hospital

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discharges.

The role requires significant understanding of complex community patient pathways, and analytical and judgement skills regarding patients’ clinical information and their treatment plans to ensure that neighbourhood team services are delivered in a timely and efficient manner.

Day to day operational management support will be provided to the patient flow co-ordinator by the Locality Business Support Co-ordinator, with the Area Nurse Manager in the relevant locality providing leadership and support regarding daily, weekly and monthly tasks and priorities.


Staffed by community nursing, therapy and mental health clinicians, neighbourhood teams provide integrated care for populations of 30,000- 50,000 based around GP registered lists. Neighbourhood teams proactively care for those with long-term conditions, the dying, care home residents, and mental health service users’ conditions where care can be provided at home. 

Main Tasks, Duties and Responsibilities

1. Coordinate and manage the patient flow co-ordination of functions for Neighbourhood Teams and associated Therapy and Mental Health Teams. This will include management of patient flow through SystmOne (S1).

2. Liaise with patient to gain consent and then ongoing liaison and all professionals involved in the patient’s care as listed above

3. Take responsibility for tracking patients who are on their Neighbourhood Team caseload and ensure NT staff are aware of any hospital admissions and their progress through the pathway.

4. Close and regular liaison with patient’s GP practices to ensure that practices are up to date with each patient’s current health status, acting as a conduit for two way communication and updates regarding specific patients known to GP practices and community health services including neighbourhood teams, specialist services, urgent care services and community hospitals

5. Liaise with Community Intermediate Care Services and other community based services to support timely hospital discharges including ensuring any follow up appointments have been booked and transportation is arranged

6. To build and maintain relationships with GP practices, Community Therapy, Mental Health Teams and Community Specialist Services, Adult Social Care and third sector providers to ensure timely transfer of information between the teams.

7. To develop and sustain effective communication with wards at Addenbrookes,

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Hinchingbrooke, Peterborough and Queen Elizabeth Hospitals to feedback the outcomes of individual patient referrals including interventions carried out and details of any ongoing support that may be required including when active MDT patients are admitted into the hospital and ensuring that vital information regarding current community service provision is shared.

8. To deal in a professional, helpful and sensitive manner with service users, staff and other agencies by telephone or face to face, taking messages, advising patients about visits, referring other issues as appropriate and answering routine enquiries

9. To complete administrative tasks related to facilitating patient flow across neighbourhood team pathways as instructed. This may including taking minutes at MDT meetings, and other patient focused meetings, photocopying, faxing, dealing with other forms as required to support the timely delivery of clinical services to patients.

10.To extract caseload information from various clinical systems, and undertake analysis of information for audit, performance management and capacity purposes, including data entry, retrievals, manipulation and reporting formatting & to feed back to team members.

11.To be responsible for maintaining a service directory and updating on a regular basis; sourcing referral criteria, understanding how services are accessed, ensuring information is available to all members of the wider teams

12.Allocation of urgent same day response to appropriate available Service. Allocation of visits to clinician’s rota’s based on triage and wait times. Rearrange appointments when required e.g. if urgent appointment is booked reschedule of other appointments to another day or clinician

13.Completion of the Delayed Transfers of Care (DToC) spreadsheet each week and monthly statistical provision for informatics as requested

14.Supporting lead nursing, therapy and mental health clinicians in weekly monitoring of patient flow from assessment beds, producing data figures as requested in relation to key performance indicators (KPI’s), as well as directly inputting and providing assistance to clinicians to input into patient’s case management summaries, using agreed templates

15.Managing a system of daily reviewing of the ‘urgent care dashboard’ and discharge planning screen and initiating actions/tasks and referrals to the relevant teams/professionals as appropriate, inputting the data and actions onto the information management system to update patient records.

16.Working closely with Advanced Clinical Nurse Practitioners (ACNPs), the post will support all clinical staff including therapy and mental health staff in neighbourhood teams to ensure that care and support for each patient is driven by clear goals and is time limited based on the level of intervention.

17.Ensure the agreed care plan records are developed, reviewed, discussed at clinical meetings when appropriate and updated at agreed intervals, and ensuring that all

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management plans are carried out and are co-ordinated to ensure that outputs are not delayed

18.Arranging MDT meetings and agreeing with neighbourhood team nursing, therapy and mental health staff, Social, Primary and Voluntary Care Sector partners a timetable of regular MDT meetings and attendees

19.Agreeing with neighbourhood team staff, social, primary and voluntary care sector partners which patients who will be discussed using local knowledge, information on recent crisis or events, including A&E attendances and admissions identified through the Urgent Care dashboard and when available a risk stratification tool. Some patients discussed will be those currently or recently admitted to hospital, and those for whom there has been urgent and admission avoidance MDT work.

20.Attending all NT MDT meetings, ensuring the meetings are focussed on the agreed patients, maintaining a record of all agreed actions and decisions & ensuring the patient’s management plan and case management summary is updated after each meeting

21.To support the Annual Flu Vaccination Plan

22.To support the information governance procedures for each neighbourhood team - undertaking work of a confidential nature which must be carried out with maximum discretion and diplomacy.

23.Observe and maintain strict confidentiality with regards to any patient/family/staff/records and information in line with the requirements of the Data Protection Act and CPFT policy

24.The post holder must adhere to the Trust risk assessment and risk management processes

25.The post holder must adhere to infection control policies and procedures

26.Undertake mandatory training and any other training relevant to the role as required by CPFT.

27.The post holder will participate in clinical and other audits as required

28.Provide patients and their families /carers with information on standards they should expect from the team

29.The post holder is required to participate in relevant emergency preparedness process for their team.

Equipment & Systems

1. Ensure that their service develops appropriate advance technological skills and knowledge base

2. Ensure the accurate and timely collection and utilisation of team-generated information

3. Analyse and provide key performance management data to aid service development

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and meet team and service targets

4. Ensure that staff have access to appropriate mobile technology’s, and relevant clinical systems (System 1 (S1) / Rio) to enable the completion of data, care plans and other key record information



Research & Audit

1. To contribute to reviews and audit of case management system.

2. To collate agreed data reports

Communication & Relationships

1. Maintaining own professional development and requirement to take part in appraisal and supervision process


good practice guidelines and Trust policy.

2. To participate in the Trust’s annual Appraisal process.

3. To attend all relevant mandatory training as and when required to do so.


of children, young people and vulnerable adults.

2. Implementation of NICE guidance and other statutory / best practice guidelines. (if appropriate)

3. Infection Control - To be responsible for the prevention and control of infection.

4. Incident reporting - To report any incidents of harm or near miss in line with the Trust’s incident reporting policy ensuring appropriate actions are taken to reduce the risk of reoccurrence.



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issues in relation to both the specific client group and mental health.

2. To comply with the Professional Codes of Conduct and to be aware of changes in these. To maintain up to date knowledge of all relevant legislation and local policies and procedures implementing this.






Therefore all staff are required to be aware of the Trust’s Equality and Diversity Policy and the commitments and responsibilities the Trust has to:

Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act.

Advance equality of opportunity between people who share a protected characteristic and those who do not.

Foster good relations between people who share a protected characteristic and

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those who do not.






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Job Title: Patient Flow Co-ordinator

Band: TBC – Subject to Agenda for Change Job Matching






English and Maths to NVQ Level 3, Diploma or equivalent

Relevant clinical qualification

Educated to degree level or ability to demonstrate ability at this level

Experience Experience of working with GP practices or health teams

Extensive experience at a senior administrative level

Experience of initiating and seeing through to completion tasks or work streams within health care

Experience of working effectively with colleagues across partner organisations

Experience of S1 and databases

Experience of working with patients with varying and/or complex needs and their families

Experience of either working within or the commissioning of services

Customer care course/ experience

Experience of working in services for older people and people with complex needs

Experience of health systems including SystmOne and EMIS


Knowledge & Skills

Able to demonstrate commitment to high quality care and service provision

Understanding of NHS Information Systems

Ability to work with a high degree of autonomy and flexibility

Self-motivated and able to work on own initiative with the ability and confidence to make decisions.

Confident nature with a proactive and constructive approach to problem solving

Well-developed organisational and planning skills

Ability to prioritise and respond flexibly to frequent changing demands

Exceptional communication skills, with the ability to convey sensitive information

Ability to assimilate and manage appropriately complex information

Proven team working skills

Experience liaising with a range of staff from different professions and organisations

Ability to resolve conflict and remain calm under pressure.

Ability to foster good working relationships, to facilitate collaborative working

Well-developed inter-personal skills

Negotiation skills (persuading people to do things)

Proven ability to create reports and maintain project information systems

Demonstrable numerical

Knowledge of health commissioning

skills

Excellent IT skills (including Word, Excel, PowerPoint, knowledge of databases)

Advanced knowledge of Word Processing, Spreadsheets and Presentation packages

Data preparation and manipulation skills (Excel)

Experience of taking minutes and drawing up action points and project managing the completion of these.

Demonstrates understanding of safeguarding issues


Recognises the limits of own authority within the role


Understands the principles of confidentiality








Other Ability to travel independently in the community


Job Description

Job Title: Advanced Community Nurse Practitioner

Band: 7



Directorate: Older People and Adult Community











Job PurposeTo work autonomously taking overall responsibility for nursing care, quality and clinical activity within the Neighbourhood Teams by providing advanced professional nursing leadership and guidance, clinical advice and management in relation to the key dimensions of health care quality: To educate, develop and clinically lead nursing staff within the NT to deliver

community nursing interventions and to support the care of patients with complex needs.

Patient safety The effectiveness of all health care interventions Patient experience The environment in which care is delivered To ensure the delivery of a clinically effective service which meets the needs of

individuals, families and communities in line with local and national development plans, Trust policies and procedures.

To provide the highest standard of clinical nursing care by using advanced assessment and diagnostic reasoning skills along with expert knowledge and critical understanding. Holistically assess patient’s needs and instigate and provide clinical treatments based on evidence based practice.

Be responsible for teaching and developing staff to enhance their practice and skills to manage capacity, caseloads and patient complexity.

Be advisory and supervisory role models; oversee community nursing caseloads and safer staffing.

To work with our local GP’s and Partner Agencies to provide care approach to a defined high risk patient group with complex long term conditions with the aim of preventing hospital admissions/ readmissions and facilitating timely discharge.

To take the lead in collaboration with other disciplines and agencies to facilitate inter-professional/ agency working with the aim of supporting people to maximise their health and well-being in the community.

Clinically lead and support the team to recognise, prioritise and respond appropriately to urgent and emergency situations including the assessment and management of risk.

Key Responsibilities

Clinical / Service Specific1. As an autonomous practitioner, working as an integral member of the community

nursing service the post holder will be expected to take a lead role in the advanced clinical assessment, diagnosis, management and treatment of patients who require case management in a community setting

2. To use advanced nursing, clinical, diagnostic and prescribing skills, to carry out a thorough holistic assessment, including a systematic physical examination, to develop a patient centred comprehensive care plan.

3. To initiate and provide advanced clinical/therapeutic care treatments, in partnership with other providers, based on best possible evidence that will improve health outcomes

4. To use advanced clinical skills and expert knowledge to proactively identify subtle changes in the patient’s condition as early as possible and to manage these in a manner that optimize well-being.

5. To be responsible for teaching and developing staff to enhance their clinical practice to manage capacity and patient complexity.

6. To investigate serious incidences and ensure learning from these incidences is embedded within the team.

7. To work closely with other members of the team, provider services, health and social care partners and GP to ensure that individuals are enabled to live at home with dignity and independence and empower them to reach and maintain their optimum function

8. To actively promote self-management which enables the patient to proactively manage their long term condition and know how to confidently manage or respond to any expected exacerbation or deterioration in their condition.

9. To work collaboratively with the patient and or family/career in the use of technology including tele-technology in the management of their condition.

10.Actively participate in regular clinical supervision as supervisor and supervisee11.Provide training to support the development of less experienced staff.12.Maintain clinical and professional competence by portfolio evidence that shows

an up to date knowledge of nursing, therapy, health, social and integrated working care trends and policy.

13.Provide advice and support to patients with regard to healthy lifestyles, health promotion, and well-being and disease prevention.

14.Recognise and report environmental health problems affecting patients and provide health protection interventions that promote health and safe environments for patients and staff.

15.To identify learning and development needs within the Neighbourhood Teams and to participate in the creation and delivery of educational programmers to manage patients within the community setting. Development of workforce – utilising clinical expertise and knowledge.

16.To critically evaluate nursing practice and identify areas of improvement and Lessons Learnt, taking responsibility for supporting staff to identify innovative

quality improvement ideas and developing these to effectively improve practice.17.Management to create an environment for successful change and practice

development To apply the theoretical perspectives of change18.Understand the complexity of multi-agency environments, the need for

interdependency decision making and support staff to feel confident and competent in moving across agency and professional boundaries.

19.Be able to lead on aspects of quality assurance, audit and develop nurse indicators, utilise data to improve patient outcomes and safety, demonstrate an outcomes based approach to practice.

20.Be leads for the consistent and equitable approach of sharing of clinical updates, supporting staff with any change in processes to ensure these are transferred into practice and enabling continuous professional development of self and others through the development of Professional Development Groups

21.Work in partnership and collaboratively with primary care, all disciplines within the neighbourhood teams and professional leads.

22.Be responsible for clinical supervision for band 6 nurses, embedding a reflective, continuous learning culture driving highly quality, safe, effective practice.

23.Ensuring the learning environment is conducive for students; provide mentoring and coaching to staff, Post Graduate Students and pre-registration nursing students.

Research & Service Evaluation1. To participate in and lead on clinical and organisational audit activities related to the

service.2. To critically evaluate and interpret evidence based research findings from diverse

sources making informed judgements about their implications for developing or re-designing services and clinical practice.

3. To continually evaluate the quality and effectiveness of the practice of self and others.

4. To evaluate outcomes for patients in collaboration with other health and social care colleagues.

5. To contribute to the wider development of practice through networking locally and nationally; presenting and publishing.

6. To participate in appropriate research projects and service evaluations.7. Include informal and formal clinical or non-clinical research and development (R & D)

activities

Information Technology1. Maintain confidentiality in accordance with the data protection act.2. Ensure that accurate and timely patient records are kept which comply with trust

policy and NMC guidance, reporting on any issues as appropriate3. Ensure all patient care is documented in the primary care patient record e.g. System

One

Financial Responsibility1. Responsible and accountable for the effective and efficient use of clinical, physical

and financial resources.

Human Resources1. Clinical supervision / co-ordination of all nursing staff2. To adhere to all trust policies and procedures. Participate in development and

reviewing of clinical polices as required.

Training & Development1. To participate in regular supervision in accordance with good practice guidelines and

Trust policy.2. To participate in the Trust’s annual Appraisal process. 3. To attend all relevant mandatory training as and when required to do so.

















Job Title: Advanced Community Nurse Practitioner

Band: 7





RGN Level1 Educated to degree level or

equivalent experience Post registration qualification

relevant to community practice

Evidence of professional development

Advanced clinical assessment qualification or willingness to undertake within 12 months of commencement in post

Non-medical prescriber or willingness to undertake within 12 months of commencement in post

Leadership qualification

Mentorship qualification

Willingness to undertake MSc level study

Teaching qualification

Experience Significant Post Qualification Experience in Community Nursing

Experience of mentoring/teaching both pre and post registration nurses

Experience of managing both complex patients and those with long term conditions

Working autonomously Advanced clinical

assessment diagnosis and

treatment of patients Experience of promoting self-

management, independent living and use of assistive technology.

Skills & Abilities Commitment to deliver high quality care and service provision

Ability to work flexibly as part of a team

Demonstrate effective communication and inter-personal skills at all levels

Demonstrate initiative and ability to work independently, is able to problem solve and prioritise own and others work

Has the ability to plan and organise the team effectively

Ability to motivate self and others

Ability to adapt leadership style to ensure effective engagement of staff to deliver quality outcomes for the patient.

Knowledge & Understanding

Ensure the use of evidence based practice and translate this for use within the clinical team environment

Understand current developments within the NHS and how this impacts on leadership style ensuring quality care delivery for service users

Physical Requirements

A valid driving license Satisfactory DBS Good attendance record Ability to move and

manoeuvre people and equipment

Kneel, bend and stoop in cramped environments

Other Positive approach to older people

Older People’s and Adult Community Directorate - cpft.nhs.uk G/Reimagining NTs... · Web viewIf...

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